Health inspection·June 7, 2024

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide medically-related social services to one of 3 sampled residents (Resident 1) when there was no social worker available from 4/22/24 to 5/10/24. Residents Affected - Few This failure had the potential not to maintain the highest practicable physical, mental, and psychosocial well-being of Resident 1. Findings: Review of Resident 1's clinical record indicated, Resident 1 was originally admitted on [DATE] with diagnoses including peripheral vascular disease (a slow and progressive disorder of the blood vessels), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and diabetes mellitus (high blood sugar). He was transferred to a hospital on 5/3/24, then readmitted to the facility on [DATE], then discharged to the hospital on 5/20/24. Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 5/13/24 indicated, Resident 1 was cognitively intact. During an interview on 6/6/24 at 4:24 PM with Ombudsman (a person who assists residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) by phone, Ombudsman stated, the facility did not have a social worker for 3-4 weeks from April to early May when asked if he heard any issue with transfer or discharge at the facility. Ombudsman stated, the social worker's job included assisting with discharge procedures and scheduling appointments. During an interview on 6/10/24 at 10:14 AM with Complainant by phone, Complainant stated, There was no social worker when we were there. She stated, she heard the facility hired the social worker, but stated, I never met them. During an interview on 6/10/24 at 1:19 PM with Director of Nursing (DON), DON stated, Yes when asked if the facility should have a social worker. During a concurrent interview and record review on 6/11/24 at 10:06 AM with DON, Resident 1's clinical records were reviewed. When asked if there were social services notes for Resident 1, DON showed Resident 1's Nurses Notes, dated 4/26/24 at 5:23 PM. It indicated, Had a Care Conference with wife . today. Dr XXX (Doctor's name), DON, treatment nurse present in care conference . DON verified there was no social services notes during Resident 1's stay at the facility when asked again. (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 2 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 06/07/2024 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)