The Sequoias

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, when a carton of orange juice and 4 cartons of apple juice and a paper cup wrapped in plastic, inside the refrigerator in the pantry, has no expiration date, has no use by date, cup has no label. This failure has the potential to put residents at risk for foodborne illnesses. During a concurrent observation and interview on 8/4/25 at 10:30 AM, with Registered Dietitian (RD), in the refrigerator in the pantry, found one orange juice carton, and four apple juice cartons, with no expiration date and no use by date, and one paper cup wrapped in plastic no label. RD stated, every food stored in the refrigerator should have expiration dates or use by dates and should be labeled. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide Advanced Beneficiary Notice (ABN, a document informing residents Medicare will no longer pay for services and allows residents to make informed decisions on whether to continue certain services, which may incur out of pocket costs) to one (Resident 22) of three residents, when Resident 22 was discharged from Medicare Part A (temporary insurance which covers hospital and skilled nursing services) to long term care. This failure could have resulted in Resident 22 not given a chance to make informed decisions regarding his care or for his right to appeal. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise plan of care for Resident 32, one of 12 sampled residents, after 10 incidents of falls, to prevent further falls. This failure could result in resident's harm .Review of Resident 32's Facesheet, dated 8/5/24, indicated, Resident 32 was admitted on [DATE] with diagnoses including: Peripheral Vascular Disease (a condition that blood vessels are narrowed causing less blood flow to the limbs), Pain left leg , Cognitive Communication Deficit, Generalized Anxiety Disorder. During a concurrent observation and interview on 8/4/25 at 10:50 AM, in Resident 32's room, Resident 32 was observed in bed and had a caregiver(CG) from a private agency. CG stated she has been with patient for four years now, since last year doing 12 hour shift, was 24 hours before. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications (narcotics that have high abuse potential) were fully accounted for when a random controlled medication use audit for two out of four sampled residents (Residents 4, 24) did not reconcile. The residents' medications were signed out of the Controlled Drugs Records (CDR, inventory record of controlled drugs) but not documented on the Electronic Medication Administration Record (eMAR, record of medications administered to a resident) to indicate they were administered to the residents. This failure resulted in inaccurate accountability of controlled medications and had the potential for abuse and narcotic diversion (unlawful distribution or use) of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use was implemented when: 1. The Infection Preventionist (IP, a licensed nurse that has specialized training in infection prevention) did not communicate or provide notification to the primary medical doctor when the residents' presenting symptoms did not meet criteria for antibiotic use based on McGeer criteria (Standardized criteria to help consistently identify and classify infections treated with antibiotics) for 2 out of 6 residents (Residents 22 and 17).2. The IP did not track the antibiotic use for 1 out of 6 residents (Resident 26). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage in the kitchen when there was a garlic oil container beyond its use-by date in the refrigerator. This failure had the potential to put residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure there was a clean comfortable homelike environment when these two issues were found: 1. Two window screens had gaps. 2. Washbasins in four different rooms were found stored on the bathroom floor. Failure to ensure window screens were properly maintained had the potential to allow flying pests into residents' living spaces. Failure to store Resident's washbasins in a sanitary manner had the potential for residents to be exposed to dirty personal care equipment or infectious agents.

Inspectors wroteBased on interview and record review the facility failed to transmit one of 12 sample residents' MDS (Resident 22) in a timely manner and failed to complete and transmit one of 12 sample residents' MDS (Resident 26). Failure to transmit required assessments violated the facility's contractual agreement with the State and CMS. Additionally, the facility failed to provide a policy governing the tracking and timely transmission of MDSs.

Inspectors wroteBased on interviews and record reviews the facility failed to accurately code Resident 10's Minimum Data Set (MDS) assessment, one of 12 sample residents. Failure to accurately code Resident 10's assessment regarding restraints did not ensure health care providers could make safe and individualized health care decisions/recommendations based on Resident 10's MDS. Additionally, the facility failed to provide a policy regarding accurately coding a resident's MDS assessment.

