Millbrae Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the attending physician reviewed the resident's total program of care and failed to write, sign, and date progress notes as required for 3 out of 12 sampled residents (Residents 1, 2, and 3). This failure had the potential to result in the residents not receiving timely evaluation of their medical regimen and necessary adjustments to treatments, placing the residents at risk for unmet medical needs and a decline in physical, mental, or psychosocial well being. During a review of Resident 1's Electronic Medical Record (EHR), the Resident 1's EHR indicated Resident 1 was admitted on [DATE] and has a Brief Interview for Mental Status (BIMS) Summary Score of 14 as of 06/01/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure required face to face physician visits were conducted and that the corresponding documentation was completed and maintained in the residents' medical records, as required, for 5 of 12 sampled residents (Residents 1, 2, 3, 4, and 5). This failure has the potential to result in negative outcomes for residents, including delays in identifying changes in condition, missed opportunities for timely medical interventions, unmanaged or worsening chronic conditions, increased risk of avoidable hospitalizations or emergency department visits, inadequate medication management, and overall decline in residents' health status due to lack of timely clinical oversight. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate and timely encoding and transmission of resident assessments for 18 of 116 sampled residents. The facility did not encode the Minimum Data Set (MDS, It's a detailed check up form the nursing home fills out to understand what a resident needs and to plan the right care) assessments within the required timeframe and did not ensure successful transmission to the Centers for Medicare & Medicaid Services (CMS) database. This failure to complete and transmit required resident assessment data resulted in incomplete clinical information being available for care planning, increased risk of inaccurate care plans, and potential negative impact on each resident's ability to receive individualized, person centered care. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident assessment tool) quarterly assessment was completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act of 1987) assessment for six of 19 sampled residents (Resident 71, Resident 73, Resident 94, Resident 111, Resident 121, and Resident 16). Failure to complete quarterly resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of the residents.1. Review of Resident 71's admission record indicated, was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement person centered care plans for two (2) of 28 sampled residents (Residents 12, 120, and 130) when:Resident 12 did not have a care plan for limited range of motion, despite being ordered Restorative Nursing services (person-centered programs designed to help patients maintain or improve their highest level of physical, mental, and psychosocial independence)Resident 130 received 5 L/min of oxygen instead of the prescribed 2 L/min, contrary to the care plan and physician orders. These deficient practices had the potential to result in unmet care needs, inadequate supervision, and failure to provide services in accordance with physician orders and individualized assessments.2. During initial pool observation on 5/4/2026 at 2:19PM, Resident 130 was noted to be receiving 5 L/min of oxygen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prescription medications and biologicals were labeled and stored according to manufacturer's instructions and facility policy and procedures, as evidenced by the following:A bottle of Dabigatran etexilate (a prescription oral blood thinner) capsule and one vial of multi-dose Heparin Sodium 5,000 unit/mL (a fast-acting injectable anticoagulant used to prevent blood clots) were opened and undated. Residents and staff personal items such as pouch, jewelry, hearing aid, dentures, cellphones, cellphone charger, eyeglasses, and iPad were stored in the controlled medication compartment of Medication Carts #4 & #1. [...]

