MILLBRAE SERRA CONVALESCENT HOSPITAL

The information listed below provides an in-depth look into the type and quality of care offered at Millbrae Serra Convalescent Hospital. It is important to note that when evaluating if a nursing home is right for you or a loved one, ratings should not be taken as the sole deciding factor, but as one of many aspects to be considered.

Address

MILLBRAE SERRA CONVALESCENT HOSPITAL
150 SERRA AVENUE
MILLBRAE, CA 94030
(650) 697-8386

Nursing Home Ratings

Health Inspections
Quality Measures
Nursing Staff
R.N. Staff Only
Overall Rating

Percent of Beds Occupied

89%

Number of Residents and Certified Beds

  • Residents: 111
  • Certified Beds: 125

This Facility Accepts

  • Medicare
  • Medicaid

Operational Details

  • Operated By For Profit - Corporation
  • Offers Both Resident and Family Counseling Services
  • This Facility is Not Part of a Chain or Franchise

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Nearby Cities:

Burlingame | San Bruno | San Mateo

Resident Services

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.

Resident ServicesResident ConditionsPercent of Service Days

Very High Rehabilitation

Rehabilitation 500 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 0-5100.0%
Total Percent:100.0%
 

Rating Details For Millbrae Serra Convalescent Hospital

Nursing Staff -

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.

Nursing Hours Per Resident Per DayReportedExpected
Registered Nurse (RN) Hours31 Minutes45 Minutes
Licensed Practical/Vocational Nurse (LPN/LVN) Hours43 Minutes33 Minutes
Certified Nursing Assistant (CNA) Hours2 Hours and 15 Minutes2 Hours and 20 Minutes
Total Licensed Nurse Hours1 Hour and 14 Minutes1 Hour and 18 Minutes
Total Nurse Hours3 Hours and 29 Minutes3 Hours and 38 Minutes

Quality of Care -

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.

This FacilityCalifornia Average

Long-Term Stay Preventive Actions

Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season90-100%87%
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination90-100%86%

Long-Term Stay Deficiencies

Percent of Long-Stay Residents Who Had a Urinary Tract Infection10%8%
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse9%10%
Percent of Long-Stay Residents Who Are More Depressed or Anxious8%9%
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased8%11%
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores4%12%
Percent of Long-Stay Residents Who Have Moderate to Severe Pain3%4%
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair4%8%
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder71%58%
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder3%5%
Percent of Long-Stay Residents Who Were Physically Restrained-7%
Percent of Low-Risk Long-Stay Residents Who Have Pressure Sores1%3%
Percent of Long-Stay Residents Who Lose Too Much Weight8%7%

Health Inspection Details -

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.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

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

Fire Safety

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.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

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
Source: Medicare Nursing Home Compare; Department of Health Services of California - Licensing and Certification Program - Retrieved 2011