Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based from
interviews and record review, the facility failed to ensure the allegation of resident to resident abuse was
promptly reported to the State Agency (SA, which is the California Department of Public Health, CDPH) in
accordance with the facility's policy and procedure for four of eight sampled residents Resident 1 and
Resident 2, Resident 3 and Resident 4).
Failure to promptly report allegation of abuse had the potential for further abuse to happen and thereby
increasing the chances of harm to the residents.
Findings:
During a record review for Resident 1, admission Record, dated, 1/3/24, indicated, admitted to facility on
10/16/19 with diagnoses including: Convulsions (an involuntary muscle contraction causing shaking),
Diabetes Mellitus (uncontrolled blood sugar), Dementia (memory loss). Resident 1 has a BIMS (Brief
Interview for Mental Status) a mental test, score of 7, severe cognitive impairment. Unable to interview.
During a record review for Resident 2, admission Record, dated, 1/3/24, indicated, admitted on [DATE] with
diagnoses including: Abdominal Aortic Aneurysm (localized enlargement of the aorta in the abdomen),
Hypertension (HTN) high blood pressure,Chronic Obstructive Pulmonary Disease (COPD), a lung disease
characterized by long term respiratory and airflow limitation.
Resident 2 is alert and oriented, BIMs (Brief Interview for Mental Status) a mental test, score of 15,
self-responsible. Unable to interview, was discharged to Board and Care home on 4/6/22.
During a record review for Resident 3, admission Record, dated 12/21/23, indicated, admitted to facility on
1/19/23 with diagnoses including: Fracture of Femur (part of the hip), Dementia (loss of memory). Resident
is ambulatory with a walker, with BIMS (Brief Interview for Mental Status) a mental test, a score of 6, severe
cognitive impairment.
During a record review for Resident 4, admission Record, dated 12/21/23, indicated, admitted on [DATE]
with diagnoses including: Fractured Right Knee, COPD, Alcohol Abuse, Diabetes Mellitus (high blood
sugar).
Resident is alert and oriented, discharged on 9/13/23. Unable to interview.
Review of facility document, Summary of Investigation, dated 9/29/21, indicated, At around 7:05 AM,
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
056122
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056122
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Millbrae Care Center
33 Mateo Avenue
Millbrae, CA 94030
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
on 9/25/21 resident 1, noted walking hallway towards room [ROOM NUMBER], was banging on the door for
no apparent reason. Resident 2 immediately yells for resident to stop banging on the door. Resident 1 was
raising his hand in the air what what in aggressive manner. Resident 2 showing same aggressive stance
what do you want. Nurse on duty comes between both residents .begin to push each other while ignored
nurse in between. No physical harm noted for both. Resident exchanged words .nurse able to separate
them. Nurse called 911 for 5150. While on the phone, nurse hears loud yelling from the front station .nurse
noted both residents contact each other .Resident 2 was noted with knees on ground kneeling while
Resident 1 is facing front of Resident 2 as he grabs his waist locking him into place. Nurse on duty able to
separate them as police arrives on scene and enters building at 7:30 AM. Resident 1 was brought to the
hospital. Resident 2 refused to go to the hospital. Conclusion: No further incident reported. Behavior of both
residents are manageable at this time and being followed by NP Psychiatry for behavior management.
Facility staff will continue to monitor both residents for safety.
Review of Resident 1's nurses notes for monitoring, no issues.
Review of Resident 1's care plan for incident, no issues.
Review of Resident 2's nurses notes for monitoring, no issues.
Review of Resident 2's care plan for incident, no issues.
Review of Resident 3's Care plan for 8/19/23 incident, hitting roommate with the walker on his shoulder, no
issues.
Review of Resident 3's IDT (Interdisciplinary team review) dated 8/19/21, indicated, resident 3 attempted to
steal food from resident 4's bedside table. Resident 4 protect his food by shoving resident 3's left arm but
resident 3, grabbed a walker and hit resident 4 on his left shoulder.
Review of Resident 4s IDT, Resident 4 was sent to ER for evaluation of shoulder. Both residents were
transferred to different rooms.
