Inspection Results » Millbrae Skilled Care

Health Inspection on August 6, 2018 ^[1]

1. Pattern: Immediate jeopardy to the resident health or safety

   • Provide and implement an infection prevention and control program. (Corrected 2018-12-27)

2. Isolated: Actual harm that is not immediate jeopardy

   • Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Corrected 2018-11-02)

3. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Hire a qualified full-time social worker in a facility with more than 120 beds. (Corrected 2018-12-27)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-12-27)

4. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • 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. (Corrected 2018-12-27)
   • Keep all essential equipment working safely. (Corrected 2019-01-23)
   • 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. (Corrected 2018-11-02)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-11-02)
   • Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. (Corrected 2018-12-27)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2018-11-02)
   • Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. (Corrected 2018-11-02)
   • 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. (Corrected 2018-11-02)
   • PASARR screening for Mental disorders or Intellectual Disabilities (Corrected 2018-11-02)
   • Implement a program that monitors antibiotic use. (Corrected 2018-11-02)
   • 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. (Corrected 2018-11-02)

5. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-11-02)
   • Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Corrected 2018-11-02)
   • Assist a resident in gaining access to vision and hearing services. (Corrected 2018-11-02)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2018-11-02)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-12-27)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-11-02)
   • Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. (Corrected 2018-11-02)
   • 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 (Corrected 2018-12-27)
   • Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. (Corrected 2018-11-02)
   • Plan the resident's discharge to meet the resident's goals and needs. (Corrected 2018-11-02)
   • Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. (Corrected 2018-11-02)
   • Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. (Corrected 2018-11-02)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-12-27)