Deficiency Records for Sequoias San Francisco Convalescent Hospital
Updated as of April 01, 2024
A list of the most recent deficiencies for Sequoias San Francisco Convalescent Hospital. 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? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-12 | 2023-07-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-05-12 | 2023-07-10 | 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 | 2023-05-12 | 2023-07-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-12 | 2023-07-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-05-12 | 2023-07-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-12 | 2023-07-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-12 | 2023-07-10 | N |
| Use approved construction type or materials. | Fire Safety | 2023-05-16 | 2023-06-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-16 | 2023-06-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-16 | 2023-06-08 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-05-16 | 2023-06-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-16 | 2023-06-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-16 | 2023-06-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-16 | 2023-06-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-16 | 2023-06-08 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-05-16 | 2023-06-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-16 | 2023-06-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-08-30 | 2019-11-07 | 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 | 2019-08-30 | 2019-11-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-30 | 2019-11-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-02 | 2019-10-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-02 | 2019-10-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-02 | 2019-10-22 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-10-02 | 2019-10-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-11-07 | 2018-11-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-11-07 | 2018-11-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-07 | 2018-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-07 | 2018-11-30 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2018-11-07 | 2018-11-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-07 | 2018-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-07 | 2018-11-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-31 | 2018-10-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-08-31 | 2018-10-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-31 | 2018-10-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-08-31 | 2018-10-04 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2018-08-31 | 2018-10-04 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2018-08-31 | 2018-10-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-31 | 2018-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-31 | 2018-10-04 | N |
