Health inspection·August 5, 2024

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) completed the assessments to seven of nine sampled residents (Resident 1, 2, 3, 4, 5, 6, and 7) when the residents had a change in condition. The facility deficient practice has the potential harm on the resident safety and well-being. Findings: A review of the facility fall incidents on 8/5/24, indicated Residents 1,2,3,4,5,6, and 7 had fall incidents. During an interview on 8/5/24 at 1:02 PM, the Director of Nursing (DON) reviewed the post fall assessments and stated, the assessments for Residents 1,2,3,4,5,6, and 7 were completed by Licensed Vocational Nurse (LVN) 1,2,3,4, and 5. During an interview on 8/6/24, at 4:30 PM, the Administrator stated, If an LVN is assigned to the resident, the LVN performs the post fall assessment and evaluate the resident for injury. The Registered Nurse is not necessarily present. During a review of the job description for LVN dated 5/2017, indicated, .Under the direct supervision of a registered nurse, implement and established plan of care for each assigned group of residents. Responsibilities includes total care for chronically ill and technologically dependent residents, administrations of medications, performance of treatments, provision of resident/family education as directed, and maintenance of record of the care provided. Under the direct supervision of an RN, assist with planning, coordination, and provision of individualized resident care in accordance with the established policies and procedures of the facility . .The licensed vocational nurse performs services requiring technical and manual skills which include the following: (a) Uses and practices basic assessment (data collection), participates in planning, executes interventions in accordance with the care plan or treatment plan, and contributes to evaluation of individualized interventions related to the care plan or treatment plan. (b) Provides direct patient/client care by which the licensee: (1) Performs basic nursing services as defined in subdivision (a); (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 08/05/2024 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)