Inspectors wroteBased on observation, interviews, and record review the facility failed to develop an individualized care plan for one of 12 sample residents (Resident 11). The facility failed to address Resident 11's behavior of refusing footrests for her wheelchair. Failure to develop an individualized care plan did not ensure the facility was providing care tailored to Resident 11's personal needs.

Inspectors wroteBased on interview, and record review, the facility failed to ensure there was monitoring for adverse side effect (harmful effects suspected to be caused by a medicine) or behavioral monitoring for Ambien (same as Zolpidem, a drug used to treat insomnia) for one of 3 sampled residents (Resident 136). This failure could result in Resident 136 receiving unnecessary use of, ineffective, and/or lack of monitoring for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic [a type of psychiatric medication which are available on prescription to treat psychosis]; (ii) Anti-depressant [prescription medicines to treat depression]; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all medications were properly labeled in one out of one sampled medication carts when Resident 132's Prednisone (a medication used to decrease swelling in the body) label was not consistent with the physician order written in the electronic medical record (EMR). This failure has the potential to result in a medication error that could over dose a resident or under dose them.

Inspectors wroteBased on interview and record review, the facility failed to transmit their Payroll Based Journal (PBJ) data to Center for Medicare Services (CMS) in a timely manner. Failure to transmit staffing data did not ensure the facility was fulfilling their contract agreement with the State and CMS. Additionally, the facility provided an incomplete PBJ data transmission policy which lacked certain key policy elements.

Inspectors wroteBased on interviews and record review the facility failed to ensure an intervention recommended by a physician was communicated in a timely fashion for Resident 1, one of 12 sampled residents. Resident 1 had a fracture of unknown origin, and his physician recommended no Hoyer lift (a transfer device). This recommendation was not communicated in a timely manner to all direct caregivers. Failure to communicate physician's recommendations to direct caregivers had the potential to inflict and/or worsen an injury. Additionally, the facility failed to provide their policy regarding shift-to-shift endorsement.

Inspectors wroteBased on interview and record review the facility failed to provide residents with the written summary of the Baseline Care Plan (BCP, Baseline Care Plan is developed and implemented for each resident that includes the instructions needed to provide effective and person centered care of the resident that meet professional standard of quality care and must be developed within 48 hours of a resident's admission) for seven (7) residents out of 12 sampled residents, Residents 4, 16, 18, 6, 13, 14, 75. Failure to provide written summary of the BCP to the residents had the potential to compromise person-centered care to each resident, and to safeguard against adverse events that are most likely to occur right after admission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and treatment according to standards of clinical practice for two of 12 sampled residents (Resident 4 and Resident 21) when: 1. The Omeprazole (a medication used to treat frequent heartburn and stomach ulcers) was not administered according to current physician's order for Resident 4. This failure resulted in a medication error. 2. The facility's procedure on management of indwelling catheter and closed drainage system was not implemented for Resident 21. This failure had the potential to cause cross contamination of infection that may jeopardize the health and safety of Resident 21.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage are contained and a dumpster are covered. This facility's failure has the potential to attract pest to the area.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain its infection control program when: 1. Cleaning and disinfection of the glucometer (a device used to measure blood sugar level) was not performed after use for Resident 18 who was on fingerstick blood sugar monitoring. 2. Resident 21's urinary drainage bag was left uncovered and touching the floor. 3. For Resident 13, the canister and the suction drainage tubing for urine collection was unlabeled and undated and the suction drainage tubing for urine collection was not cleaned after use. Failure to implement infection prevention practices may result in cross contamination of infection that may jeopardize the health and safety of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to effectively assess or develop therapeutic interventions to one of one sampled resident (Resident 14). The failure resulted in Resident 14 experiencing severe weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled according to federal regulations and facility policy and procedure when: 1. There was no direction change refer to chart label on the Omeprazole (a medication used to treat frequent heartburn and stomach ulcers) medication blister pack (a card that packages doses of medication within small, clear, or light-resistant amber-colored plastic bubbles) for Resident 4. 2. Suppository medications for two discharged residents were not removed from the active medication storage cabinet. These deficient practices had the potential to cause harm to residents through infection and medication errors.