Other·June 27, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during an investigation of a Complaint during an Abbreviated Survey. Complaint Number: CA00621906. Representing the Department of Public Health: Surveyor ID: 34180 RN, HFEN The inspection was limited to the specific Complaint incidents investigated and does not represent the findings of a full inspection of the facility. One deficiency related to original allegation was issued for Complaint CA00621906.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 06/27/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GY0U11 Facility ID: CA910000047 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 05/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility failed to follow its policy for fall management, provide necessary supervision and implement resident's care plans for fall prevention for two of three sampled residents (Residents 1 and 2). Residents 1 and 2 were assessed as a high risk for falls, had a history of falls with falls in the facility due to the facility's failure to provide the necessary safety measure, such as a fall prevention program. This deficient practice resulted in Residents 1 and 2 falling sustaining injuries that required a transfer to general acute care hospitals (GACH), undergoing surgeries and receiving strong narcotic pain medications. Resident 1 sustained a right femur (thigh bone) fracture (broken bone) and had an ORIF surgery (a surgery to repair a broken bone with screws, plates, rods, or pins to hold the broken bones together), and Resident 2 had a right femur fracture and underwent a surgical repair with an intramedullary rod placement (a metal rod used for the treatment of a fractured bone; to hold a bone in placed). Findings: a. A review of Resident 1's Admission Record indicated that Resident 1 was initially admitted to the facility on 1/6/13 and last re-admitted on 10/28/18. Resident 1' diagnoses included muscle weakness, unspecified lack of coordination, and dementia (a condition characterized by a group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning). A review of Resident 1's Minimum Data Sets (MDS), a standardized assessment and carescreening tool, dated 6/18/18 and 12/17/18, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GY0U11 Facility ID: CA910000047 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 05/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated Resident 1's Brief Interview for Mental Status ([BIMS] a screening tool to assess cognition [thought process]) was severely impaired with a score of 01, had an unsteady gait (walking) and was only able to stabilize with staff assistance and required a one-person physical assist with transferring and utilized a wheelchair as a mobility device. The MDS indicated Resident 1 was incontinent (inability to control) of bladder and bowel function. A review of Resident 1's "Fall Risk Assessment," dated 6/18/18 indicated the resident had total score of 11. According to the Fall Risk Assessment, a total score of 10 or more represents a high risk. A review of Resident 1's history and physical (H/P), dated 7/17/18, indicated Resident 1 did not have the capacity to understand and make decisions. A review of a "Change of Condition (COC) note, dated 9/13/18, indicated at 8 a.m., on the same day ,Resident 1 was observed with a right lateral lower leg skin tear. The COC note indicated when Resident 1 was asked how did she sustained a skin tear, Resident 1 could not answer. A review of an Interdisciplinary Team ([IDT] a meeting with multi-disciplines to develop care that meets the patient needs and goals) Conference Record, dated 9/14/18, indicated Resident 1 was confused, but could understand and be understood at times. The IDT note indicated Resident 1's right lower leg skin tear was due to hitting the wheelchair footrest, which had Resident 1's leg "caught up." The IDT's plan included removing the foot pedals from Resident 1's wheelchair. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GY0U11 Facility ID: CA910000047 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 05/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's "Fall Assessment," dated 10/24/18, four months later, had improved which indicated Resident 1 had a score of 9. A review of Resident 1's "Admission Assessment, dated 10/24/18, after the resident was readmitted, indicated the resident was assessed as being unsteady while standing and required total assistance from the staff with transferring and bed mobility. A review of Resident 1's "Side Rail Evaluation," dated 10/24/18, indicated the resident required assistance with transferring, ambulation, and bed mobility. A review of Resident 1's plan of care, dated 10/24/18 and titled, "Falls Risk Prevention and Management, Patient at risk for falls related to limited mobility, due to lack of awareness, cognitive (thought process) deficit, and unsteady gait. The staff's interventions included for the staff to provide Resident 1 with an environment that minimized hazards over which the facility had control; the bed in