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse involving Resident 160 to the State Survey Agency, as required by facility policy and federal regulations. Failure to promptly report allegations of abuse had the potential to place residents at risk for unaddressed harm and compromise the facility's duty to protect residents' health, safety, and rights. Review of Resident 160's admission record indicated, was admitted to the facility on [DATE] with diagnoses that included a heart attack, a urinary tract infection, type 2 diabetes (high blood sugar), left lower leg closed fracture, and Alzheimer's disease (memory loss and confusion). Review of the Minimum Data Set (MDS) dated [DATE] indicated the Resident 160's cognition was moderately impaired. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation of an allegation of abuse involving Resident 160. This failure had the potential to place residents at risk for unaddressed harm and compromised the facility's duty to protect residents' health and safety. Review of Resident 160's admission record indicated, was admitted to the facility on [DATE] with diagnoses that included a heart attack, a urinary tract infection, type 2 diabetes (high blood sugar), left lower leg closed fracture, and Alzheimer's disease (memory loss and confusion). Review of the Minimum Data Set (MDS) dated [DATE] indicated the Resident 160's cognition was moderately impaired. During a concurrent interview and record review on 5/8/26 at 1:29 PM, the Registered Nurse Supervisor (RNS) reviewed Resident 160's progress notes titled Nurses Notes. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure proper notification when residents are discharged , when one of three residents, Resident 158 went home, Ombudsman was not notified. This failure could put a resident with no protection and an advocate to inform them of options and rights with regards to discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure the annual Minimum Data Set (MDS, a resident assessment tool) was completed within the required period of 14 calendar days of Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) for two of 19 sampled residents (Resident 73 and Resident 111). Failure to complete a comprehensive resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of Resident 73 and Resident 111.1. Review of Resident 73's admission record indicated, was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA, is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team, a collaborative group of professionals from diverse fields who work together interdependently to achieve shared goals) has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of 19 sampled residents (Resident 73) who was admitted to hospice care on 11/5/25. This failure could potentially delay the provision of appropriate treatment and services for Resident 73. Review of Resident 73's admission record indicated, was admitted to hospice on 11/5/25 with diagnoses including heart failure, high blood pressure, and dementia (a group of symptoms affecting memory, thinking and social abilities). [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility did not collaborate with Hospice the plan of care for two out of five residents (Residents 27and 16)This failure could result to residents not receiving care as planned. During a review of Resident 27's admission Record, dated 5/6/26, the admission record indicated, admitted on [DATE] with diagnoses including: Alzheimer's Disease( a progressive, irreversible brain disorder that destroys memory and thinking), Osteoarthritis of Knees(a common form of arthritis). During an observation on 5/5/26 at 11 AM, observed resident up on wheelchair, smiling, not responding to questions. During an interview on 5/5/26 at 11 AM with Certified Nursing Assistant (CNA) 4, stated, she has been her permanent CNA for many years. Since after her fall, she is now in wheelchair, can still walk to the bathroom with assistance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their smoking policy and procedures (P&P) when it allowed two of eight residents (Resident 4 and Resident 81) who smoked in the facility to keep possession of their own lighters and cigarettes inside the resident care area. This failure posed an increased risk for combustion and/or fire, resulting in the potential for serious injury and/or death to residents, staff, and visitors. During an interview on 05/06/2026, at 12:20 PM, at Resident 4's room with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, the orange plastic tube with liquid inside found on the overbed table beside the resident's bed is a disposable cigarette lighter used by Resident 4 for smoking. LVN 2 further stated, there is a smoking schedule, but Resident 4 does not follow it. LVN 2 stated, Resident 4 keeps his cigarette in his room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care and services were provided as required for two of six sampled residents (Resident 130 and Resident 4). The facility did not provide appropriate supervision during the residents' nebulizer treatments (A nebulizer treatment is a process in which a machine turns liquid medication into a mist that the resident breathes in through a mask or mouthpiece to help improve breathing). This failure resulted in the residents not receiving respiratory treatment in accordance with the facility's policy, procedure, and individualized care plans, placing the residents at risk for unmet respiratory needs. During an observation on 5/4/2026 at 2:30 PM at Resident 130 room, Resident 130 was found sleeping with the nebulizer tubing on the resident's chest. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control program when:Certified Nursing Assistant (CNA) 4 did not perform hand hygiene when handling soiled linens and entering resident rooms. Residents and staff personal items such as pouch, jewelry, hearing aid, dentures, cellphones, phone charger, eyeglasses, and iPad were stored in the controlled medication compartment of the medication cart. Foreign currency was kept in the top drawer of the Medication Cart #4, alongside opened bottles of over the counter oral medications, epinephrine injections (the primary emergency treatment for severe allergic reactions), and suppositories (medications administered through the rectum, vagina, or urethra). These failures had the potential for cross contamination of infection that can compromise the health and safety of residents and staff.1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop a person-centered care plan for two of two sampled residents (Resident 1, and Resident 2) when:Smoking and going out on pass (when a resident leaves the facility temporarily) was not addressed for Resident 1. Going out on pass was not addressed for Resident 2. The facility failure had the potential for the residents not to receive necessary care and services. A review of the face sheet indicated Resident 1 was admitted with diagnoses including heart failure (when the heart muscles do not pump as strong as it should) and diabetes (abnormally high blood sugar level). A review of the Minimum Data Set (MDS, a standard assessment tool) dated 1/15/26, indicated Resident 1 was cognitively intact. The MDS further indicated Resident 1 was independent with all aspects of activities of daily living (ADL). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the care plan for one of one sampled resident (Resident 3) after Resident 3 had two fall incidents. The failures had the potential to put the resident at risk of not receiving appropriate care. A review of the face sheet indicated Resident 3 was admitted with diagnoses including dementia (decline in memory or decision-making ability), muscle weakness, and abnormalities in gait (how a person walks) and mobility. A review of the Interdisciplinary Team notes dated 1/20/26, indicated Resident 3 had two fall incidents on 1/14/26. During a concurrent observation and interview on 1/28/26, at 12:49 PM, with Resident 3, Resident 3 was sitting up in a wheelchair in the hallway, alert, verbally responsive, calm and pleasant. Resident 3 was able to state his name. [...]

