Health inspection·May 19, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Based on observation, interviews and record reviews, the facility failed to manage residents ' belongings for Resident 1, 2, and 3, three of 6 sampled residents. Facility staff did not: Residents Affected - Few 1. Follow facility policy in identifying/marking residents ' belongings. 2. Have a facility policy to periodically update resident inventory. These failures resulted in Resident 1 and 3 with missing belongings. Findings: Review of Resident 3 ' s medical records titled INVENTORY OF PERSONAL EFFECTS, dated 02/10/2023, indicated he was admitted with two shirts, two sweaters, and a pair of white mitt/glove. During a concurrent observation and interview with the Certified Nursing Assistant 1 (CNA) caring for Resident 3, on 05/19/2025 at 2:00 PM, CNA 1 looked through Resident 3 ' s belongings and stated he had 14 white tee shirts, and four dark tee shirts. None of the clothing were marked to identify these clothing belonged to Resident 3. CNA stated all of Resident 3 ' s clothing were donated, and he has no idea what happened to Resident 3 ' s clothing/personal belongings identified during admission. During an interview on 05/19/2025 on 1:20pm Resident 1 stated she was missing a red and black flannel jacket and one of her right shoes was missing. During an interview on 06/13/2025 at 12:40 PM Resident 2 ' s Responsible Party, she stated Resident 2 ' s belongings were missing for at least two weeks. The RP stated staff found Resident 2 ' s missing sweatpants, two long shirts and a pair of shoes yesterday. During an observation of Resident 2 ' s clothing, on 06/13/2025 at 1:00 PM, none of Resident 2 ' s clothing were marked to identify who they belong to. Review of the facility ' s policy titled Residents ' Personal Property, dated December 2016, indicated .Prior to, or upon admission, residents will be advised of the kinds and amounts of clothing and possessions permitted for personal use, and whether the facility will accept responsibility for maintaining these items (e.g., cleaning and laundry) . Any personal clothing or possessions retained by the facility for the resident during his or her stay will be identified and inventoried upon admission and the copy of inventory provided to the resident. Review of the policy found no language (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 05/19/2025 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)