a low position and frequent visual checks as often as needed. The care plan also had the use of floor mats as an option, but had a line drawn through it to indicate it was not being implemented. A review of the Situation, Background, Appearance and Review ([SBAR] an internal communication tool) dated 12/20/18, indicated at 8:30 a.m., Resident 1 fell, an assessment was completed and Resident 1 was assisted back to bed and was observed with internal rotation of the right leg. A review of Resident 1's "Post Fall Assessment," dated 12/20/18, indicated the resident's right leg was shorter than the left, it FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GY0U11 Facility ID: CA910000047 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 05/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was immobilized (unable to move) and Resident 1 had pain to the right leg of 8 on a pain scale with 10 being the worse pain. The Post Fall Assessment indicated the intrinsic (natural) factors that determined the fall occurrence was Resident 1's balance and/or strength and the extrinsic (external) factors indicated falling during a transfer from the wheelchair to the bed. A review of Resident 1's Medication Administration Record (MAR) for the month of 12/2018, indicated Resident 1 received Norco (a narcotic pain medication) 5/325 milligrams (mg), orally for pain on 12/20/18 at 9:30 a.m. A review of Resident 1's Transfer Record, dated 12/20/18, indicated Resident 1 was transported to the GACH for further evaluation and treatment due to right leg pain with an internal rotation ([out of alignment]arms or legs moved toward the center of the body) post fall. A review of the GACH's Nurses' Note, dated 12/20/18 and timed at 4:12 p.m., indicated Resident 1 was admitted to a Medical-Surgical unit from the Emergency Department (ED). A review of the GACH's history and physical (H/P) for Resident 1, dated 12/22/18, indicated Resident 1 underwent an open reduction internal fixation (ORIF) of the right femur (a surgery to repair a broken bone with screws, plates, rods, or pins to hold the broken bones together), as a result of the fall. Resident 1 was hospitalized for a total of five days. A review of the GACH's MAR indicated Resident 1 was administered Dilaudid 1 mg every four (4) hours as needed for pain from 12/20/18 until 12/25/18. On 5/17/19 at 10:15 a.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GY0U11 Facility ID: CA910000047 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 05/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Licensed Vocational Nurse 1 (LVN 1), stated residents who had an unwitnessed fall and constantly gets out of bed or the wheelchair, required safety measures. LVN 1 stated the safety measures included the bed being in the lowest position, fall mats on both sides of the bed, and for the staff to keep an eye on the residents who were at risk for falls. LVN 1 was asked how are the residents who were at risk for falls supervised, LVN 1 stated frequent supervision should be performed by all staff, especially the LVNs and Certified Nursing Assistants (CNAs). LVN 1 further stated when a resident falls continuously, a review of the resident's medications would be required, as well as an IDT meeting. At 12:27 p.m., on 5/17/18, during an interview, the Director of Nursing (DON) stated the facility did not have a fall program. The DON was asked how were resident falls prevented, the DON stated by placing the beds in the lowest position, and conducting one hour to two (2) hour visual checks on the residents, the DON was unable to indicate the amount of residents who required visual monitoring. The DON stated the visual monitoring log was implemented in 4/2019. During a concurrent interview and record review of the facility's hourly visual monitoring log, dated for the month of 4/2019, the DON stated the visual monitoring log did not indicate any residents' names or room numbers. The DON was asked what fall prevention measures did the facility have in place prior to 4/2019, the DON stated placing residents back to bed after breakfast for napping purposes, changing and checking residents. On 5/17/19 at 12:55 p.m., LVN 2 stated for residents who were at risk for falls and had an unwitnessed, a safe environment was provided by supervision with visual monitoring, a low bed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GY0U11 Facility ID: CA910000047 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 05/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and floor mats to prevent an additional fall. LVN 2 stated Resident 1 had an unsteady gait and required staff assistance and did not have any floor mats prior to falling. On 5/17/19 at 1:45 p.m., during an interview, the DON was asked how did the facility prevent residents from falling and when the facility did not have a fall prevention program, the DON stated the residents who were at risk for falling were transferred to a wheelchair during the day, placed close to the nurses' station and/or in activities. The DON further stated residents who