Inspectors wroteBased 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. This failure had the potential to result in residents not receiving appropriate and personalized care.

Inspectors wroteBased 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: 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a system for preventing infection for 3 (Resident #81, #21, and #116) of 24 sampled residents. Specifically, the facility failed to disinfect Resident #81's mattress after staff stepped on the mattress and disinfect a blood pressure cuff after resident use and prior to use for Resident #21 and Resident #116.

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure residents did not smoke in non-designated areas not equipped with needed safety equipment and devices. In addition, the facility failed to enforce their smoking policy regarding the storage of lighters for 2 (Resident #39 and Resident #106) of 3 sampled residents reviewed for smoking. This deficient practice had the potential to affect all 7 residents identified by the facility as smokers.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to complete a discharge Minimum Data Set (MDS) for 1 (Resident #108) of 3 residents reviewed for closed records. Specifically, the facility failed to complete a discharge MDS assessment for Resident #108, after the resident was discharged to a hospital on [DATE].

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded to reflect the presence of behaviors for 1 (Resident #93) of 2 residents reviewed for behaviors. Specifically, the facility failed to ensure behavioral symptoms exhibited during the seven-day look-back period were coded on Resident #93's 08/23/2024 quarterly MDS.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to resubmit a Level I Preadmission Screening and Resident Review (PASRR) for 1 (Resident #71) of 3 residents reviewed for PASRR requirements after receiving a letter that indicated a Level II Mental Health Examination was not scheduled and to reopen the case, a new Level I Screening would need to be submitted.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications were not left at the bedside for 1 (Resident #21) of 5 residents observed during medication administration. Specifically, facility staff left medications at the bedside of a resident who had impaired eyesight and had not been assessed as safe to self-administer medications.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to obtain laboratory services in a timely manner for 1 (Resident #15) of 5 residents reviewed for unnecessary medications. Specifically, Resident #15 had an order to check their Keppra (an anticonvulsant) level every six months. The facility failed to obtain the resident's Keppra level in September 2024, six months after the previous level was obtained.

Inspectors wroteBased on interview, record review, and facility document review, the facility failed to ensure 1 (room [ROOM NUMBER]) of 40 resident rooms was not equipped to accommodate more than four residents. room [ROOM NUMBER] was occupied by four residents but had six beds available for use when at full occupancy.

Inspectors wroteBased 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.

Inspectors wroteBased 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. This failure had the potential not to maintain the highest practicable physical, mental, and psychosocial well-being of Resident 1.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the allegation of resident to resident abuse was promptly reported to the State Agency (SA, which is the California Department of Public Health) in accordance with the facility policy and procedure for one of four sampled residents Resident 1. Failure to promptly report allegation of abuse has potential for further abuse to happen thereby increasing the harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to ensure safety for one of one sampled resident (Resident 3) when Resident 3 was found outside the facility unaccompanied. The facility's failure had the potential for resident harm. Resident 3 was admitted with diagnoses including dementia (a decline in memory or other thinking abilities). A review of Minimum Data Set (MDS, a standard assessment tool) dated 2/23/24, Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive function (includes learning, thinking, and decision-making abilities) score of 5 indicated severe cognitive impairment (rarely makes decision). MDS also indicated Resident 3 has wandering behavior. During observation on 4/11/24, at 11:45 AM, Resident 3 was alert, smiling. Resident 3 got out of bed and ambulated to the bathroom. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively assess weight loss, revise, and implement therapeutic interventions for one of one sampled resident (Resident 19) when Resident 19 had an unplanned weight loss. The facility's failure resulted to Resident 19 to experience a gradual, unintended, progressive weight loss overtime.

