Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Millbrae Care Center during CMS and state inspections, most recent first.
Late and Incomplete MDS Submission: The facility failed to complete and transmit multiple MDS assessments on time for several residents. Some quarterly and annual MDSs were completed late, others remained in progress past required deadlines, and several records were submitted late to CMS. An MDS nurse confirmed delays for multiple residents, including assessments that were still not finalized or transmitted when reviewed.
Delayed Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments within the required timeframe for multiple residents. Several quarterly assessments were signed well after the ARD, and multiple assessments were still marked in progress when reviewed. During interview, the MDS nurse acknowledged that the assessments should have been completed and signed earlier, and that in-progress assessments were not completed.
A resident with limited mobility and ordered RNA services had no care plan addressing ROM or the restorative program, despite being discharged from therapy and placed on RNA for ambulation, AROM, bed mobility, transfers, and sit-to-stand. Another resident was observed receiving oxygen at 5 L/min even though the care plan and MD order specified 2 L/min via NC for COPD; an LVN stated the flow was sometimes increased when the resident said it was not enough.
Improper medication labeling and storage were observed in medication carts and the medication room. An opened bottle of Dabigatran etexilate, an opened multi-dose vial of Heparin sodium, and two opened vials of Tubersol were found without open or use-by dates. Surveyors also found residents’ valuables and staff personal items, including a pouch, jewelry, hearing aid, dentures, cellphones, charger, eyeglasses, an iPad, and foreign currency, stored in controlled med compartments of medication carts. The DON stated personal belongings should not be kept in the med cart.
Failure to Report Allegation of Abuse: A resident with impaired cognition and multiple medical diagnoses alleged that a worker inserted a finger into her rectum during care, causing pain and screaming. The concern was raised by the daughter after discharge, but the allegation was not documented as reported or investigated, and the Administrator confirmed it should have been reported even though the resident had already left the facility.
Failure to Investigate Allegation of Abuse: A resident with moderately impaired cognition and diagnoses including DM2, Alzheimer's disease, and a recent fracture reported that two workers were cleaning her when one inserted a finger into her rectum, causing pain and screaming. The allegation was brought to the DSD, but the RNS could not find documentation that it was reported or investigated, and the Administrator confirmed the incident was not investigated.
Failure to Notify Ombudsman During Resident Discharge: A resident with cellulitis of the back and depression left the facility after going out without an OOP form and later signed out AMA. RN stated staff and the SW tried to keep the resident for wound care needs, but no Ombudsman notification was sent and the required form could not be found.
A facility failed to complete annual MDS assessments within the required 14-day window after the ARD for two residents. An RN assessment coordinator signed one assessment 83 days after the ARD and another 26 days after the ARD, and the MDS nurse confirmed both were completed late during record review and interview.
Failure to complete SCSA for a resident enrolled in hospice. A resident with heart failure, HTN, and dementia was admitted to hospice, and the MDS nurse stated the SCSA should have been completed within 14 days of hospice admission. The assessment was instead signed complete much later than required.
Failure to Collaborate With Hospice on Resident Care Plans: Two residents receiving hospice services did not have hospice care plans developed in collaboration with the hospice agency. One resident with Alzheimer’s disease and osteoarthritis was observed in a wheelchair and had orders for palliative care and hospice, but the care plan lacked hospice agency information and facility contact details. Another resident with CVA had no hospice care plan and no hospice information in the EHR for staff reference.
Smoking paraphernalia left in resident care areas. The facility allowed two residents who smoked to keep their own lighters and cigarettes in resident rooms and other care areas, despite policy stating residents may not keep even disposable lighters and that smoking items should be secured at the nurses’ station. Staff observed a resident with a disposable lighter on the overbed table and another resident smoking with two lighters, cigarette packs, and a container of dried greenish leaves. Care plans for both residents stated the lighter should be kept by the nursing station.
Two residents with COPD and respiratory treatment orders were not properly supervised during nebulizer therapy. One resident was observed sleeping with the nebulizer tubing on the chest while the machine remained on, and staff stated the resident was left to do the treatment independently. Another resident was seen using a nebulizer without staff present, with the mask not secured, and was later found asleep with the machine still on. Staff interviews confirmed the residents were expected to be supervised until treatments were complete.
Staff failed to follow infection control practices when a CNA handled soiled linens and re-entered a resident room without hand hygiene after removing gloves. In addition, personal items belonging to residents and staff, including jewelry, hearing aids, dentures, cellphones, an iPad, and chargers, were stored in medication cart compartments with medications and controlled items, contrary to the facility's medication storage policy.
Surveyors found that the facility did not develop person-centered care plans for two residents related to smoking and going out on pass, despite active MD orders permitting these activities. One resident with heart failure and diabetes, cognitively intact and independent in ADLs, had orders allowing smoking and passes, but the care plan lacked any related interventions. Another resident with cellulitis, minimal cognitive impairment, and independence in ADLs had an order to smoke, yet no smoking care plan was in place. RN 1 confirmed these omissions during record review, and the Administrator reported that the DON was responsible for ensuring completion of resident care plans, in contrast to the facility’s policy requiring comprehensive, measurable, IDT-developed care plans that address individual needs and risk factors.
A resident with dementia, muscle weakness, and gait/mobility abnormalities had two documented fall incidents, but the care plan was not revised to address these events as required by facility policy and practice. The resident was observed alert and in a wheelchair, able to state his name but not his location or reason for being at the facility, and reported feeling sleepy and attempting to walk to use the bathroom at the time of the falls. An LVN stated that care plans should be initiated and updated after changes in condition such as falls, yet both interviewed LVNs confirmed the resident’s care plan did not reflect the recent falls and reported they had not received in-service training on care planning, despite the DON and DSD being responsible for such education under facility policy.
Due to insufficient social work staffing, required IDT care conferences were not conducted for multiple residents over several months. As a result, residents and their families were not included in regular care planning discussions, and updates on care plans and medications were not communicated as required by facility policy.
Staff did not consistently mark or track residents' personal belongings, resulting in missing items for three residents. Clothing was not labeled, and inventories were not updated as required, leading to unaccounted-for possessions and confusion about ownership. Interviews confirmed that several personal items were missing for extended periods before some were recovered.
The facility failed to maintain infection control for three residents. A CNA did not wear a gown for a resident on Enhanced Barrier Precautions, a mattress was not sanitized after a CNA stepped on it, and a blood pressure cuff was not disinfected between uses for multiple residents. The staff involved were aware of the protocols but did not follow them due to misunderstandings and lack of training.
The facility failed to enforce its smoking policy, allowing residents to smoke in non-designated areas without necessary safety equipment. Two residents, both with intact cognition, kept their smoking materials, including lighters, against policy. Staff interviews revealed that residents often smoked in front of the building due to the designated area being too far, and there was uncertainty about fire safety equipment in these areas.
