Deficiency Records for Millbrae Care Center
Updated as of June 01, 2019
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? |
|---|---|---|---|---|
| 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 ne | 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 |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-07-21 | 2017-08-17 | Y |
| Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2017-03-06 | 2017-05-15 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-06 | 2017-05-15 | Y |
| Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2017-04-10 | 2017-05-11 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-04-10 | 2017-05-11 | Y |
| Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2016-06-09 | 2016-07-20 | Y |
| Tell the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2016-07-14 | 2016-07-18 | Y |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-06-02 | 2016-07-07 | N |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2016-06-02 | 2016-07-07 | N |
| Properly maintained smoke detectors. | Fire Safety | 2016-06-02 | 2016-07-07 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-06-02 | 2016-07-07 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-06-02 | 2016-07-07 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-05-27 | 2016-06-23 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-05-27 | 2016-06-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2016-05-27 | 2016-06-23 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-05-27 | 2016-06-23 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-05-27 | 2016-06-23 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-05-27 | 2016-06-23 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-05-27 | 2016-06-23 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2016-05-27 | 2016-06-23 | N |
