Health inspection·June 4, 2025

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 Based on interview and record review, facility staff failed to provide social service-related services to 14 of 14 sample residents (Residents: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) when there was only one social worker (SW 1) in the building and quarterly care conference meetings for at least 14 residents were not completed during the period of March 2025 to June 2025. Residents Affected - Some This failure had the potential to result in residents not receiving appropriate and personalized care. Findings: The census on 06/04/2025 was 128 residents. During an interview on 06/04/2025 at 12:10 PM, SW 1 stated she was the only social worker in the building for approximately three months (March to June 2025). SW 1 stated with the facility workload, she was unable to coordinate and conduct IDT (interdisciplinary team) /care conference meetings. SW 1 explained that IDT meetings were attended by a variety of healthcare professionals, like nurses, therapists, social workers, and others, to discuss and manage resident care. During these meetings family members and/or responsible parties were invited to attend so that they could be made aware and participate in resident care discussions. SW 1 identified a list of 14 residents without IDT. SW 1 stated these IDT/care conference meetings should be conducted minimally quarterly (every three months). During a concurrent record review and interview on 06/04/2025 at 2:00 PM, Medical Record Staff (MRS) was asked to search the records of these 14 residents and provide the date the last IDT/care conference was conducted for these residents. Date of last IDT/care conference notes within a resident ' s medical record: Resident 1 = 10/18/24 (approximately 8 months ago) Resident 2 = 12/18/24 (approximately 6 months ago) Resident 3 = 11/12/24 (approximately 7 months ago) Resident 4 = 12/18/24 (approximately 6 months ago) Resident 5 = 10/15/24 (approximately 8 months ago) Page 1 of 3 056122 056122 06/04/2025 Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030

F 0745 Resident 6 = 12/18/24 (approximately 6 months ago) Level of Harm - Minimal harm or potential for actual harm Resident 7 = 12/6/24 (approximately 6 months ago) Resident 8 = 11/12/24 (approximately 7 months ago) Residents Affected - Some Resident 9 = 12/16/24 (approximately 6 months ago) Resident 10 = 11/20/24 (approximately 7 months ago) Resident 11 = 10/9/24 (approximately 8 months ago) Resident 12 = 11/18/24 (approximately 7 months ago) Resident 13 = 11/18/24 (approximately 7 months ago) Resident 14 = 9/18/24 (approximately 8 months ago) Resident 15 = 11/12/24 (approximately 7 months ago) During an interview on 06/04/2025 at 2:30 PM, Resident 1 ' s family member, family member stated they has not been invited recently to an IDT meeting. They stated they were not updated on Resident 1 ' s plan of care nor Resident 1 ' s current medications. During an interview on 06/13/2025 at 11:48 AM, the Administrator stated IDT/care conference meetings were conducted to discuss care issues such as: weight loss, skin issue, falls, psychoactive medications, behavior, clothing, diet, diet preference, activities etc. The Administrator stated nursing chair these meetings, but Social Services was responsible for scheduling and coordinating these meetings with families/responsible parties and the care team. The Administrator stated residents were discussed during daily standup meetings, however daily standup meetings were not a total replacement for IDT/care conference meeting since: 1. Daily stand up dealt with acute care issues. 2. Chronic issues such as diabetes management, slow progressive weight loss, medication updates, ongoing behavior management, may not have been discussed with families and/or responsible parties if IDT/care conferences were not conducted. During an interview on 6/18/2025 at 3:37 PM, the Administrator stated that there was only one social worker in the building from March 10, 2025, to June 7, 2025 (a total of 89 days). A review of facility policy and procedure (P&P) titled Care Plan Conference, dated December 2016, P&P indicated .It is the policy of this facility to provide each resident, resident ' s family, surrogate or representative a medium to .(hold) a care conference to meet and discuss the progress, needs and goals of care. The interdisciplinary team, in conjunction with the resident, resident's family, surrogate or representative, will develop the plan of care based on the comprehensive assessment. The care plan conference is held to identify resident needs and establish obtainable goals.care plan conferences are held: Within 7 days of completion of the initial MDS assessment .At interval of every 90 days thereafter; with any subsequent completed assessments; and .When there is a change in 056122 Page 2 of 3 056122 06/04/2025 Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030

F 0745 resident status or condition. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 056122 Page 3 of 3