Sequoias San Francisco Convalescent Hospital

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

Environmental Deficiencies

Keep all essential equipment working safely.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Smoke Deficiencies

Have an alternate power supply for its alarm system.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Construction Deficiencies

Use approved construction type or materials.

Smoke Deficiencies

Have properly installed hallway dispensers for alcohol-based hand rub.

Smoke Deficiencies

Have an alternate power supply for its alarm system.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Emergency Preparedness Deficiencies

Provide emergency officials' contact information.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Properly provide smoke detection systems in areas open to corridors.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

Pharmacy Service Deficiencies

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Provide properly protected cooking facilities.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

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.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Construction Deficiencies

Use approved construction type or materials.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.