A facility failed to complete a discharge MDS assessment for a resident discharged to a hospital. The resident had a complex medical history and was expected to return after a hospital stay. The MDS Coordinator did not complete the assessment, assuming the resident would return. The DON and Administrator were unaware of the oversight, despite policies requiring timely completion of discharge assessments.
A facility failed to accurately code a resident's behavioral symptoms on the MDS, despite documented incidents of hitting, scratching, and taking items. The resident, with a history of dementia and psychotic disorder, exhibited these behaviors during the seven-day look-back period, but the MDS did not reflect them. Staff interviews confirmed the presence of these behaviors, highlighting a lapse in adherence to the facility's MDS accuracy policy.
A facility failed to resubmit a Level I PASRR for a resident with schizophrenia after receiving a letter indicating a Level II evaluation was not scheduled. The resident's PASRR Level I screening was positive, but the case was closed incorrectly by the state, as the resident had not been discharged. Interviews with staff revealed that the facility did not complete another PASRR, leading to the deficiency.
A resident with impaired vision was left with medications at their bedside without being assessed for self-administration. The RN left the medications, stating the resident preferred to take them after breakfast, contrary to facility policy. The resident, who had a history of legal blindness and other health issues, admitted to forgetting to take their medication, highlighting the risk of this practice. Interviews revealed staff were unaware of the policy requiring assessments for self-administration.
A resident with a history of epilepsy had an order to check their Keppra level every six months, but the facility failed to obtain the test in the required timeframe. Despite the Keppra level being checked in March and found within the therapeutic range, no follow-up test was conducted in September as ordered. Interviews with staff, including the LVN, MD, and DON, indicated an expectation for compliance with physician orders, but the test was not performed.
A facility was found non-compliant with regulations limiting resident room capacity to four residents. Room [ROOM NUMBER] had six beds but was occupied by four residents. The facility requested a waiver, citing adequate space per resident, but lacked a policy on room variances. The DON noted no prior citation for this issue, and the Administrator confirmed a waiver application was submitted.
The facility failed to ensure that RNs conducted post-fall assessments for several residents after fall incidents. Instead, LVNs performed these assessments, which is outside their scope of practice as they should operate under RN supervision. This deficiency could potentially harm resident safety and well-being.
A resident with multiple health conditions did not receive necessary social services due to the absence of a social worker for several weeks. The facility lacked a contingency plan, resulting in no social services documentation for the resident during their stay, as confirmed by the DON and SSD.
The facility failed to effectively assess and address a resident's weight loss, resulting in a gradual, unintended, progressive weight loss over time. Despite the resident's frequent walking and good meal consumption, the recommended nutritional supplements and interventions were not administered, and the care plan was not updated. Inconsistent documentation and a backlog in social services further contributed to the issue.
The facility failed to provide preventive treatment and services to maintain and improve ROM for 18 residents. Despite physician orders for an RNA Program, the program was not implemented, potentially limiting residents' ROM and leading to contractures. Interviews with staff confirmed the RNA program had not been in place since October.
The facility failed to implement its Restorative Nursing Assistant (RNA) Program, resulting in non-compliance with F688. The absence of RNAs since October 2023 was not addressed during QAPI meetings, potentially limiting residents' range of motion and leading to contractures. The Director of Nursing was unavailable for an interview.
The facility failed to respond to a resident's call for assistance in a timely manner, resulting in a resident waiting over half an hour for peri-care. Additionally, the facility did not ensure a functional communication system for 17 residents, as call lights in their bedrooms were broken, preventing them from calling for help.
The facility failed to maintain a safe and sanitary environment in shower room [ROOM NUMBER], which was found with mold, exposed rusty metal, and various substances on the walls and floor. Staff interviews revealed that this was the only shower room in use, leading to infrequent showers for residents and inadequate cleaning due to understaffing.
A resident with multiple medical conditions had to wait half an hour for peri-care, despite the facility's policy to promptly respond to call lights. The resident and his wife reported consistently slow response times, and the Infection Preventionist did not provide an explanation for the delay.
The facility failed to provide tissue paper for a resident with multiple medical conditions for two days, despite the resident's requests and the availability of the Supply Supervisor to retrieve supplies if notified.
A resident with multiple diagnoses experienced a fall resulting in a traumatic brain injury, which was not reported to the State Agency as required by the facility's policy. The incident led to significant medical intervention, including surgery and transfer to another rehab center.
A resident with a history of stroke, dysphagia, dementia, epilepsy, and sepsis experienced significant weight loss, but the facility failed to update the care plan with new interventions since 2019. Despite an IDT meeting noting the weight loss, the recommended interventions were not included in the care plan, and the weight loss was not adequately addressed in subsequent assessments.
The facility failed to provide OT services to a resident with multiple diagnoses, despite a physician's order. The resident did not receive any OT treatments between 9/3/22 and 9/11/22, and the facility lacked a policy and procedure for rehabilitation services.
The facility failed to comply with the regulation limiting the number of residents per room to four, as one room was observed to contain six residents. The room was dark, crowded, noisy, and lacked privacy, with visitors contributing to the lack of space. One resident expressed frustration with the situation. The Administrator planned to apply for a room waiver to allow the six-resident room.
Late and Incomplete MDS Assessment Submission
Penalty
Summary
The facility failed to ensure accurate and timely encoding and transmission of resident MDS assessments for 18 of 116 sampled residents. Record review and interviews showed that multiple quarterly and annual assessments were either completed late, remained in progress past required timeframes, or were transmitted late to the CMS database. For Resident 71, the quarterly MDS with an ARD of 2/12/26 was completed on 2/13/26 but not transmitted until 5/5/26. For Resident 16, the quarterly MDS with an ARD of 1/31/26 was completed on 2/2/26 and transmitted on 4/23/26. The MDS nurse also identified other assessments that were still in progress, including Residents 28, 94, and 151, and noted that Resident 15’s quarterly MDS due 11/24/25 was completed 12/8/25 and accepted 1/22/26. Additional review of Final Validation Reports showed late submissions for Residents 6, 110, 130, 14, and 80, with several records indicating that a prior assessment could not be found within the required look-back period. During interview, the MDS nurse stated that Resident 15’s annual assessment was due 2/24/26 with an ARD of 3/1/26, but it was still in progress in May 2026 and not completed or submitted. The report also noted that Resident 151’s annual assessment had been completed, but the quarterly assessment remained in progress, and that the facility had a new MDS nurse working on these assessments.