Review of SOC 341, Report of Suspected Dependent Adult/Elder Abuse, dated 9/25/21 completed for
Resident 1 and Resident 2, indicated, Transmission Report to CDPH, date: 9/25/21 at 04:20 PM. Resident
to resident altercation report is 9/25/21 at 7:05 AM.
Review of SOC 341, Report of Suspected Dependent Adult/Elder Abuse, dated 8/19/23 completed for
Resident 3 and Resident 4, indicated, Transmission Report to CDPH, dated 08/21/23 at 03:36 PM.Resident
to resident altercation report is 8/19/23 at 6:20 AM.
Interview on 12/19/23 at 11AM, with Director of Social Services (DSS), stated, has started here since
August, don't know the incident. SOC 341 (Report of Suspected Abuse form) can be done by anyone,
everyone is a mandated reporter. Any abuse, physical, financial, should be reported. On physical abuse,
make sure residents are safe and separated.
Interview on 1/3/24, at 11 AM, with the Administrator, stated, Yes, the allegation should be reported
promptly. I had been in serviced by corporate on that. That issue is our QAPI meeting.
Review of facility document, Abuse and Neglect Prohibition Policy, dated 6/22, indicated: F.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056122
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056122
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Millbrae Care Center
33 Mateo Avenue
Millbrae, CA 94030
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Reporting of incidents, investigations, and facility's response to the investigation: i. All alleged
violations-Immediately but not later than: 1. 2 hours-if the alleged violation involves abuse or results in
serious bodily injury. Iv. The licensing and Certification Program District Office is required to receive these
reports.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056122
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056122
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Millbrae Care Center
33 Mateo Avenue
Millbrae, CA 94030
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to complete elopement risk assessment for 2 residents, and
provide supervision for (Resident 1 and Resident 2) when they left the building unsupervised.
Resident 1 was found on the street in the next town, in shirt and slippers on 11/11/23 at around 5 PM.
Resident 2 went missing on 7/20/21, at 9PM. Was found 7/21/21 in her San Francisco apartment.
This failure has potential to result in harm or danger to these cognitively impaired residents.
Findings:
Review of admission record, dated 12/22/23, indicated, admitted with diagnoses including: Cellulitis Right
lower leg (infection), type 2 Diabetes Mellitus (a disease which increases the sugar level in the blood and
urine) Dementia ( problem with memory), major Depressive Disorder( a mental condition with feeling of
inadequacy and guilt.)
Review of MDS (Minimum Data Set), section C, Cognitive Pattern, dated 9/19/23, indicated, BIMS Score of
5. Indicates severe cognitive impairment.
Interview on 12/19/23 at 11:37AM, with Resident 1, stated, Yes probably I left, I forgot to tell somebody, I go
to the store. Resident 1 observed in his room, standing, and walking in the room. Not aware of what
happened on 11/11/23 as reported.
Interview with complainant, on 12/19/23 at 2:40PM, on the phone, stated, does not know the patient. I was
driving on Cane/El [NAME], saw this gentleman had difficulty walking, not looking out for cars and almost
falling. My boyfriend helped him cross the street. He was not dressed for cold weather, wearing t-shirt and
slippers and sweatpants. This was around 5 PM. He said he wanted to go to Palo [NAME], he stated he
was coming from Millbrae. [NAME] St is in San [NAME]. Asked where he lives, stated, I don't know, I forgot.
Me and my boyfriend got him to my car, got him a sandwich, he was very nice and called San [NAME]
Police. San [NAME] Police transferred call to Millbrae Police, since we were on our way to Peninsula ER. It
took 30-40 minutes before Millbrae Police came, we did not go to ER there was a long line and Police
coming. Police stated, no missing person report. Police found out he lives in Millbrae Care Center, called
the center, and answered, Patient is here in his room. Police stated, How can he be in his room when he is
with me. Police took him back to facility. Complainant stated, they should be taking care of their patients and
let their families know of what is happening to them. Luckily, he did not have a fall, it was dark that time.
Writer thanked the complainant for her concern and help to Resident 1.
Review of facility document, Interdisciplinary Team Review, undated, indicated, On 11/11 found resident
outside facility at around 1900, charge nurse able to redirect back to facility in his room., monitored resident
for whereabouts every 15. No other episodes of elopement reported after incident.
