MILLBRAE SERRA CONVALESCENT HOSPITAL

The information below lists services this facility has provided for residents from December through December 2010. During this period, the most common type of service provided was "Very High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by Millbrae Serra Convalescent Hospital. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.

Very High Rehabilitation

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for California are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

Long-Term Stay Preventive Actions

Long-Term Stay Deficiencies

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 04/08/2011.

Administration

Hire a Qualified Social Worker; or in Homes with More Than 120 Beds, Hire a Qualified Full-Time Social Worker. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Keep Accurate and Appropriate Medical Records. Inspection Date: 03/30/2009 Correction Date: 04/21/2009

Environmental

Keep Safe, Clean and Homelike Surroundings. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Provide Needed Housekeeping and Maintenance. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Get Rid of Garbage Properly. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Have a Program to Keep Infection from Spreading. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Keep All Essential Equipment Working Safely. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Provide Rooms That Are Big Enough for Each Resident. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Have Enough Backup Water Supply for Important Areas of the Nursing Home. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 03/01/2010 Correction Date: 03/25/2010
Provide Rooms That Are Big Enough for Each Resident. Inspection Date: 03/01/2010 Correction Date: 03/25/2010
Make Sure That the Nursing Home Area is Safe, Easy to Use, Clean and Comfortable. Inspection Date: 03/01/2010 Correction Date: 03/25/2010
Keep Safe, Clean and Homelike Surroundings. Inspection Date: 04/08/2011 Correction Date: 05/04/2011
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 04/08/2011 Correction Date: 05/04/2011
Have a Program to Keep Infection from Spreading. Inspection Date: 04/08/2011 Correction Date: 05/04/2011
Provide Rooms That Are Big Enough for Each Resident. Inspection Date: 04/08/2011 Correction Date: 05/04/2011
Make Sure That a Working Call System is Available in Each Resident's Room or Bathroom and Bathing Area. Inspection Date: 04/08/2011 Correction Date: 05/04/2011

Mistreatment

1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents. Inspection Date: 03/01/2010 Correction Date: 03/25/2010
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property. Inspection Date: 03/01/2010 Correction Date: 03/25/2010

Nutrition and Dietary

Prepare Food That is Nutritional, Appetizing, Tasty, Attractive, Well-Cooked, and at the Right Temperature. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Prepare Food That is Nutritional, Appetizing, Tasty, Attractive, Well-Cooked, and at the Right Temperature. Inspection Date: 03/01/2010 Correction Date: 03/25/2010
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 03/01/2010 Correction Date: 03/25/2010
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 04/08/2011 Correction Date: 05/04/2011

Pharmacy Service

Keep the Rate of Medication Errors (Wrong Drug, Wrong Dose, Wrong Time) to Less Than 5%. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Properly Mark Drugs and Other Similar Products. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects. Inspection Date: 03/01/2010 Correction Date: 03/25/2010
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly. Inspection Date: 03/01/2010 Correction Date: 03/25/2010
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly. Inspection Date: 04/08/2011 Correction Date: 05/04/2011
Properly Mark Drugs and Other Similar Products. Inspection Date: 04/08/2011 Correction Date: 05/04/2011

Quality Care

Provide Activities to Meet the Needs of Each Resident. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Make Sure That Each Resident Gets Help to Keep Vision and Hearing. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary. Inspection Date: 03/01/2010 Correction Date: 03/25/2010
Make Sure That Each Resident's Nutritional Needs Were Met. Inspection Date: 03/01/2010 Correction Date: 03/25/2010
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Inspection Date: 04/08/2011 Correction Date: 05/04/2011

Resident Assessment

Make Sure All Assessments Are Accurate, Coordinated by an Rn, Done by the Right Professional, and Are Signed by the Person Completing Them. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 03/01/2010 Correction Date: 03/25/2010
Make Sure All Assessments Are Accurate, Coordinated by an Rn, Done by the Right Professional, and Are Signed by the Person Completing Them. Inspection Date: 04/08/2011 Correction Date: 05/04/2011
Screen Residents when They Are First Admitted to Send Them to an Area with Special Care for People with Developmental Disabilities or Mental Illness, if Needed. Inspection Date: 04/08/2011 Correction Date: 05/04/2011