Delayed Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure quarterly MDS assessments were completed at least every 92 days following the previous OBRA assessment for six of 19 sampled residents. Resident 71’s quarterly MDS had an ARD of 11/14/25 but was not signed complete until 12/17/25, and the MDS nurse stated it should have been completed and signed on 11/27/25. Resident 73’s quarterly MDS had an ARD of 8/28/25 and was signed complete on 10/30/25; the MDS nurse stated it should have been completed and signed on 9/11/25. Resident 94’s quarterly MDS with an ARD of 11/25/25 was signed complete on 12/15/25, and another quarterly MDS for the resident with an ARD of 2/25/25 was still in progress. Resident 111’s quarterly MDS with an ARD of 8/28/25 was signed complete on 10/30/25, and another quarterly MDS with an ARD of 2/19/26 was in progress. Resident 121’s quarterly MDS with an ARD of 8/27/25 was signed complete on 10/29/25, and another quarterly MDS with an ARD of 2/23/26 was in progress. Resident 16’s quarterly MDS with an ARD of 10/31/25 was signed complete on 1/12/26. The Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual states that the quarterly assessment must be completed at least every 92 days following the previous OBRA assessment of any type, and that the MDS completion date must be no later than 14 days after the ARD. During interview and record review, the MDS nurse acknowledged that several of the quarterly assessments should have been completed and signed earlier than they were, and stated that assessments marked in progress were not completed.
Care Plans Not Developed or Followed for ROM and Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement person-centered care plans for Resident 12 and Resident 130. Resident 12 was admitted with diagnoses including UTI, gram-negative sepsis, polyneuropathy, muscle weakness, a pressure ulcer of the right heel, and gait and mobility abnormalities. The MDS dated 4/9/24 indicated moderate cognitive impairment, impairment of both upper extremities, and dependence on two or more helpers for walking and chair/bed-to-chair transfers. Although Resident 12 was discharged from therapy and placed on the RNA program on 3/25/26, the active orders included RNA services for ambulation with a front wheeled walker, AROM to both upper and lower extremities, bed mobility and transfers, and sit-to-stand three times per week or as tolerated. Review of the care plan showed these RNA orders were not addressed, and RN 2 confirmed there was no care plan outlining the resident’s limited ROM or the ordered RNA services. Resident 130 was observed receiving oxygen at 5 L/min during the initial pool observation. During interview, LVN 2 stated the resident was using 2 L of oxygen therapy but sometimes asked to increase it because it was not enough, and when the oxygen level was checked it was noted to be at 4 L; LVN 2 stated it should be supervised and checked frequently. The care plan for Resident 130 indicated oxygen therapy at 2 L/min via nasal cannula with humidification, and the physician order dated 1/28/2026 indicated oxygen inhalation via nasal cannula for COPD. The facility policy on oxygen administration stated that excessive flow rates are to be avoided and noted that a nasal cannula may deliver as much as 40% oxygen at 5 L/min.
Improper Medication Labeling and Storage
Penalty
Summary
Drugs and biologicals in the facility were not labeled and stored according to accepted professional principles and the facility’s policy. During inspection of Medication Cart #4, a bottle of Dabigatran etexilate and a multi-dose vial of Heparin sodium were found opened without open or use-by dates. LVN 1 confirmed both items were opened and undated, and stated that Heparin should be discarded after 28 days while Dabigatran follows the manufacturer’s expiration date. The manufacturer’s instructions reviewed by surveyors stated that Dabigatran must be used within 4 months once opened and kept tightly closed in the original package, and that punctured multi-dose Heparin vials must be dated and discarded within 28 days. Surveyors also observed personal items stored in the controlled medication compartments of Medication Carts #4 and #1, including a pouch, jewelry, a hearing aid, dentures, cellphones, a cellphone charger, eyeglasses, an iPad, batteries, and foreign currency. LVN 1 and RN 3 confirmed the items were residents’ valuables, and LVN 1 stated that the currency was kept in the medication drawer as good luck. In Station 1’s medication storage room, two vials of Tubersol in the refrigerator were opened and undated, and RN 3 stated the solution should be discarded 28 days after opening. The DON stated that personal belongings should not be kept in the medication cart because of concerns about infection control and the risk of drug diversion.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Survey Agency as required by facility policy and federal regulations. The resident was admitted with diagnoses including a heart attack, urinary tract infection, type 2 diabetes, a left lower leg closed fracture, and Alzheimer's disease, and the MDS indicated moderately impaired cognition. A progress note documented that after the resident was discharged home with her daughter, the daughter raised a concern and asked staff to speak directly with the resident about what happened. The resident stated that between Monday and Thursday of the prior week, two workers came to her room to clean her and one worker inserted his finger into her rectum so hard that she screamed; she said it hurt very badly, that she was in pain, and that when he removed his finger he showed it to her and said she had a lot of stool. The note stated the concern was brought to the DSD and the daughter was assured a follow-up would be done, but the RNS could not locate documentation that the allegation had been reported or investigated, and the Administrator stated they were not aware of the allegation and confirmed it should have been reported regardless of the resident's discharge.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of abuse involving a resident who was admitted with diagnoses including a heart attack, urinary tract infection, type 2 diabetes, a left lower leg closed fracture, and Alzheimer's disease. The resident's MDS indicated moderately impaired cognition. In a progress note, the resident was documented as reporting that between Monday and Thursday of the same week, two workers came to her room to clean her and one of the workers inserted a finger into her rectum so hard that she screamed, causing pain. The resident stated that when the finger was removed, the worker showed it to her and said, "you have a lot of poop," and that she told him not to touch her again. The allegation was brought to the DSD, and the daughter was told the facility would follow up on the incident. However, during interview and record review, the RNS could not locate documentation showing the allegation was reported or investigated, and the Administrator stated they were not aware of the allegation and confirmed it was not investigated. The facility policy required alleged abuse to be reported immediately and investigated within the required timeframe, but the record reviewed did not show that this occurred.
Failure to Notify Ombudsman During Resident Discharge
Penalty
Summary
The facility did not ensure proper notification when a resident was discharged, as Ombudsman notification was not sent when Resident 158 left the facility. Resident 158 was admitted with diagnoses including cellulitis of the back and depression, and RN 1 stated the resident was alert and oriented x4. The resident went out of the facility on 2/2/26 without signing an out-on-pass form, staff attempted to contact the resident and her son without success, and the resident returned on 2/3/26 to gather belongings and stated she did not want to stay. According to RN 1, the social worker and nurse tried to persuade the resident to remain for wound care needs, but the resident decided to leave against medical advice. Police were called before the resident returned, and the resident signed an AMA form acknowledging the consequences of leaving without home health follow-up. Review of the discharge-related documentation showed no notification sent to the Ombudsman, and RN 1 stated there was a specific form for Ombudsman notification but could not find it. The facility policy required notification of the resident and, if known, the family member, surrogate, or resident representative at least 30 days prior to transfer or discharge and included providing the state long term care ombudsman’s name, address, and phone number.