were constantly walking unattended would be placed on one-on-one monitoring. b. A review of the Resident 2's Admission Record indicated the resident was initially admitted to the facility on 10/28/18 and last readmitted on 2/9/19. Resident 2's diagnoses included muscle weakness, other abnormalities of gait and mobility, epilepsy (a brief episode of uncontrolled body jerking and loss of mental awareness) and a history of falling. A review of Resident 2's MDS, dated 11/4/18, indicated Resident 2 had a BIMS score of 10 with a moderately impaired cognition, an unsteady gait with only the ability to stabilize with staff assistance. According to the MDS, Resident 2 required a one-person physical assist with transferring and walking with an assistive device. The MDS indicated Resident 2 had a fall within a month prior to admission to the facility. A review of Resident 2's "Admission Assessment," dated 10/28/18, indicated the resident was assessed as having a history of falls within the past six (6) months, having poor safety judgement and required limited assistance with transferring, ambulating and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GY0U11 Facility ID: CA910000047 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 05/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE bed mobility. A review of Resident 2's "Fall Assessment," dated 10/28/18, indicated Resident 2 had a total score of 14. According to the Fall Assessment, a total score of 10 or more represents a high risk. A review of Resident 2's care plan, dated 10/28/18 and titled, "Fall Risk Prevention and Management for poor balance, lack of awareness, unsteady gait, engages in independent transfer/ambulation despite of explanation of risk and a history of falls. The staff interventions included for the staff to provide an environment that supports minimized hazards, which included low bed, call light in reach, remind the resident to use the call light and monitor for side effects of medications. A review of Resident 2's "Weekly Summary," dated 1/18/19, indicated the resident was assessed as requiring a one-person physical assist with transferring. A review of Resident 2's Post Fall Assessment," dated 1/22/19, indicated "The resident (Resident 2) was unable to indicate a level of pain and move extremities without pain and first aid was not provided [sic]." A review of Resident 2's untimed SBAR note, dated 1/22/19, indicated the resident was found on the floor after losing his balance while attempting to go to the bathroom. According to the SBAR, the physician was notified at 7:40 p.m. and gave an order to transfer Resident 2 to the GACH and administer Norco for pain. A review of the "Resident Transfer Record," dated 1/22/19, indicated Resident 2 had severe pain to the right leg and knee. The transfer FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GY0U11 Facility ID: CA910000047 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 05/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE record indicated Resident 2 was administered Norco 5/325 mg, one tablet orally, and was transferred to a GACH. A review of Resident 2's "Therapy Post-Fall Screen," dated 1/23/19 and timed at 5:45 p.m., indicated Resident 2 did not have any root cause related to falling. A review of Resident 2's "IDT Conference Note," dated 1/23/19, indicated Resident 2 ambulated independently unsupervised and lost his balance and fell while attempting to go to the bathroom. A review of the GACH's physicians' progress note, dated 1/23/19, indicated Resident 2 had x-rays of the right hip secondary to right hip pain. The x-ray report indicated a displaced intertrochanteric (where the thigh and hip connect) fracture of the proximal (center) right femur. The physician's progress note indicated Resident 2 underwent surgery of a corrective surgery with an intramedullary rod placed into Resident 2's right femur and required a 7-day hospital stay. On 5/17/19 at 10:10 a.m., during an interview, LVN 3 stated Resident 2 ambulated slowly and possibly had some type of physical foot deformity (abnormality) and fell during the night. A review of the facility's revised policy, dated 11/7/18 and titled, "Fall Management Program," indicated the resident's risk for fall was assessed by a Licensed Nurse by completing the Admission Assessment form and by the IDT utilizing the Resident Assessment Instrument (RAI) process quarterly, annually, and significant change in condition identification. According to the policy, indicated residents who sustains multiple falls as defined FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GY0U11 Facility ID: CA910000047 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 05/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE as more than one fall in a day, week, or month, will be considered a high risk and as a result may sustain a major injury, these residents may require more frequent observation of activities and whereabouts. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GY0U11 Facility ID: CA910000047 If continuation sheet 10 of 10