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. Page 1 of 2 056122 056122 06/07/2024 Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/11/24 at 10:18 AM with DON, DON stated, there was no contingency plan in case of social worker's absence when asked. She verified, there was no social worker from 4/22/24 to 5/10/24 in the facility because the previous social worker already quit, and the other social worker (SW) was not available from 4/22/24 to 5/10/24 due to her vacation and her father's hospitalization, and the new Social Services Director (SSD) was hired on 5/13/24. DON stated, social workers help of meeting with a resident and family. She stated, social workers assist the resident's grievance, complaints and concerns when asked what kind of social services are provided to residents. During an interview on 6/11/24 at 10:35 AM with SSD, SSD stated, Discharge planning to make safe discharge . I accommodate IDT (interdisciplinary team) meeting . I provide psychosocial needs to the resident and family by education of the problems and disability . care conference meeting IDT, connect to dental, vision, podiatry (a branch of medicine devoted to the study, diagnosis, and treatment of disorders of the foot), ENT (ear, nose, and throat doctor) . Discharge transportation, in home support services to help with ADL's (activities of daily living), Meals on Wheels (a service that delivers daily hot meals to the homes of elderly or disabled people), hot food delivery (for discharged residents) . I provide support to the resident and family members, filing APS (Adult Protective Services), ombudsman . complete assessments, create care plan . I check grievance and follow up on their behalf . Apply for Medi-Cal (California's Medicaid program, covering those who have a low-income) for residents . when asked what kind of social services are provided to residents. During a concurrent interview and record review on 6/11/24 at 10:57 AM with SSD, Resident 1's Nurses Notes, dated 4/26/24 at 5:23 PM, was reviewed. After reviewing Nurses Notes which indicating, Had a Care Conference with wife . today. Dr XXX (Doctor's name), DON, treatment nurse present in care conference ., she verified, no social services was provided to Resident 1 when asked. She stated, . We advocate on behalf of the residents . to solve any issues they may have . She stated, they have a team meeting every day to resolve their residents' grievances. Review of the facility's organizational chart, undated, indicated, the social service was directly under Administrator. Review of the facility's policy and procedure (P&P) titled, Social Worker dated May 2017 indicated, . The Social Worker job description will provide the scope of the position for the facility . POSITION SUMMARY To assist in meeting the psychosocial needs of residents/families, to assist them in coping with problems related to illness and disability, and to enable residents/families to utilize medical and support services available in order to achieve their optimal level of functioning . 056122 Page 2 of 2