Late Completion of Annual MDS Assessments
Penalty
Summary
The facility failed to ensure that annual MDS assessments were completed within 14 calendar days of the ARD for two sampled residents. For Resident 73, the annual MDS had an ARD of 2/11/26 and was signed complete by the RN assessment coordinator on 5/5/26, 83 days after the ARD. During a concurrent record review and interview on 5/6/26 at 3:06 PM, the MDS nurse reviewed the assessment and confirmed it was completed late, stating it should have been completed and signed on 2/25/26. For Resident 111, the annual MDS had an ARD of 11/28/25 and was signed complete by the RN assessment coordinator on 12/24/25, 26 days after the ARD. During concurrent interview and record review on 5/6/26 at 3:12 AM, the MDS nurse reviewed the quarterly MDS and stated the annual MDS should have been completed and signed on 12/12/25. The report also cited the LTC Facility Resident Assessment Instrument 3.0 User's Manual, which states that the MDS completion date must be no later than 14 days after the ARD.
Failure to Complete SCSA for Resident Enrolled in Hospice
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for Resident 73 after the resident was admitted to hospice care. Resident 73 was admitted to hospice on 11/5/25 with diagnoses including heart failure, high blood pressure, and dementia. The resident’s MDS with an ARD of 11/12/25 indicated that an SCSA was completed when the resident was enrolled to hospice care, but the assessment was not signed as complete until 1/24/26. During interview and record review, the MDS nurse stated that residents placed on hospice need a significant change in status assessment and that it should be completed within 14 days of the hospice admission. The MDS nurse also stated that the SCSA for Resident 73 should have been completed on 11/25/25. Review of the LTC Facility Resident Assessment Instrument 3.0 User’s Manual indicated that an SCSA is required when a terminally ill resident enrolls in hospice and that the MDS completion date must be no later than 14 days from the ARD and no later than 14 days after the determination that the criteria for an SCSA were met.
Failure to Collaborate With Hospice on Resident Care Plans
Penalty
Summary
The facility did not collaborate with Hospice in the plan of care for two residents. Resident 27’s record showed admission with diagnoses including Alzheimer’s disease and osteoarthritis of the knees, and the physician’s orders listed palliative care ordered on 4/22/26 with Hospice under Sutter Health for cerebral atherosclerosis. During observation, the resident was up in a wheelchair, smiling, and not responding to questions. A CNA stated the resident had been her permanent CNA for many years, was now in a wheelchair after a fall, could still walk to the bathroom with assistance, had been under Hospice care since the prior month, ate 100% of meals, had no skin breaks, and that hospice staff came to the facility. RN 1 reviewed the care plan and stated the resident was admitted to Hospice on 4/22/26 as ordered, but the care plan should focus on pain management and comfort and should be in collaboration with the Hospice agency; RN 1 also stated hospice agency information and the facility team member contact person were not in the care plan. Resident 16’s admission record showed hospice care beginning on 3/29/26 with a diagnosis of CVA. During concurrent record review and interview, RN 3 reviewed the resident’s plan of care and stated there was no hospice care plan developed in collaboration with the Hospice agency. RN 3 also stated there was no hospice information in the resident’s electronic health record for facility staff to refer to. The facility policy on Hospice Care stated that when a resident elects hospice care, staff communicate with the hospice agency to establish a coordinated plan of care based on the resident’s needs and living situation, and that the plan of care should reflect participation of the hospice agency, the facility, and the resident and family to the extent possible.
Smoking paraphernalia left in resident care areas
Penalty
Summary
The facility failed to follow its smoking policy and procedures when it allowed two residents who smoked to keep possession of their own lighters and cigarettes inside resident care areas. During observation and interviews, Resident 4 was found with a disposable cigarette lighter on the overbed table beside the bed, and staff stated that Resident 4 kept cigarettes in the room and did not follow the smoking schedule. A CNA assigned to the resident stated that cigarettes and lighters were supposed to be kept at the nurses’ station, but the resident kept them with him and did not inform staff when he wanted to smoke. RN 1 stated that cigarette lighters for smokers should always be kept at the nurse’s station. The facility’s smoking policy stated that residents may not keep even disposable lighters and that all other forms of lighters, including matches, are prohibited. Resident 4’s care plan also stated that the lighter should be kept by the nursing station and that smoking paraphernalia should be secured at all times. Resident 38 was admitted with diagnoses including dementia with other behavioral disturbance, nicotine dependence, high blood sugar, and high blood pressure. The MDS assessment indicated a memory problem and modified independence with daily decision making. During observation, Resident 38 was seen smoking on the patio outside the room and had two lighters, three cigarette packs, and a glass container holding dried, greenish leaves. Resident 38 stated that he kept his own smoking paraphernalia. The MDS nurse stated that, per facility policy, lighters are not allowed at the bedside, and the resident had received education and a copy of the smoking policy and demonstrated understanding. Resident 38’s smoking care plan stated that the lighter should be kept by the nursing station.
Inadequate Supervision During Nebulizer Treatments
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents who were receiving nebulizer treatments. Resident 130 had diagnoses of chronic respiratory failure with hypoxia and COPD and had physician orders for albuterol sulfate via nebulizer every 6 hours while awake, arformoterol tartrate via nebulizer twice daily, and budesonide inhalation suspension via nebulizer twice daily with instructions to rinse the mouth after use. During observation, Resident 130 was found sleeping with the nebulizer tubing on the chest while the machine remained on beside the bed. An LVN stated the resident wanted to do the treatment on his own, that staff did not wait until he finished, and that staff only reminded him to turn off the machine because he often forgot. The LVN was observed giving the respiratory medication and then leaving the resident unattended during the treatment. Another LVN stated it was routine for the machine to remain at the bedside and that the resident did not want it removed. Resident 4 also had COPD and a physician order for ipratropium-albuterol solution via nebulizer every 4 hours as needed for shortness of breath or wheezing. During an initial tour, Resident 4 was awake in bed with the nebulizer on, holding the mask near the nose and mouth with the elastic straps not secured on the ears, and no staff present in the room; the resident turned off the nebulizer independently. On a later visit, Resident 4 was sleeping in bed with the nebulizer machine still on beside the bed. An LVN stated the resident needed supervision by the assigned nurse until nebulizing was done, and a CNA stated the LVN knew when the resident needed nebulizer treatment. The report also noted the resident became agitated when needing medication and nebulizer treatment.
Infection Control Lapses With Hand Hygiene and Medication Cart Storage
Penalty
Summary
The facility failed to implement its infection control program when CNA 4 exited a resident room with an Enhanced Barrier Precaution sign posted, wearing a surgical mask and gloves while carrying a transparent bag of soiled linens, discarded the bag into a soiled-linen hamper, removed gloves, and then re-entered the resident room without performing hand hygiene. During follow-up interview, CNA 4 acknowledged forgetting hand hygiene after handling soiled linens and stated that hand hygiene is required before and after handling soiled linens and when entering or exiting a resident room. The Infection Preventionist stated that staff are required to practice hand hygiene before and after delivering care to residents, when handling soiled linens, and when donning and doffing PPE. The facility policy on Hand Hygiene stated that staff with direct resident contact will use appropriate hand hygiene, including before and after physical contact with resident equipment or personal articles likely to be contaminated and after removing gloves. The facility also stored residents' and staff personal items in medication carts. On Medication Cart #4, a black pouch, a necklace in a blue jewelry container, a hearing aid, and a cellphone were found in the controlled medication compartment, and a printed red pouch containing the LVN's personal belongings was found in the bottom drawer with oral medications. On Medication Cart #1, an iPad, hearing aids, eyeglasses, dentures, batteries, and a cellphone charger were stored in the controlled medication compartment. The LVN and RN confirmed the items were residents' valuables, and the DON stated that personal belongings should not be kept in the medication cart because of infection control concerns and the risk of drug diversion. The facility policy on Storage of Medication stated that the medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications.
