Millbrae Family Care Home

§1569.695 Emergency Plans(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This health and safety code has not been met as evidenced by: Based on documentation reviewed, LPA observed that there is no disaster drill log present. Per interviews with staff, a disaster drill has not been conducted in about a year. This poses an immediate health and safety risk to residents and staff in the facility.

Require fire clearance before non-temporary bedridden admission

Based on record review, the licensee did not comply with the section cited above, as one out of 6 residents is bedridden, per MD report, which poses an immediate health, safety or personal rights risk to persons in care.Client #6 is bedridden, per MD report dated 8/2022. Facility maintains fire clearance for 6 Non-ambulatory residents.

Based on client records review, the licensee did not comply with the section cited above, as 4 out of 4 clients diagnosed with dementia have MD reports that are more than 1 year old and 3 out of 4 clients diagnosed with dementia have appraisals that are more than 1 year old, which poses a potential health, safety or personal rights risk to persons in care. Clients #1, #2, #3, #5 are diagnosed with dementia, but MD reports are over one year old and appraisals for clients #1, #3, #5 are over one year old.

Record centrally stored prescriptions and refill data

Based on review of client records and centrally stored medications, the licensee did not comply with the section cited above. All medications for at least 2 residents are not logged on CSMR (LIC622), which poses a potential health, safety or personal rights risk to persons in care.Six RX medications filled in November 2023 and 1 med filled in October 2023 for client #4 are not logged and meds for client #3 and client #5 are not logged since 8/23 and 9/23, respectively.

Based on staff record review, the licensee did not comply with the section cited above, as 3 out of 3 staff have not received required 4 hours of training on postural supports, restricted health conditions, and hospice care, which poses a potential health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above, as wood fence boards, chairs, commodes, building equipment, dresser, are stored in back and side yards. This poses a potential health, safety or personal rights risk to persons in care.

Based on review of staff records, the licensee did not comply with the section cited above , as 3 out of 7 staff do not have proof of current first-aid training, which poses a potential health, safety or personal rights risk to persons in care.