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 (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 3 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 04/11/2024 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)