Failure to Develop Person-Centered Care Plans for Smoking and Pass Privileges
Penalty
Summary
Surveyors identified a failure to develop person-centered comprehensive care plans addressing smoking and going out on pass for two residents. For the first resident, who was admitted with heart failure and diabetes and was assessed on the MDS as cognitively intact and independent in all ADLs, physician orders dated in January 2026 authorized the resident to smoke and to go out on pass. During a concurrent interview and record review, RN 1 confirmed that the resident’s care plan did not contain any interventions or approaches related to smoking or going out on pass, despite these active physician orders. For the second resident, who was admitted with cellulitis of the back and assessed on the MDS as having little to no cognitive impairment and being independent in all ADLs, physician orders dated in January 2026 also authorized the resident to smoke. During interview and record review, RN 1 confirmed that there was no care plan addressing smoking for this resident. The Administrator stated that the DON was responsible for ensuring resident care plans were completed, but the DON was not available for interview. The facility’s written policy on comprehensive plans of care required development of a comprehensive, measurable, interdisciplinary care plan that addresses resident needs, strengths, preferences, and risk factors, and is periodically reviewed and revised with resident participation.
Failure to Revise Care Plan After Resident Fall Incidents
Penalty
Summary
The facility failed to update the person-centered care plan for a resident after two fall incidents, as required by its policies and regulatory standards. The resident had diagnoses including dementia, muscle weakness, and abnormalities in gait and mobility. Interdisciplinary Team notes documented that the resident experienced two falls on 1/14/26. During an observation and interview, the resident was alert, verbally responsive, and sitting in a wheelchair in the hallway, able to state his name but unable to identify his current location or the reason for residing in the facility. When asked about the falls, the resident reported feeling sleepy, attempting to walk, and needing to use the bathroom at the time of the incidents. In interviews, LVN 1 stated that care plans are initiated when there is a change in condition such as a fall and that care plans are reviewed and updated after each fall, but also stated she had not received in-service training on care planning. LVN 2, upon reviewing the resident’s care plan, confirmed that it did not address the two fall incidents. LVN 2 also stated she had not received in-service training on care planning. The Administrator reported that the DON and DSD were responsible for providing in-services to licensed nurses, but they were not available for interview. Facility policies on person-centered plans of care and post-fall management required that care plans reflect current standards of practice, include interventions to manage risk factors, and be reviewed and revised by the IDT when changes in the resident’s care and treatment occur, including after falls, but this was not done for the resident following the two fall events.
Failure to Provide Timely Social Services and Care Conferences
Penalty
Summary
Facility staff failed to provide medically-related social services to all sampled residents due to inadequate staffing, specifically having only one social worker on site for approximately three months. During this period, the social worker was unable to coordinate and conduct required interdisciplinary team (IDT) care conference meetings for at least 14 residents. These meetings are essential for discussing and managing resident care, involving various healthcare professionals and family members or responsible parties. A review of medical records revealed that the last IDT/care conference for the affected residents occurred between six to eight months prior, well beyond the required quarterly interval. Interviews with staff confirmed that the social worker was solely responsible for scheduling and coordinating these meetings, and the workload prevented timely completion. The administrator acknowledged that daily standup meetings, which addressed acute care issues, did not substitute for the comprehensive discussions held during IDT/care conferences, especially for chronic or ongoing care needs. Additionally, a family member of one resident reported not being invited to recent IDT meetings and not being updated on the resident's plan of care or current medications. Facility policy requires care plan conferences to be held within seven days of the initial assessment, every 90 days thereafter, and with any significant change in resident status or condition. The failure to conduct these meetings as required resulted in residents not receiving appropriate and personalized care planning.
Failure to Safeguard and Track Residents' Personal Belongings
Penalty
Summary
The facility failed to properly manage and safeguard residents' personal belongings for three out of six sampled residents. Staff did not follow the facility's policy regarding the identification and marking of residents' clothing and personal items. Observations revealed that residents' clothing was not labeled to indicate ownership, and staff were unable to account for items listed on the residents' admission inventories. For example, one resident was admitted with specific clothing items, but at the time of review, only unmarked donated clothing was present, and the original items could not be located. Interviews with residents and their responsible parties confirmed that personal belongings, such as jackets, shoes, sweatpants, and shirts, had gone missing for extended periods. In one case, a resident reported missing a flannel jacket and a shoe, while another resident's responsible party stated that several items had been missing for at least two weeks before some were recovered. Staff were unable to explain the whereabouts of the missing items or why the clothing was not properly marked as required by facility policy. A review of the facility's policy on residents' personal property indicated that while items are to be inventoried and marked upon admission, there was no directive for staff to periodically update the inventory list. The administrator confirmed that the facility did not have a process for regularly updating residents' inventories and relied on families to inform staff when new belongings were brought in. This lack of systematic updating and marking contributed to the loss and mismanagement of residents' personal property.
Plan Of Correction
F 557 Millbrae Care Center makes its best effort to operate in substantial compliance with both Federal and State Law. Preparation and/or execution of this Plan of Correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by provisions of 42 CFR 483, et seq., and Health and Safety Code 1280. In response to the Department's findings, we submit the following Plan of Correction which shall constitute the facility's credible allegation of compliance. The facility has submitted this plan of correction to comply with its regulatory obligation under Title 18 and 19 and to meet the ten (10) days of survey condition mandate. Likewise, the facility does not waive any objections to the merits or form any allegations contained herein. Please note that the facility may contest the merit and/or form of any of the deficiency findings alleged below and may take reasonable steps to appeal them.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for three residents. For Resident #83, who had a history of clostridium difficile and was on Enhanced Barrier Precautions (EBP), a Certified Nursing Aide (CNA) did not wear a gown while providing incontinence care, despite the requirement to do so. The CNA was aware of the need for personal protective equipment (PPE) but mistakenly believed the signage outside the resident's room was for another resident. This oversight occurred despite the presence of gowns and gloves outside the room and the facility's policy on EBP. In another instance, the facility did not have a policy for sanitizing a mattress on the floor, which was used for Resident #81 due to a history of falls. During an observation, a CNA stepped on the resident's mattress with shoes and did not change the sheets or sanitize the mattress afterward. The CNA acknowledged the mistake but noted a lack of training on maintaining mattress hygiene. The Infection Preventionist and Director of Nursing confirmed that the sheets should have been changed in such situations, but the staff had not been trained for this specific scenario. Additionally, the facility failed to disinfect a blood pressure cuff between uses for multiple residents. A Registered Nurse (RN) used the same cuff on three residents without cleaning it between uses. The RN admitted to forgetting to disinfect the cuff due to nervousness. The Director of Nursing stated that the facility provided two vital sign machines per medication cart to prevent such issues, but it was unclear why the second machine was not used. The Administrator confirmed the expectation for staff to disinfect equipment between resident uses.
