Cadence Millbrae

Safe, healthful, comfortable accommodations

87468.1(a)(2) Personal Rights of Residents in All Facilities - To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This regulation has not been met as evidenced by: Based on interviewes conducted, and incident report recieved, it was confirmed that the med-tech on duty was observed to pull the hair of a resident. This was witnessed by another staff on duty. This was reported to facility leadership and camera footage was reviewed confirming the abuse. This poses an immediate health and safety risk to resident in care.

Give PRN medication by physician order

87465(c)(2) Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This regulation has not been met as evidenced by: Based on interviews and documentation reviewed, LPA discovered that the medication was prescribed for the duration of 2024 but was stopped on two spans of time from 2/18/24 through 04/07/24 and 04/27/24 through 08/17/24 without documentation on file from the physician of the resident to discontinue.

Retain original records for at least three years

87506(e) Resident Records - Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This regulation has not been met as evidenced by: Based on recrod request, the facility is unable to provide a resident document dated 06/27/2023 that should be maintained for 3 years following the termination of service to the resident.

87463 Reappraisals - (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This regulation has not been met as evidenced by: Based on the investigation the facility failed to reassess resident who was identified as a fall risk and develop a plan of care to prevent falls and meet the resident's needs.

Right to sufficient care and qualified staff

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities - (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This regulation has not been met as evidenced by: Based on the investigaiton the facility did not provide care and supervision to meet the needs of a resident who was identified as a fall risk and suffered a fall on May 29, 2023 that resulted in arm separation. There was no staff to supervise and was no where to be found.

Regular observation and documentation of resident changes

87466 OBSERVATION OF RESIDENT - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes...are observed...such brought to the attention of the resident's physician and the resident's responsible person. This requirement was not met as evidenced by: Based on the investigation licensee failed to monitor changes in resident and failed to seek medical attention to address medical needs.

87464 BASIC SERVICES -Basic services shall ... include care and supervision as defined in 87101(c)(3) and Health and Safety Code 1569.2(c), meaning the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with ADLs without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by: Based on investigation the licensee failed to ensure adequate supervision of a client who was a fall risk by leaving resident with fall risks alone, which poses immediate health, safety, or personal rights risk to clients in care.

TRANSFERABILITY OF LICENSEIn the case of change of ownership or licensee a new application for license shall be submitted by the prospective new licensee. This requirement was not met, as Cogir Management USA Inc. acquired Cadence, and application for new licensure has not yet been submitted.This poses a potential health, safety or personal rights risk to clients in care.

Comply with all admission agreement terms

ADMISSION AGREEMENTSThe licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.This requirement was not met, as licensee failed to ensure that residents' apartments were air conditioned--as stated in residency agreements--which posed a potential health, safety or personal rights risk to clients in care.

Cool occupied rooms to regulated temperature range

MAINTENANCE AND OPERATIONA comfortable temperature for residents shall be maintained at all times. The facility shall cool rooms to a comfortable range, between 78 degrees F and 85 degrees F, or in areas of extreme heat to 30 degrees F less than the outside temperature.This requirement was not met, as extreme heat existed in September 2022, when temperature was up to 97 degrees, and rooms on the west side of building were not comfortably cool. Licensee failed to ensure that residents' apartments were maintained at comfortable temperature, which posed a potential health, safety or personal rights risk to clients in care.