Health inspection·April 11, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 on 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) in accordance with the facility policy and procedure for one of four sampled residents Resident 1. Failure to promptly report allegation of abuse has potential for further abuse to happen thereby increasing the harm to the resident. Findings: Record review of Resident 1's admission Record, dated 4/10/24, indicated, admitted to facility on 9/21/23 with diagnoses including: Seizures ( Involuntary body twitching), Alcohol dependence with Withdrawal, Major Depression. Resident 1 went Against Medical Advice (AMA) on 9/25/23. During a review of facility document, Investigative Report, dated 9/30/23, indicated, Resident 1 is alert and oriented, self-responsible, ambulatory with Brief Interview of Mental Status (BIMS) score of 14. On 9/25/23 at 3PM, Resident 1 discharged from the facility against medical advice. Resident 1 returned to the facility on 9/25/23 at 8:45 PM with Officer K.F. Resident 1 alleged that on 9/23/23 around 3PM, while using the bathroom, his roommate kicked the door and yelled, Hurry up and get out and claimed the bathroom door hit his leg. Skin assessment of his leg done by licensed nurse, no bruising or redness noted. Resident 1 reported this incident on 9/23/23 around 4:35 PM to Licensed Nurse ( LN) but did not mention the door hitting his leg. LN offered room change at that time but he refused. During a review of facility document. Nurses Notes, dated 9/23/23 at 16:35, indicated, Resident complaint to LN that around 0300 resident went to the bathroom and while using the restroom [ROOM NUMBER]D kicked the door and yelled, Hurry up and get out. Per resident he did not notify any staff because he did not want to make it a big deal. Resident requested to have resident 11 D removed by staff. LN notify him that we are not able to do that. LN offered him another room, but he refused. Per resident he will stay in room [ROOM NUMBER] and file a complaint with SS (social services) and Administrator. LN reminded him that there are nurses/staff 24/7 and we are here to assist in case he feels unsafe or has issues. Resident is calm and felt better after speaking with LN. During a review of facility document, Nurses notes, dated 9/25/23 at 15:23 PM, indicated, AMA note: Resident decided to leave the facility against medical advice, today 9/25/23. Resident was informed Page 1 of 3 056122 056122 04/11/2024 Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of his Last Covered day (LCD) for skilled services dated 10/2/23. Resident decided that he wanted to leave earlier than the discharge date . Resident is alert and oriented and is self -RP. Resident was informed that leaving the facility without a discharge order from the physician is considered against medical advice. Resident verbalized understanding of risks of leaving AMA .understand he will not have order for home health or Durable Medical Equipment(DME), no medications will be provided and transportation will not be arranged by the facility. Resident verbalized understanding and signed AMA. SSA respected resident's decision . Charge nurse signed as witness. Resident left around 3:10 PM together with his belongings. LTC Ombudsman notified. During an interview on 4/11/24, at 12 noon and concurrent chart review, with Administrator, per Administrator, she only knew of the incident when patient came back with police officer after AMA that day of 9/25/23. Per Administrator, no SOC 341 was reported on the day of incident. During an interview on 4/11/24 at 12 Noon with Director of Nursing (DON), per DON, will need a reported SOC and care plan and team meeting to address incident. No SOC, no care plan and no IDT meeting found in chart. During an interiew and concurrent chart review on 4/11/24 at 1:45 PM, with H.M. LVN, per LVN she has worked for 5 years now in this facility. Per LVN, I remember now, he has a lot of issues with other people. Was passing medication and patient mentioned it to me, the roommate kicked the bathroom door. To notify the DON and Administrator if I think its an abuse, I did not see him scared, some people are just don't like each other. He never mentioned, I'm scared so I don't think its an abuse. Per LVN, Abuse reporting in services are given yearly and more often when needed. During a review of facility document, Abuse Neglect Prohibition Policy , dated 6/22, indicated, Procedure: B. Training: 1. The facility's abuse and neglect training program will be provided to all employees, through orientation and on-going sessions related to abuse .at a minimum of annually and will include review of : iii. How staff should report their knowledge related to allegations without fear or reprisal . F. 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. ii submit a written report to the local Ombudsman or the law enforcement agency using the California Report of Suspected Dependent Adult/Elder Abuse Form (SOC 341) . iv. The Licensing and Certification Program District Office is required to receive these reports. 056122 Page 2 of 3 056122 04/11/2024 Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview, and record review, the facility failed to provide supervision to ensure safety for one of one sampled resident (Resident 3) when Resident 3 was found outside the facility unaccompanied. The facility's failure had the potential for resident harm. Resident 3 was admitted with diagnoses including dementia (a decline in memory or other thinking abilities). A review of Minimum Data Set (MDS, a standard assessment tool) dated 2/23/24, Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive function (includes learning, thinking, and decision-making abilities) score of 5 indicated severe cognitive impairment (rarely makes decision). MDS also indicated Resident 3 has wandering behavior. During observation on 4/11/24, at 11:45 AM, Resident 3 was alert, smiling. Resident 3 got out of bed and ambulated to the bathroom. Resident 3 speaks a non-English language. A review of the Interdisciplinary Team (IDT) notes dated 1/8/24, indicated, Resident 3 walked out of the facility. A Certified Nurse Assistant (CNA) noted resident's absence routine during staff rounding and was located outside the facility. During an interview on 4/11/24, at 11:40 AM, Registered Nurse (RN) 1 stated, [Resident 3] was confused. She has dementia. [Resident 3] was located a couple of blocks away along El [NAME] Road (one of the most use road by drivers). RN 1 further stated, [Resident 3] stated that she was looking for food. She's always hungry. She had gained weight. A review of the care plan titled, Resident is elopement risk dated 12/13/23, indicated, . Goal: the resident will not leave facility unattended. Monitor behavior of wandering and or exit seeking behavior. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, TV, book. Monitor residents whereabouts every shift. Staff to make checks to ensure resident is in areas of choice within the facility . A review of the Policy and Procedure titled, Elopement Behavior Management dated 12/2016, indicated, .It is the policy of this facility to ensure that each resident who is elopement risk is identified, assessed, and provided appropriate intervention, adequate supervision .Definition: elopement - a situation in which a resident with impaired or poor safety awareness or judgement successfully leaves the facility or a secured area undetected or unsupervised by staff. The following interventions will be taken to monitor the resident's whereabouts and minimize recurrence: Implement visual check sheet for 72 hours post incident. The checks will be done and documented every 15 minutes. If available, one-on-one supervision from the facility will be used for the resident until the physician can determine the cause. Staff will encourage activities that the resident enjoys to occupy the resident . 056122 Page 3 of 3