Failure to Enforce Smoking Policy and Designated Areas
Penalty
Summary
The facility failed to ensure residents adhered to the designated smoking areas and did not enforce its smoking policy regarding the storage of lighters. The facility's policy, released in June 2022, specified that residents should be informed about smoking limitations and designated areas, and that metal containers with self-closing covers should be available in smoking areas. However, observations revealed that residents were smoking in non-designated areas, such as the garden area near the front door, which lacked necessary safety equipment like ashtrays and fire extinguishers. Two residents, identified as smokers, were found to be keeping their smoking materials, including lighters, contrary to the facility's policy. Resident #39, with a history of tobacco use and intact cognition, stated they smoked wherever they wanted as long as it was 25 feet from the doorway and kept their own smoking materials. Similarly, Resident #106, with a diagnosis of nicotine dependence and intact cognition, also kept their smoking materials, including a lighter, with them. Both residents were assessed as safe smokers, yet they did not adhere to the designated smoking area. Interviews with staff, including CNAs, RNs, and the DON, revealed a lack of enforcement of the smoking policy. Staff acknowledged that residents often smoked in front of the building due to the designated area being too far, especially for those with mobility issues. The DON and Administrator confirmed the designated smoking area was out back but admitted that residents frequently smoked out front. The facility's approach to managing this issue was limited to reeducating residents, and there was uncertainty among staff about the presence of fire safety equipment in the non-designated smoking areas.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a discharge Minimum Data Set (MDS) assessment for a resident who was discharged to a hospital. The resident, who had a medical history including pressure ulcers, type two diabetes mellitus, acute kidney failure, essential hypertension, difficulty walking, and a history of falling, was admitted to the facility in October 2023 and discharged to an acute care hospital in August 2024. Despite the resident's discharge, the facility did not complete the required discharge MDS assessment within the stipulated timeframe, resulting in a deficiency. The MDS Coordinator, responsible for completing discharge MDS assessments, did not complete the assessment for the resident, as she assumed the resident would return to the facility after a hospital stay. The Director of Nursing and the Administrator both expected MDS assessments to be completed timely and according to the schedule, but were unaware that the discharge MDS was not completed. The facility's policy and the CMS Long-Term Care Facility Resident Assessment Instrument Manual require discharge assessments to be completed when a resident is discharged to a hospital, which was not adhered to in this case.
Inaccurate MDS Coding for Resident Behaviors
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident was accurately coded to reflect the presence of behavioral symptoms during the seven-day look-back period. The resident, who had a medical history including adjustment disorder, senile degeneration of the brain, psychotic disorder with hallucinations, and dementia, exhibited behaviors such as hitting, scratching, and taking items from the nurses' station. Despite these documented behaviors, the quarterly MDS assessment did not reflect any physical or verbal behavioral symptoms or rejection of care. Interviews with staff, including Certified Nursing Aides (CNAs) and the Director of Nursing (DON), confirmed that the resident exhibited behaviors that should have been coded on the MDS. The facility's policy on MDS accuracy required that the interdisciplinary team verify coding accuracy, but this was not adhered to in this case. The failure to accurately code the resident's behaviors on the MDS was identified during a review of the resident's medical records, progress notes, and interviews with facility staff.
Failure to Resubmit PASRR for Resident with Schizophrenia
Penalty
Summary
The facility failed to resubmit a Level I Preadmission Screening and Resident Review (PASRR) for a resident after receiving a letter indicating that a Level II Mental Health Examination was not scheduled. The resident, who was admitted to the facility with a diagnosis of unspecified schizophrenia, had a positive Level I PASRR screening completed by a local hospital. However, the State of California Department of Healthcare Services closed the case, stating that a Level II evaluation was not scheduled because the individual was discharged from the facility, which was incorrect as the resident had not been discharged. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), revealed that the facility did not complete another PASRR for the resident. The DON and the Administrator confirmed that the hospital typically completed the PASRR before admission, and the facility accessed the results online. The Administrator stated that if a Level I PASRR was positive, the facility should request a Level II PASRR and respond to recommendations in the Level II results letters. The failure to ensure the completion and accuracy of PASRR paperwork led to the deficiency.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to ensure medications were not left at the bedside for a resident who had impaired eyesight and had not been assessed as safe to self-administer medications. During a medication administration observation, a registered nurse (RN) was seen preparing and placing multiple medications on the bedside table of a resident with impaired vision, who was legally blind and had not been evaluated for self-administration of medications. The RN left the medications with the resident, stating that the resident preferred to take them after breakfast, despite the facility's policy requiring that medications be administered at the time they are prepared and that residents must be assessed as safe to self-administer medications. The resident involved had a medical history that included legal blindness, glaucoma, and other significant health conditions such as hypertension and diabetes. The resident's care plan noted impaired visual function and directed staff to assist in promoting independence by placing items consistently. However, there was no documentation of a self-administration assessment or a care plan indicating the resident was safe to self-administer medications. The resident admitted to forgetting to take their medication the previous night, highlighting the risk of leaving medications unattended. Interviews with facility staff, including the RN and the Director of Nursing (DON), revealed a lack of awareness and adherence to the facility's medication administration policies. The RN was unaware of the requirement for a special assessment before leaving medications with residents, and the DON confirmed that staff had been instructed not to leave medications at the bedside. The facility's administrator also emphasized the expectation that nurses ensure residents take medications as ordered and return them to the medication cart if not taken immediately.
Failure to Obtain Timely Laboratory Services for Keppra Level Monitoring
Penalty
Summary
The facility failed to obtain timely laboratory services for a resident who had an order to check their Keppra level every six months. The resident, who had a medical history of convulsions and epilepsy, was admitted to the facility with an order to administer Keppra 1000 mg twice daily for seizures and to check the Keppra level every six months. Although the Keppra level was checked in March 2024 and found to be within the therapeutic range, there was no documented evidence that the facility obtained another Keppra level in September 2024, as required by the physician's order. Interviews with facility staff, including the LVN, Medical Director, and DON, revealed that there was an expectation for nursing staff to follow through with physician orders for laboratory testing. The LVN mentioned that laboratory orders should be visible in the resident's electronic medical record to ensure compliance. The Medical Director and DON both expressed that the facility should have obtained the Keppra level as ordered. The Administrator also stated that nursing staff were expected to follow standing orders for laboratory tests.