Inspectors wroteBased on interview and record review the facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM, the extent or limit to which a part of the body can be moved) for 18 of 18 sampled residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18,) when physician order for Restorative Nursing Assistant Program (RNA, nursing interventions that promote the residents ability to adjust to living as independently and safely as possible) was not implemented. The facility failure had the potential for the residents to limit the ROM and a possible development of a contracture (shortening of muscles and joints which limit and interfere with daily functioning).

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its plan of action to correct the identified deficiency regarding the Restorative Nursing Assistant (RNA, nursing interventions that promote the resident's ability to perform activities of daily living as independently and safely as possible) Program. The facility failure resulted in non-compliance to F688 which had the potential for the residents to limit range of motion (ROM, how far a person can move or stretch a part of the body) and a possible development of contracture (shortening of muscles and joints which limits and interfere with daily functioning). (Refer to F688)

Inspectors wroteBased on interview, observation, and record review, the facility failed to respond to a residents call for staff assistance in a timely manner when Resident 38, one of 43 sampled residents, waited half an hour to receive peri-care (hygienic care) due to soiled undergarments. This failure had the potential to cause skin injury and emotional distress to the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and sanitary environment when shower room [ROOM NUMBER]was found uncleaned and unhygienic. The facility failure has the potential for residents to cause uncomfortable experience during bathing and use of the shower room.

Inspectors wroteBased on interview, observation, and record review, the facility failed to treat residents with dignity when Resident 38, one of 43 sampled residents, waited half an hour to receive peri-care (hygienic care) for soiled undergarments. This failure had the potential to cause injury and emotional distress to the resident.

Inspectors wroteBased on interview and record review, the facility failed to accommodate the residents needs for tissue paper for Resident 37, one of one sampled resident, (a disposable piece of absorbent paper used as a handkerchief), who did not speak English, when tissue paper was unavailable to the resident for two days. This failure did not create an infection-controlled, individualized, respectful, and home-like environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the allegation of accidents, was promptly reported to the State Agency (SA, which is the California Department of Public Health, CDPH) in accordance with facility's policy and procedure for one of two sampled residents (Resident A). This failure to report fall with injury has potential for further accidents to happen not being reported.

Inspectors wroteBased on interviews and record reviews, the facility failed to identify and document changes in Resident's A condition when: weight loss started on 1/12/23, IDT (Interdisciplinary Team) meeting done on 8/14/23, The care plan had no updates on intervention since 2019. These failures had the potential for Resident 1's condition not assessed and needs not addressed, could result in Resident A not getting the care that she needs.

Inspectors wroteBased on interview and record review, the facility failed to provide Occupational therapy ( OT, used to improve abilities that are needed to live life as independently as possible) services to one of one sampled resident (Resident 20) when OT services was ordered by the physician. The facility failure had the potential for further physical decline during Resident 20's stay in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate no more than four residents per room when one resident room contained a total of six residents. This failure had the potential for residents to receive less privacy, care and attention, more noise and distraction.

Inspectors wroteBased from interviews and record review, the facility failed to ensure the allegation of resident to resident abuse was promptly reported to the State Agency (SA, which is the California Department of Public Health, CDPH) in accordance with the facility's policy and procedure for four of eight sampled residents Resident 1 and Resident 2, Resident 3 and Resident 4). Failure to promptly report allegation of abuse had the potential for further abuse to happen and thereby increasing the chances of harm to the residents.

Inspectors wroteBased on interview and record review, the facility failed to complete elopement risk assessment for 2 residents, and provide supervision for (Resident 1 and Resident 2) when they left the building unsupervised. Resident 1 was found on the street in the next town, in shirt and slippers on 11/11/23 at around 5 PM. Resident 2 went missing on 7/20/21, at 9PM. Was found 7/21/21 in her San Francisco apartment. This failure has potential to result in harm or danger to these cognitively impaired residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively assess or develop therapeutic interventions including but not limited to implementation of a therapeutic diet for one of two sampled residents (Resident 35). This failure resulted in Resident 35 experiencing severe weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident centered care for two of two sampled residents (Resident 43 and Resident 114) when: a. Effective interventions were not developed to prevent urinary tract infection (UTI, urine infection, bladder infection) for Resident 43; b. Intervention were not reevaluated for effectiveness to address weight loss for Resident 114. This facility failure resulted to a. Recurrent UTI for Resident 43 and; b. Weight loss for Resident 114.