No nursing notes for monitoring resident for 72 hours found.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056122
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056122
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Millbrae Care Center
33 Mateo Avenue
Millbrae, CA 94030
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
No Social Workers notes for 72-hour monitoring found.
Level of Harm - Minimal harm
or potential for actual harm
Review of Care Plan, dated 5/22/23, indicated, Resident is an elopement risk/wanderer. Intervention:
Wander Gard alert on left wrist. Care plan not updated on 11/11/23 incident.
Residents Affected - Some
Wandering and Elopement risk assessment not done for date of 11/11/23 incident.
Interview and concurrent record review on 12/19/23 at 11:13AM, with Social Services (SS), stated, resident
is alert and verbally responsive. Patient ambulatory needs someone for safety. no report of elopement.
Elopement assessment initial one done by nursing, not social services. Had actual elopement date 4/30/23
and 11/11/23.
Resident 2, is admitted on [DATE], with diagnoses including: Aphasia, (difficulty talking) Cerebral Infarction
(Ischemic stroke, resulting from disrupted blood flow to the brain), Altered Mental Status( change in mental
status).
Review of nurses notes , dated 7/16/21,admitted with diagnoses of Aphasia, HTN, CKD st 3. DNAR status.
Alert and Oriented x 1, assessment done, denies pain, ambulates without device, steady gait, regular diet.
On 7/17/21, nurses notes, no psychosocial distress, meds given, adjusting well.
On 7/18/21, nurses notes, VS stable, alert and oriented x2, husband visited, became anxious when
husband left attempting to leave the facility, given Diazepam 5 mg.
On 7/19/21, SS Notes, IDT met .patient alert, responsive with cognitive impairment, on skilled services. D/C
plan not determined. Lives alone in senior apartment with IHHS 2.3 hours per day. On SS income. No
relatives, no siblings. IHSS provider became her friend and helping her with decision making. Patient might
not be able to return to apartment due to safety concerns. SSD will coordinate with SW listed.
On 7/20/21, nurses notes, resident has episodes of trying to leave the facility, resident assisted back into
facility by staff.
On 7/20/21, nurses notes, resident tried to leave multiple times, writer tried to place wander gard but
resident refused, started to get agitated and aggressive toward staff.
Review of MDS, Cognitive Pattern, Cognitive Skills for Daily Decision Making, indicated, 3. Severely
Impaired.
Review of facility document, Summary of Investigation dated, 7/22/21, indicated, On July 20, 2021 at
around 9:15 PM. Resident 2 was noted missing in her room, thorough search to the whole building,
surroundings, and neighborhood was done immediately. At approximately 10:30 PM, resident was reported
missing to Millbrae Police Department. Resident Physician and Friend/RP were notified of this incident.
Ombudsman, CDPH notified. SOC was faxed to CDPH and Ombudsman on 7/21/21. On July 21, 2021 at
around 11:20AM, facility received a call from Apartment Manager, reported that resident 2 was seen inside
her unit by their apartment maintenance staff and confirmed she is this resident. Millbrae Police was
notified, SF Police was also notified, stated she will request Police Officer to go to her apartment for
wellness check. APS was also notified. No negative outcome from this incident. Resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056122
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056122
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Millbrae Care Center
33 Mateo Avenue
Millbrae, CA 94030
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
was found inside her apartment.
Level of Harm - Minimal harm
or potential for actual harm
Review of care plan for attempts to leave facility, not addressed.
Residents Affected - Some
Interview on 12/20/23 at 10AM, with Infection Preventionist (IP), stated and confirmed, no care plan found
for attempting to leave.
Wandering and Elopement Risk assessment not addressed on admission.
Review of facility Policy and Procedure, Wandering Behavior Management, dated 12/16, indicated, It is the
policy of the facility to ensure that each resident who is a wandering risk is identified, assesses and
provided appropriate intervention, adequate supervision and assistive devices.
Assessment and Care Planning:
a.
Upon admission to the facility, the license nurse will complete a wandering and elopement risk assessment.
b.
Completed every quarter and with COC
c.
Develop a plan of care for resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056122
If continuation sheet
Page 6 of 6
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the January 3, 2024 survey of MILLBRAE CARE CENTER?
This was a inspection survey of MILLBRAE CARE CENTER on January 3, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MILLBRAE CARE CENTER on January 3, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.