Non-compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with the regulatory requirement that resident rooms hold no more than four residents. Room [ROOM NUMBER] was equipped with six beds, although it was occupied by only four residents at the time of the survey. The facility had requested a waiver from the California Department of Public Health to allow more than four residents per room, citing that the room had 86 square feet per resident and a total floor area of 544.7 square feet. Despite this, the facility did not have a policy addressing room variances, and the Director of Nursing noted that the facility was not cited for this issue during the last recertification survey. The Administrator confirmed that a waiver application had been submitted for the room in question.
Failure to Ensure RN Conducts Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) completed the necessary assessments for seven out of nine sampled residents following a change in their condition, specifically after fall incidents. The review of the facility's fall incidents revealed that these residents experienced falls, and the post-fall assessments were conducted by Licensed Vocational Nurses (LVNs) instead of RNs. This practice was confirmed during interviews with the Director of Nursing (DON) and the Administrator, who stated that LVNs performed the assessments and evaluated the residents for injuries without the presence of an RN. The job description for LVNs, dated May 2017, indicates that they operate under the direct supervision of an RN and are responsible for implementing established care plans, administering medications, and performing treatments. However, the scope of their practice includes basic assessment and data collection, which does not extend to the comprehensive assessments required after a change in a resident's condition, such as a fall. This deficiency in practice has the potential to harm resident safety and well-being, as the assessments were not conducted by the appropriately qualified personnel.
Absence of Social Worker Leads to Deficiency in Resident Care
Penalty
Summary
The facility failed to provide medically-related social services to a resident due to the absence of a social worker from April 22, 2024, to May 10, 2024. During this period, Resident 1, who was cognitively intact and had diagnoses including peripheral vascular disease, heart failure, and diabetes mellitus, did not receive necessary social services. The resident was admitted, transferred to a hospital, readmitted, and then discharged again to the hospital without the assistance of a social worker. Interviews with the Ombudsman and the complainant confirmed the absence of a social worker during this time, and the Director of Nursing (DON) acknowledged the lack of a contingency plan for the social worker's absence. The facility's organizational chart indicated that the social service was directly under the Administrator, and the facility's policy outlined the social worker's role in meeting the psychosocial needs of residents and families. Despite this, there were no social services notes for Resident 1 during their stay, as verified by the DON and the newly hired Social Services Director (SSD). The SSD described the range of services typically provided, including discharge planning, psychosocial support, and grievance resolution, none of which were documented for Resident 1 during the period in question.
Failure to Address Resident's Weight Loss
Penalty
Summary
The facility failed to effectively assess and address the weight loss of Resident 19, who experienced a gradual, unintended, progressive weight loss over time. Despite the facility's policy requiring immediate action for significant weight changes, Resident 19's weight loss was not adequately monitored or managed. The resident, who had dementia and osteoarthritis, was observed to be active and eating well, yet her weight continued to decline. The facility's staff, including CNAs and LVNs, noted her frequent walking and meal consumption but did not follow through with the recommended nutritional supplements and interventions. The RD's notes indicated a significant weight loss, but the care plan was not updated accordingly, and the supplements were not administered as prescribed. Additionally, the facility's documentation practices were inconsistent, with numerous omitted entries in the CNA flow sheets and a lack of follow-up on the RD's recommendations. The social services department also had a backlog, and the last care conference for Resident 19 was held in 2022. The facility's failure to address these issues resulted in Resident 19's continued weight loss without appropriate intervention or documentation.
Failure to Implement Restorative Nursing Assistant Program
Penalty
Summary
The facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM) for 18 residents. Despite physician orders for a Restorative Nursing Assistant (RNA) Program, the program was not implemented for any of the residents. This failure had the potential to limit the residents' ROM and possibly lead to the development of contractures, which could interfere with their daily functioning. Resident 1, who was admitted with rheumatoid arthritis and muscle weakness, reported that there had been no RNA services for months. The resident had to request a physician's order for physical therapy due to the lack of RNA services. Similarly, Resident 2, who had difficulty walking and a history of a left femur fracture, stated that no one helped them exercise, and the RNA program was not implemented for several months. Other residents, including those with diagnoses such as muscle weakness, epilepsy, repeated falls, and osteoarthritis, also did not receive the RNA services as ordered. Interviews with staff confirmed that the RNA program had not been in place since October, and no one had stepped up to fill the role. The facility's standards for the Restorative Nursing Program were not followed, leading to a significant lapse in care for the residents involved.
Failure to Implement Restorative Nursing Assistant Program
Penalty
Summary
The facility failed to implement its plan of action to correct the identified deficiency regarding the Restorative Nursing Assistant (RNA) Program. This failure resulted in non-compliance with F688, which had the potential to limit residents' range of motion (ROM) and possibly lead to the development of contractures. During an interview, the Administrator acknowledged that there had been no Restorative Nurse Assistants (RNAs) since October 2023, and the issue was not addressed during the Quality Assurance and Performance Improvement (QAPI) meetings. The Director of Nursing was unavailable for an interview. A review of the facility's Policy and Procedure for the QAPI Program indicated that the facility is required to maintain an ongoing, systematic, and proactive process to improve resident care, outcomes, and safety. The QAPI program is supposed to facilitate an interdisciplinary, interdepartmental collaborative approach to improve the quality of resident life and care. However, the facility's administration and QAPI committee failed to identify and prioritize the problem of the missing RNA program, leading to the deficiency.
Failure to Respond to Call Lights and Ensure Functional Communication System
Penalty
Summary
The facility failed to respond to a resident's call for assistance in a timely manner, resulting in Resident 38 waiting for over half an hour to receive peri-care due to soiled undergarments. Resident 38, who has multiple diagnoses including diabetes, congestive heart failure, and brain disease, expressed that the call light response time has consistently been slow, with wait times usually being 30 minutes or more. The resident's wife corroborated this, stating that he often experiences pain and requires medication, repositioning, or peri-care. The Infection Preventionist was unable to provide a reason for the delay in response time. Additionally, the facility failed to ensure a functional communication system for 17 of 128 sampled residents, as call lights in their bedrooms were found to be broken. This resulted in residents being unable to call for help with their needs or in case of a fall injury. For instance, Resident 1, who has rheumatoid arthritis and muscle weakness, had to yell or make phone calls to the receptionist to get help because her call light had not worked for six months. Similar issues were observed with other residents, including those with severe cognitive impairments and those requiring substantial assistance with activities of daily living. The facility's Policy and Procedure on Answering Call Lights, dated August 2017, and the Policy and Procedure on Equipment Repair and Maintenance, dated December 2016, were not adhered to. These policies emphasize the importance of responding to residents' requests promptly and ensuring the proper functioning of all equipment. Despite these guidelines, the maintenance supervisor acknowledged the nonfunctioning call lights and stated that a new system was being procured, but no immediate corrective actions were taken to address the current deficiencies.