Resident Rights

Provide Services to Meet the Needs and Preferences of Each Resident. Inspection Date: 03/30/2009 Correction Date: 04/21/2009
Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items and Services Medicaid Covers and Which the Resident Must Pay For; or 2) How to Apply for Medicaid, Along with the Names and Addresses of State Groups That Can Help. Inspection Date: 03/01/2010 Correction Date: 03/25/2010
Immediately Tell the Resident, Doctor, and a Family Member If: the Resident is Injured, There is a Major Change in Resident's Physical/Mental Health, There is a Need to Alter Treatment Significantly, or the Resident Must Be Transferred or Discharged. Inspection Date: 03/01/2010 Correction Date: 03/25/2010
Provide Services to Meet the Needs and Preferences of Each Resident. Inspection Date: 03/01/2010 Correction Date: 03/25/2010
Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items and Services Medicaid Covers and Which the Resident Must Pay For; or 2) How to Apply for Medicaid, Along with the Names and Addresses of State Groups That Can Help. Inspection Date: 04/08/2011 Correction Date: 05/04/2011

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Millbrae Serra Convalescent Hospital had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 04/13/2011.

Automatic Sprinkler Systems

Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 04/16/2009 Correction Date: 05/04/2009
Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 03/23/2010 Correction Date: 05/10/2010
Portable Fire Extinguishers. Inspection Date: 03/23/2010 Correction Date: 05/10/2010
Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 04/13/2011 Correction Date: 05/18/2011
Portable Fire Extinguishers. Inspection Date: 04/13/2011 Correction Date: 05/18/2011

Building Construction

Approved Construction Type or Materials. Inspection Date: 04/13/2011 Correction Date: 05/18/2011

Corridor Walls and Doors

Corridor and Hallway Doors That Block Smoke. Inspection Date: 03/23/2010 Correction Date: 05/10/2010
Corridor and Hallway Doors That Block Smoke. Inspection Date: 04/13/2011 Correction Date: 05/18/2011

Electrical

Properly Installed Electrical Wiring and Equipment. Inspection Date: 03/23/2010 Correction Date: 05/10/2010
Weekly Inspections and Monthly Testing of Generators. Inspection Date: 04/13/2011 Correction Date: 05/18/2011

Exit and Exit Access

At Least Two Remote Exits on Each Floor or Fire Section of the Building. Inspection Date: 03/23/2010 Correction Date: 05/10/2010

Exits and Egress

Exits That Are Accessible at All Times. Inspection Date: 03/23/2010 Correction Date: 05/10/2010

Fire Alarm Systems

Properly Maintained Smoke Detectors. Inspection Date: 04/16/2009 Correction Date: 05/04/2009

Furnishings and Decorations

Exits That Are Free from Obstructions and Can Be Used at All Times. Inspection Date: 04/13/2011 Correction Date: 05/18/2011
Restrictions on the Use of Flammable Curtains. Inspection Date: 04/13/2011 Correction Date: 05/18/2011

Hazardous Area

Properly Installed Hallway Dispensers for Alcohol-Based Hand Rub. Inspection Date: 04/16/2009 Correction Date: 05/04/2009
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 03/23/2010 Correction Date: 05/10/2010
Properly Installed Hallway Dispensers for Alcohol-Based Hand Rub. Inspection Date: 04/13/2011 Correction Date: 05/18/2011

Illumination and Emergency Power

Properly Located and Lighted "Exit" Signs. Inspection Date: 04/13/2011 Correction Date: 05/18/2011

Medical Gases and Anesthetizing Areas

Proper Medical Gas Storage and Administration Areas. Inspection Date: 04/16/2009 Correction Date: 05/04/2009
Proper Medical Gas Storage and Administration Areas. Inspection Date: 04/13/2011 Correction Date: 05/18/2011

Smoking Regulations

Posted "No-Smoking" Signs in Areas Where Smoking is Not Permitted or Did Not Provide Ashtrays Where Smoking Was Allowed. Inspection Date: 04/13/2011 Correction Date: 05/18/2011