Sequoias San Francisco Convalescent Hospital

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food contact surfaces of equipment were clean and/or in good repair including:Cutting boards;Muffin pans;Bulk-food bins;Industrial can opener;Ice machines; andItems such as cooking utensils/equipment stored in the dish room (room where equipment/utensils are washed and sanitized and stored before use) when pests were present. The failure to maintain food-contact equipment clean and/or in good repair, had the potential to result in contamination of food leading to food borne illness for 39 residents who received food from the kitchen out of a census of 39.

Inspectors wroteBased on observation and interview, the facility failed to ensureUsed fat/oil drained from cooking equipment was covered and was discarded to prevent attraction of pests (Cross reference F925). the lids to outside compost and recycle dumpsters were closed. This failure had the potential to attract pests resulting in contamination of food and/or utensils used for eating for 39 residents who received food from the kitchen out of a census of 39.

Inspectors wroteBased on interview and document review, the facility failed to ensure there was an effective, comprehensive, data-driven quality assurance and performance improvement (QAPI) program that included the Food and Nutrition Services (FANS) Department. This failure had the potential to result in not identifying issues and making system improvements in the FANS department eventually leading to contamination of food, food borne illness, and/or decreased quality of food for 39 residents who received food from the kitchen out of a census of 39. Review of the policy and procedure titled Leadership - Interrelationships of Qualified Dietitian and Directo of Dining date of revision 1/2026, showed the Qualified Dietitian meets on a regular basis with the Food and Nutrition department, at a monthly minimum. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain kitchen electrical and mechanical equipment in safe operating condition when:Parts associated with the dishmachine were leaking; andLight covering under a vent hood was missing. The failure to maintain kitchen mechanical and electrical equipment had the potential to result in food contamination from pests attracted to a wet environment, as well as fragments falling into food from an unprotected light bulb for 39 residents who received food from the kitchen out of a census of 39.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure sanitary environmental conditions in the kitchen and nourishment room when:Walk-in cooler floors, kitchen tile floor, baseboards were not in good repair and were not clean;Ceiling was not in good repair and not clean;Walls were not in good repair and/or not clean;Vents and fans were not clean;Metal storage racks were not clean;A metal rolling cart was not clean;Caulking (a flexible sealant used to fill gaps) for the 3-comapartment sink (used for cleaning pots and pans) and a walk-in freezer door was not in good repair and/or not clean, and the door gasket for a walk-in refrigerator door was not in good repair;The outer surface of a drainpipe under the 3-compartment sink was not clean;Equipment wheels were not clean;Conduit, electrical boxes were not clean;Sprinkler head in the walk-in [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program free of cockroaches and rodents: Multiple German cockroaches of varying sizes were found in the kitchen dish room. Rodent activity was found including a live mouse inside the kitchen, one live mouse in the atrium dining area, and rodent droppings throughout the kitchen. Rodent droppings were observed in the Health Center's (Skilled Nursing Facility) nourishment room (space designed for storing, preparing, and serving snacks, beverages, or light meals). Entry points/structural issues for rodents were not addressed. The facility did not address pest activity in a timely manner, and did not review all pest reports, including recommendations, provided by the pest control company. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete medication self-administration assessment for one resident out of four residents (Resident 15) observed during medication administration of inhaler and nasal spray, when no documentation that Resident 15 can self-administer medication. This failure resulted in Resident 15 given the wrong dose of nasal spray.

Inspectors wroteBased on observation, interviews and record review, the facility had a medication error rate of 7.41 % when two medication errors occurred out of 27 opportunities during the medication administration for two of four (Resident 8) and (Resident 19). The failure resulted in the nursing staff not following the facility's policy and procedures (P&P) and had the potential for the resident not receiving full therapeutic effects or causing side effects for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food sanitation when: 1. Two expired 1.86 liters of chocolate caramel were found on the shelf of the canned food storage area, 2. A kitchen equipment and stove/warmer were found unclean in the plating area of the kitchen. These failures have the potential to place the residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and/or medical supplies were properly labeled and stored. There were four expired nasal swabs, two packets of expired supplement powder, six packets of expired food thickener in Atrium medication cart. [...]

Inspectors wrote2b. Resident 42 was admitted on [DATE] with diagnoses including multiple fracture (breaking) of ribs, pleural effusion (water on the lungs). During the initial tour observation on 5/8/23, at 10:35 AM, Resident 42 was in her room sitting up on her wheelchair with oxygen concentrator (a medical device) on at one liter per minute via nasal cannula. The nasal cannula was not labeled. During a concurrent observation and interview on 5/8/23, at 10:38 AM, RN 1 checked the oxygen concentrator and the nasal cannula tubing, stated, I don't see any label. Further stated, There should be a label and change tubing every 72 hours. During an interview on 5/8/23, at 10:40 AM, DON acknowledged by stating, Yeah, we are supposed to label tubing when we put it together. During an interview on 5/9/23, at 4:05 PM, the IP stated, . the nasal cannula tubing should be dated and changed weekly. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standards of quality for Resident 13 when the licensed nurse failed to sign the medication as given on the electronic Medication Administration Record (eMAR - a tool used by nurses to keep track of the medications given to patients) as ordered by the physician (person qualified to practice medicine). This deficient practice could potentially compromise the health and safety of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure that irregularities in the Pharmacy Medication Regimen Review (MRR-a systematic evaluation of medication therapy) for one of three sampled residents (Resident 23) were acted upon when there was no evidence the attending physician reviewed and documented if actions had been taken to address the identified irregularities (includes use of medications without adequate monitoring, in excessive doses, and/or in presence of adverse consequences) for MRR dated April 2023 in response to the pharmacist's recommendations. This deficient practice had the potential risk for harm by causing adverse consequences related to medication therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 23) reviewed were free from unnecessary psychotropic medication (drugs that affect brain activities associated with mental processes and behavior) when: 1. Resident 23 received Seroquel (Quetiapine [generic] - an antipsychotic medication to treat severe mental disorder in which thought, and emotions are so weak that contact is lost with external reality) without appropriate indication, patient centered non-pharmacological approaches, and adequate behavior monitoring; 2. There was no evidence Gradual Dose Reduction (GDR - a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for Seroquel use was attempted; 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 7.69% error rate when two medication errors out of 29 opportunities were observed during a medication pass when: 1. Resident 10 received Symbicort (medication used to treat asthma and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) was not in accordance with the manufacturer's instructions for use. 2. Resident 42 received Metoprolol (medication used to treat high blood pressure, chest pain, and heart failure) not in accordance with the physician's order. These failures resulted in medications given not in accordance with the physician's order and manufacturer's instructions for use that may affect the residents' clinical conditions.