Unsanitary Conditions in Shower Room
Penalty
Summary
The facility failed to provide a safe and sanitary environment in shower room [ROOM NUMBER], which was found unclean and unhygienic. During an observation, all four shower stalls had black and gray substances on the grout, red splatters on the walls, brownish clay smeared on the floor, and exposed rusty sharp pieces of metal. The fabric curtains were damaged with holes surrounded by black substances and brown smears at the bottom. Six large containers were also found inside the shower room. Interviews with staff revealed that this shower room was the only one in use, as the other had been closed for years, making it difficult to shower all residents adequately. The red substance had been present for about three months, and the brown substance on the floor for a week. A resident reported infrequent showers, expressing frustration over the lack of adequate staffing and resources. The Maintenance Supervisor confirmed that shower room [ROOM NUMBER] had been out of service for two weeks due to plumbing issues and was locked without available keys. The room contained mold, and repairs were ongoing. The supervisor also mentioned that the housekeeping staff could not accommodate the cleaning schedule due to understaffing. Another CNA stated that dirty linens and garbage were stored in the shower room until pickup, but was unsure of the pickup schedule. The overall condition of the shower room and the lack of adequate cleaning and maintenance staff contributed to the unsanitary environment, impacting the residents' bathing experience.
Resident Waits Half an Hour for Peri-Care
Penalty
Summary
The facility failed to treat a resident with dignity when the resident had to wait for half an hour to receive peri-care for soiled undergarments. The resident, who was admitted with diagnoses including diabetes, congestive heart failure, brain disease, an open lower leg wound, and liver disease, had a cognition score of 10 and required assistance with toileting hygiene and repositioning in bed. During an observation and interview, the resident and his wife reported that the call light response time was consistently slow, with wait times usually being 30 minutes or more. The Infection Preventionist did not provide a response for the lengthy wait time. The facility's policy on answering call lights, dated August 2017, indicated that steps should be taken to ensure residents' needs and requests are considered and responded to promptly.
Failure to Provide Tissue Paper for Resident
Penalty
Summary
The facility failed to accommodate the needs of Resident 37, who did not speak English, by not providing tissue paper for two days. Resident 37, who had diagnoses including hemiplegia, bed confinement, stroke, diabetes, depressive disorder, and high blood pressure, had been asking for facial tissues over the weekend but was told by staff that none were available. The Supply Supervisor stated that he could have retrieved the supplies if he had been notified. The facility's Central Supply Program policy indicated that supplies should be ordered from approved suppliers and that the Supply Supervisor should be contacted if the required item was not available.
Failure to Report Fall with Injury
Penalty
Summary
The facility failed to promptly report an incident involving a fall with injury to the State Agency as required by their policy. Resident A, who was admitted with multiple diagnoses including lymphoma, spinal cord compression, diabetes, and anemia, experienced a fall on 12/22/23. Despite the initial assessment indicating no severe injury, the resident later complained of a headache and was subsequently sent to the hospital where a traumatic brain injury was diagnosed, necessitating a craniotomy. The incident was not reported to the California Department of Public Health (CDPH) within the required timeframe. Interviews and record reviews revealed that the facility's staff did not follow the established protocol for reporting incidents involving serious bodily injury. The resident's family confirmed that the fall resulted in significant medical intervention, including surgery and transfer to another rehabilitation center. The facility's policy mandates that such incidents be reported immediately, but this was not adhered to, leading to a deficiency in the facility's compliance with state regulations.
Failure to Update Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to identify and document changes in a resident's condition, specifically regarding significant weight loss. The resident, who had a history of cerebral infarction, dysphagia, dementia, epilepsy, and sepsis, experienced weight loss starting on January 12, 2023. Despite an IDT meeting on August 14, 2023, the care plan had not been updated with new interventions since 2019. The resident was admitted to the hospital on November 16, 2023, with septic shock, acute respiratory failure, and acute kidney injury, and returned to the facility on November 30, 2023. The care plan on nutritional problems was revised on November 12, 2023, but no new interventions were added, and the weight loss was not adequately addressed in the care plan or the MDS assessment dated December 7, 2023. Interviews and record reviews revealed that the resident had a significant weight loss of 16 pounds in 180 days, which was noted in the Weight Variance IDT Review on August 14, 2023. However, the interventions recommended, such as a fortified diet and weekly weights, were not found in the care plan. The LVN confirmed that there was no change of condition record for the weight loss in the resident's chart. The facility's Comprehensive Plan of Care indicated that care plans should be re-evaluated and modified as necessary to reflect changes in the resident's status, but this was not done in this case, leading to the deficiency in care for the resident's weight loss and overall condition management.
Failure to Provide Ordered Occupational Therapy Services
Penalty
Summary
The facility failed to provide Occupational Therapy (OT) services to a resident (Resident 20) despite a physician's order. Resident 20, who had diagnoses including atrial fibrillation, diabetes, and diastolic heart failure, was admitted on 8/31/22. An OT evaluation on 9/1/22 indicated a need for therapeutic exercises and self-care management training three to five times a week for four weeks. However, no OT treatments were provided between 9/3/22 and 9/11/22, as confirmed by the Rehabilitation Services Department staff. The Occupational Therapist responsible for the treatment had terminated her employment, and the facility lacked a policy and procedure for rehabilitation services. Interviews with the Infection Preventionist and the Rehab Director revealed that the facility could not locate a policy and procedure for rehab services. The Rehab Director confirmed that the facility should have such a policy. The failure to provide the ordered OT services had the potential for further physical decline in Resident 20 during their stay at the facility.
Facility Exceeds Resident Room Capacity
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to four, as one room was observed to contain six residents. During an observation, the room was described as dark, crowded, noisy, and lacking privacy. Visitors were present, further contributing to the lack of space and privacy, and one resident expressed frustration with the visitors' presence and noise. The room's condition and the number of residents exceeded the acceptable limit, leading to potential issues with privacy, care, and attention for the residents. An interview with the Administrator revealed that she intended to apply for a room waiver to allow the six-resident room. The facility's Quality Assurance and Performance Improvement (QAPI) program, which aims to enhance the quality of care and life for residents, was reviewed. The QAPI program emphasizes safety, high-quality clinical interventions, and resident autonomy and choice. However, the facility's failure to adhere to the room occupancy regulation indicates a lapse in maintaining these standards.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Millbrae
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Peninsula Post-acute | 1 mi | ★★★★★ | 12 | 0 |
| San Bruno Skilled Nursing | 2.4 mi | ★★★★★ | 18 | 0 |
| Linda Mar Care Center | 6.1 mi | ★★★★★ | 0 | 0 |
| Brookside Skilled Nursing Hospital | 6.1 mi | ★★★★★ | 10 | 0 |
| Pacifica Nursing And Rehabilitation Center | 6.4 mi | ★★★★★ | 4 | 0 |
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