Inspectors wroteBased observation, interview, and record review, the facility failed to provide a safe, hazard free environment to two of two sampled residents (Resident 64 and Resident 113) when: a. a knife was found at the bedside of Resident 64; b. A movable, unsecured TV was found placed on the bedside table at the foot area of the bed for Resident 113. This facility failure has the potential for Resident 64, other residents, and staff to sustain an injury; and the Television Set (TV) to fall on to Resident 113.

Inspectors wroteBased on observation, interview, and record review, the facility had 18.9% medication error rate when seven medication errors out of 37 opportunities were observed during a medication pass for Resident 61, Resident 68, and Resident 98. These deficient practice resulted in medications not given in accordance to the prescriber's order and/or manufacturer's specification which may result in residents not receiving the full therapeutic effect of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage of medication for one of 24 sampled residents (Resident 64) when unprescribed medications were found at the bedside. This failure has the potential for duplication of treatment which can lead to untoward effects for Resident 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the competencies of sanitizing (to make clean and hygienic; to disinfect) testing process and sanitizing process were completed according to manufactures' instructions when: 1. Kitchen Aide 1 did not follow the instruction of manufacture's sanitizing testing process. She did not check Quaternary Ammonium (quat: a kind of sanitizing water) solution temperature and dipped the test strip to the quat solution for 3 seconds rather than manufacturer's recommendation of 10 seconds. 2. Maintenance Supervisor (Env) did not follow the manufacture's instruction of sanitizing process for ice machine. This failure has the potential to increase spread of infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure menus were followed during lunch trayline observation. Parsley garnish was not served as menus for six of 18 residents. There was a total of 44 residents with physician ordered mechanical soft diets per tray tickets of 12/2/21. This failure had the potential to cause aspiration problem to residents who have swallowing difficulties, and to affect the residents' appetite.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain its infection control program when: 1. The blood pressure (BP) monitor (an equipment used to measure blood pressure) and medication tray were not disinfected between resident use. 2. The Licensed Nurse did not wear the required personal protective equipment (PPE) inside the isolation room (room [ROOM NUMBER]) during medication administration. 3. For Resident A, the Continuous Positive Airway Pressure (CPAP) machine (an equipment that uses a hose connected to a mask or nosepiece to deliver constant and steady pressure to help the breathing during sleep) was placed on the floor and the nosepiece connected to a hose was left uncovered inside the bedside drawer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services in a timely manner for one of five residents (Resident A) when the Sevelamer Hydrochloride (a phosphate binder medication used to control high blood level of phosphorous, a mineral found in food, in people with kidney disease who are on dialysis) was not available on 1/27/22. This failure resulted to Resident A not receiving the scheduled medication and had the potential for Resident A to suffer from high phosphate concentration in the blood.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents (Resident A) was free of significant medication error when, Resident A did not receive two doses of Sevelamer Hydrochloride (a phosphate binder medication used to control high blood level of phosphorous, a mineral found in food, in people with kidney disease who are on dialysis) on 1/27/22. This failure resulted to Resident A not receiving the scheduled medication and had the potential for Resident A to suffer from high phosphate concentration in the blood.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hot food was served that is palatable temperature and appetizing texture when test tray temperature was not in range per policy and texture was not smooth enough softer than whipped topping per standardized recipe. This deficient practice had the potential to negatively impact the residents' dining experience which may result in poor dietary intake that could potentially compromise their health and nutritional status. Definition: 1. Food palatability - refers to the taste and/or flavor of the food, acceptable to the taste. 2. Proper (safe and appetizing) temperature - both appetizing to the resident and minimizing the risk for scalding and burns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with accepted professional standards of practice when a Japanese bread crumbs bag was not stored properly in a clean container. This failure had the potential to put residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure essential equipment, including a sanitizer faucet, biofilm chemical for the floor drains, and splashguard, were maintained in a safe operating condition. This failure had the potential to cause contamination in the kitchen, which could affect overall food service operations and safety to residents and staff.