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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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-10-22 | 2024-12-16 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-10-22 | 2024-12-16 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2024-10-22 | 2024-12-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-10-22 | 2024-12-16 | N |
| Use approved construction type or materials. | Fire Safety | 2024-10-22 | 2024-11-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-10-22 | 2024-11-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-10-22 | 2024-11-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-22 | 2024-11-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-10-22 | 2024-11-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-10-22 | 2024-11-22 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-10-17 | 2024-11-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-10-17 | 2024-11-17 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-10-17 | 2024-11-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-10-17 | 2024-11-17 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-10-17 | 2024-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-10-17 | 2024-11-17 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2024-10-17 | 2024-11-17 | N |
| Have policies on smoking. | Health | 2024-10-17 | 2024-11-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-10-22 | 2024-10-22 | 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 | 2024-09-05 | Y |
| 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 |
| 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 |
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