Nursing home’s troubling history
Issues plagued Millbrae facility before outbreak
A 140bed nursing home in Millbrae, the site of one of the largest coronavirus outbreaks in the county, has a history of health violations that includes a failure of infection controls, an unsanitary environment and inadequate care of its residents, records show.
More than 100 residents and 32 staff members at Millbrae Skilled Care have been infected by the coronavirus since March and 16 people have died, in one of the worst flareups among Bay Area nursing homes. The virus has been so widespread in the building that county officials removed some residents.
Now, the state has intervened and is regularly onsite to help.
COVID19 deaths and infections at nursing homes and assistedliving facilities have helped drive the pandemic, with nearly half of infections occurring at these locations. Deaths at nursing homes account for more than 40% of all COVID19 fatalities in the state, state public health data show.
“The majority of facilities with the largest outbreaks had previous problems. When you have outbreaks like this, this is very serious,” said Patricia McGinnis, director of California Advocates for Nursing Home Reform.
Millbrae Skilled Care had plenty of problems. The Cali
fornia Department of Public Health oversees the 140bed, forprofit nursing home. Medicare gave the facility a twostar overall rating and a onestar health inspection rating, on a scale of one to five, with one being the lowest.
In the nursing home’s most recent health report on Jan. 23, inspectors said Millbrae Skilled Care failed to create a comprehensive care plan for all of its residents. One resident had no painmanagement plan and another lacked a care plan for oxygen administration. The inspectors also faulted the home for allowing an oxygen tube to kink while the resident used it.
As a result, inspectors concluded that nurses and aides lacked the appropriate training to care for every resident.
In 2018, Medicare penalized the nursing home $43,804. Violations included a “strong fecalsewage odor” that seeped into residents’ rooms and flies in the kitchen. Inspectors found a toilet inside the kitchen near storage rooms, and the floor stained with a suspicious brown liquid.
Residents complained that they didn’t want to stay in their rooms due to the “stink” and some reported wearing masks to cover the smell, according to the health inspection.
The nursing home also failed to store food in sanitary conditions, leaving residents at risk for foodborne illnesses, the report said. Inspectors found flies in the kitchen and bathroom and dead flies in storage areas, according to the health inspection.
Since the Millbrae Care Center corporation took over operations in July, the nursing home has “not received any penalties, said Abby Ma, the home’s administrator. Ma gave The Chronicle a statement on the nursing home’s coronavirus response, but declined to answer questions.
The same month the new corporation took over, a Medicare health inspection found 15 deficiencies, including failing to help a resident with tooth brushing and allowing that person to have a “thick, white layer of saliva covering inside and outside of the mouth, dry, peeling skin on the lips, yellow, and white patches on tongue,” according to the report. The nursing home also failed to submit a resident’s assessment to the state within the required time period. Inspectors also concluded that the nursing home had no infection controls in place. Staff weren’t instructed on how to properly use personal protective equipment for a resident.
Such infectioncontrol and staffing problems are common in the nursinghome industry, critics say. The coronavirus pandemic highlights existing problems within such settings.
“People are dying,” McGinnis said. “The mortality of residents is going way up. This is no way to be treating our elders.”
On April 20, the county and state sent a team of infectioncontrol workers to Millbrae Skilled Care to provide personal protective equipment, training, testing and guidance on infectioncontrol practices.
“Our staff received and continues to receive training on current and updated infection control protocols,” Ma said by email. “These measures have been in place throughout this health crisis.”
She added that the facility has sufficient protective equipment for staff and patients.
Meanwhile, 32 staff members at the home have tested positive for the virus since March. In response, the county staff worked at the facility from May 15 to June 9. The team also helped isolate residents.
The California Department of Public Health “continues to be onsite regularly,” the state’s public health department said in an email.
The county transferred some residents to other facilities during the height of the surge, but all have since returned, said Ma, the facility administrator.
Since the stayathome orders came down in March, the county has started an aggressive plan to mitigate the spread of the virus, officials said.
“The COVID19 pandemic has significantly impacted congregate living facilities across the United States, and we continue to provide resources and coordination locally in the interest of protecting the public’s health and assuring the delivery of quality care and the safety of patients and staff,” said Travis Kusman, director of emergency medical services for San Mateo County.
Since June 19, a county team has visited 373 nursing homes and assistedliving facilities 508 times. The team has also tested residents for the coronavirus at 105 such locations with another 22 scheduled, the county’s health department told The Chronicle by email. And the county has responded to more than 1,500 requests for personal protective equipment.
“We’ve identified where the problem is, and I think what the county is doing is being aggressive in trying to figure out how we are going to solve this problem,” said county Supervisor David Canepa.