Millbrae Care Center

In the surveyor’s words

From the most serious findings on record at Millbrae Care Center, in the surveyor’s own words.

• Actual harm, isolatedF692Jan 11, 2024

  Based on observation, interview, and record review, the facility failed to effectively assess weight loss, revise, and implement therapeutic interventions for one of one sampled resident (Resident 19) when Resident 19 had an unplanned weight loss. The facility's failure resulted to Resident 19 to experience a gradual, unintended, progressive weight loss overtime. Findings: A review of the facility's Policy and Procedure (P&P) titled Weight and Assessment Interventions dated 11/2017, indicated, the threshold for significant and unplanned and undesired weight loss will be 5% after a month, 7.5% after 3 months, and 10% after 6 months. […]

• Actual harm, isolatedF692Dec 3, 2021

  Based on observation, interview, and record review, the facility failed to effectively assess or develop therapeutic interventions including but not limited to implementation of a therapeutic diet for one of two sampled residents (Resident 35). This failure resulted in Resident 35 experiencing severe weight loss. Findings: Weight loss in nursing home residents is linked to poor outcomes, including higher rates of hospitalization and death (American Journal of Nursing, 2008). Facility policy titled Weight Assessment & Interventions dated 11/17 described the threshold for significant unplanned and undesired weight loss as 5% (percent) after 1 month; 7.5% within 3 months and 10% within 6 months. […]

• No harm, potential for more than minimal, widespreadF640May 8, 2026

  Based on record review and interview, the facility failed to ensure accurate and timely encoding and transmission of resident assessments for 18 of 116 sampled residents. The facility did not encode the Minimum Data Set (MDS, It's a detailed check up form the nursing home fills out to understand what a resident needs and to plan the right care) assessments within the required timeframe and did not ensure successful transmission to the Centers for Medicare & Medicaid Services (CMS) database.This failure to complete and transmit required resident assessment data resulted in incomplete clinical information being available for care planning, increased risk of inaccurate care plans, and potential negative impact on each resident's ability to receive individualized, person centered care.During a… […]

• No harm, potential for more than minimal, widespreadF688Jan 11, 2024

  Based on interview and record review the facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM, the extent or limit to which a part of the body can be moved) for 18 of 18 sampled residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18,) when physician order for Restorative Nursing Assistant Program (RNA, nursing interventions that promote the residents ability to adjust to living as independently and safely as possible) was not implemented. The facility failure had the potential for the residents to limit the ROM and a possible development of a contracture (shortening of muscles and joints which limit and interfere with daily functioning). FINDINGS: 1. […]

• No harm, potential for more than minimal, widespreadF867Jan 11, 2024

  Based on observation, interview, and record review the facility failed to implement its plan of action to correct the identified deficiency regarding the Restorative Nursing Assistant (RNA, nursing interventions that promote the resident's ability to perform activities of daily living as independently and safely as possible) Program. The facility failure resulted in non-compliance to F688 which had the potential for the residents to limit range of motion (ROM, how far a person can move or stretch a part of the body) and a possible development of contracture (shortening of muscles and joints which limits and interfere with daily functioning). […]