A list of the most recent deficiencies for Sequoia Transitional Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2023-10-17 | 2023-11-02 | N |
| Use approved construction type or materials. | Fire Safety | 2023-10-17 | 2023-11-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-17 | 2023-11-02 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-12 | 2023-10-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-12 | 2023-10-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-12 | 2023-10-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-12 | 2023-10-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-12 | 2023-10-27 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-10-12 | 2023-10-27 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-10-12 | 2023-10-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-12 | 2023-10-27 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-10-12 | 2023-10-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-12 | 2023-10-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-12 | 2023-10-27 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-10-12 | 2023-10-27 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-10-12 | 2023-10-27 | N |
| Keep all essential equipment working safely. | Health | 2023-09-22 | 2023-10-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-05 | 2023-09-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-22 | 2023-07-11 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-03-29 | 2023-04-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-29 | 2023-01-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-11 | 2022-01-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-23 | 2021-12-30 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-19 | 2021-11-01 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-07-19 | 2021-11-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-15 | 2021-09-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-19 | 2021-09-08 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-07-19 | 2021-09-08 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-19 | 2021-09-08 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-19 | 2021-09-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-19 | 2021-09-08 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-19 | 2021-09-08 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-07-19 | 2021-09-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-19 | 2021-09-08 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-07-19 | 2021-09-08 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-07-19 | 2021-09-08 | Y |
| Provide appropriate foot care. | Health | 2021-07-19 | 2021-09-08 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-07-19 | 2021-09-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-19 | 2021-09-08 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-07-19 | 2021-09-08 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-19 | 2021-09-08 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-07-19 | 2021-09-08 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-07-19 | 2021-09-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-19 | 2021-09-08 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-19 | 2021-09-08 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-07-19 | 2021-09-08 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-07-19 | 2021-09-08 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-07-19 | 2021-09-08 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-07-19 | 2021-09-08 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-07-19 | 2021-09-08 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-07-19 | 2021-09-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-19 | 2021-09-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-19 | 2021-09-08 | Y |
| Implement a program that monitors antibiotic use. | Health | 2021-07-19 | 2021-09-08 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-07-19 | 2021-09-08 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-07-19 | 2021-08-02 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-07-19 | 2021-08-02 | N |
| Use approved construction type or materials. | Fire Safety | 2021-07-19 | 2021-08-02 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-07-19 | 2021-08-02 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-07-19 | 2021-08-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-07-19 | 2021-08-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-19 | 2021-08-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-19 | 2021-08-02 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2020-02-20 | 2020-03-23 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2020-02-20 | 2020-03-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-02-20 | 2020-03-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-02-20 | 2020-03-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-02-20 | 2020-03-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-02-20 | 2020-03-23 | N |
| Use approved construction type or materials. | Fire Safety | 2020-02-20 | 2020-03-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-20 | 2020-03-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-20 | 2020-03-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-20 | 2020-03-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-20 | 2020-03-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-20 | 2020-03-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-20 | 2020-03-23 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2020-01-30 | 2020-03-18 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-01-30 | 2020-03-18 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-01-30 | 2020-03-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-30 | 2020-03-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-30 | 2020-03-18 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-30 | 2020-03-18 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2020-01-30 | 2020-03-18 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-01-30 | 2020-03-18 | N |
| Provide activities to meet all resident's needs. | Health | 2020-01-30 | 2020-03-18 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-01-30 | 2020-03-18 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-01-30 | 2020-03-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-30 | 2020-03-18 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-01-30 | 2020-03-18 | N |
