Deficiency Records for Millbrae Care Center
Updated as of January 01, 2021
This is not the most recent data for Millbrae Care Center. For the most recent information, click here.
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 and implement an infection prevention and control program. | Health | 2020-10-13 | 2020-11-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-09-16 | 2020-11-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-09-15 | 2020-11-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-09-14 | 2020-11-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-23 | 2020-02-11 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-01-23 | 2020-02-11 | Y |
| 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 | 2020-01-23 | 2020-02-11 | Y |
| 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 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-18 | 2019-06-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-03-14 | 2019-04-16 | Y |
| 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 |
| 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 |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-05-29 | 2018-07-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-29 | 2018-07-18 | Y |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-07-03 | 2017-08-29 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-07-03 | 2017-08-29 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-07-03 | 2017-08-29 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-07-03 | 2017-08-29 | N |
| Keep all essential equipment working safely. | Health | 2017-07-03 | 2017-08-29 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2017-07-03 | 2017-08-29 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2017-07-03 | 2017-08-29 | N |
| Post nurse staffing information every day. | Health | 2020-02-14 | Not Fixed | Y |
