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Deficiency Records for Millbrae Care Center
A list of the most recent deficiencies for Millbrae Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Millbrae Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-06-07 | 2024-07-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-11 | 2024-05-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-11 | 2024-05-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-11 | 2024-03-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-11 | 2024-03-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-11 | 2024-03-21 | Y |
| Assess the resident when there is a significant change in condition | Health | 2024-01-11 | 2024-03-21 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-01-11 | 2024-03-21 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-11 | 2024-03-21 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-01-11 | 2024-03-21 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-11 | 2024-03-21 | Y |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2024-01-11 | 2024-03-21 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-01-11 | 2024-03-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-11 | 2024-03-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-03 | 2024-03-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-03 | 2024-03-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-24 | 2023-09-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-24 | 2023-09-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-02 | 2023-08-18 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-28 | 2023-08-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-19 | 2023-07-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-13 | 2023-07-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-13 | 2023-07-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-30 | 2023-04-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-16 | 2023-04-03 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-02-15 | 2023-03-31 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-02-14 | 2023-03-29 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-02-14 | 2023-03-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-14 | 2023-03-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-14 | 2023-03-29 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-02-14 | 2023-03-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-15 | 2023-03-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-01 | 2022-07-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-09 | 2022-05-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-03 | 2022-03-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-03 | 2022-03-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-03 | 2022-03-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-12-03 | 2022-03-10 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-12-03 | 2022-03-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-03 | 2022-03-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-03 | 2022-01-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-03 | 2022-01-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-03 | 2022-01-28 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-12-03 | 2022-01-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-03 | 2022-01-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-03 | 2022-01-28 | N |
| Keep all essential equipment working safely. | Health | 2021-12-03 | 2022-01-28 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-12-08 | 2021-12-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-08 | 2021-12-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-08 | 2021-12-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-08 | 2021-12-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-08 | 2021-12-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-08 | 2021-12-21 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-12-08 | 2021-12-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-08 | 2021-12-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-25 | 2019-10-03 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-07-25 | 2019-10-03 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-07-25 | 2019-10-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-25 | 2019-10-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-25 | 2019-10-03 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-07-25 | 2019-10-03 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-07-25 | 2019-10-03 | N |
| Post nurse staffing information every day. | Health | 2019-07-25 | 2019-10-03 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-07-25 | 2019-10-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-25 | 2019-10-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-25 | 2019-10-03 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2019-07-25 | 2019-10-03 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2019-07-25 | 2019-10-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-25 | 2019-10-03 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-07-25 | 2019-10-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-09-10 | 2019-10-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-10 | 2019-10-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-10 | 2019-10-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-10 | 2019-10-02 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-09-10 | 2019-10-02 | N |
| Keep all essential equipment working safely. | Health | 2018-08-06 | 2019-01-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-06 | 2018-12-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-08-06 | 2018-12-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-08-06 | 2018-12-27 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-08-06 | 2018-12-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-06 | 2018-12-27 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2018-08-06 | 2018-12-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-06 | 2018-12-27 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-08-06 | 2018-12-27 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-11-06 | 2018-11-27 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-11-06 | 2018-11-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-11-06 | 2018-11-27 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-11-06 | 2018-11-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-06 | 2018-11-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-06 | 2018-11-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-11-06 | 2018-11-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-06 | 2018-11-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-06 | 2018-11-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-11-06 | 2018-11-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-08-06 | 2018-11-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-08-06 | 2018-11-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-08-06 | 2018-11-02 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2018-08-06 | 2018-11-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-06 | 2018-11-02 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-08-06 | 2018-11-02 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-08-06 | 2018-11-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-06 | 2018-11-02 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-08-06 | 2018-11-02 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-08-06 | 2018-11-02 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-08-06 | 2018-11-02 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2018-08-06 | 2018-11-02 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2018-08-06 | 2018-11-02 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-08-06 | 2018-11-02 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-08-06 | 2018-11-02 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2018-08-06 | 2018-11-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-06 | 2018-11-02 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-08-06 | 2018-11-02 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-08-06 | 2018-11-02 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-08-05 | Not Fixed | Y |
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