Health inspection·August 30, 2019

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many floor. Clips will be attached to these (the call lights) and clipped to the bed clothes to keep them within reach. There was no documentation of the facilities response to the concern regarding the bed raising buttons. During record review of the Resident Council minutes dated 7/18/19 indicated the clips for the bed controls were discussed. There was no documentation of the facilities response to the sliding bed raising button control bar concern. During record review of the Resident Council minutes dated 8/15/19 indicated no documentation for follow-up from the facility to residents regarding concerns about the sliding bed raising button control bars on beds. During an interview on 8/27/19 at 3:40 PM in hallway after the Resident Council meeting, the Director of Nursing (DON) stated they had not completed any work regarding the issue with the bed raising control bars sliding down and would put in a request order that day. During review of a Work Order 122847 dated 8/27/19 at 4:38 PM, indicated initiation of work to secure the remote control holders to the assist bars for all rooms. During record review on 8/30/19 at 10:51 AM, the Administrator provided a copy of a maintenance log titled, Completed Work Order 121227 for HC [Health Center] quarterly beds inspection dated 8/2/19 indicating, Ensure all the BC beds are safe and working in good conditions, report all the issues to supervisor. Preventative maintenance is a schedule of planned maintenance actions including equipment inspection, lubrication, calibration, etc. aimed at the prevention of breakdowns and failures before they occur. Ensure the thickness is at (left blank). Ensure no cracks, holes, slits, openings, stains etc. - need to replace mattress. The administrator also provided a copy of section 8 of the bed rails Transfer Assist User Manual, undated, which indicated a Mechanical Inspection and Maintenance Checklist that should include: Inspect rail latches; Ensure that all rails engage and lock as specified; Lubricate rail pivot points and all mechanical hinge points, bushings, and surface contact points as needed with white lithium grease; Inspect bed, rails, assist rails, or assist bars for the presence of tubing end caps and replace as required; Inspect all bed components (i.e. rails, clevis pins, hitch pins, etc .) for damage or excessive wear and replaced as necessary; Visually examine all welds for cracks; Inspect the head and foot sections for bending, warping or damage; Inspect all bolts and rivets to ensure that they are securely tightened and functioning properly. Check sleep surfaces to ensure all slats are intact; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sequoias San Francisco Convalescent Hospital 1400 Geary Blvd San Francisco, CA 94109 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Check casters to ensure they lock if applicable and roll properly. Level of Harm - Minimal harm or potential for actual harm In a concurrent interview, after reviewing the work order and user manual checklist, the Administrator stated, I do not have anything to support specific notes for routine maintenance of the assist bars. This work order does not specify the checklist was completed and should be more detailed. Residents Affected - Many 2) During a tour of the facility on 8/26/19 at 10:47 AM, the beds in rooms 215, 219 and 221 were observed to have bed rails in an up locked position regardless of whether or not a resident was in the bed. During a concurrent interview, Registered Nurse (RN) 2 stated, It is our normal practice to have bedrails up at all times and to have an assessment and consent on file. During an interview on 8/26/19 at 11:10 AM, the Director of Nursing (DON) stated, We got rid of all bed rails and switched to transfer assist bars due to changes in the regulation so we wouldn't have to do assessments and consents. During an interview on 8/26/19 at 3:40 PM, the DON stated, Grab bars are an opt out system. They are placed on almost all beds except one or two that said they didn't want them. During an interview on 8/27/19 at 12:14 PM, Resident 3 stated, Side bars were put on bed a few months ago. I was told the government wanted them there. They never asked me if I wanted them. During an interview on 8/29/19 at 11 AM, Registered Nurse (RN) 1 stated, no, we didn't perform resident assessments on use of the bed transfer assist bars. They are not restraints. During review of the clinical records on 8/30/19, there was no documented evidence to support quarterly reassessment of bed rails for 15 of 35 residents (Residents 1, 2, 3, 4, 10,12, 13, 16, 18, 19, 21, 23, 24, 25 and 28). During an interview on 8/30/19 at 11:22 AM, the DON stated, The current assist bars were installed the end of June 2019. Quarterly care conferences are held to determine updated consent status. The DON further stated, There is a lapse of timely assist bar consent reassessments for Residents 5, 7 and 11. 3. During review of the clinical records on 8/30/19, there was no documented evidence to support implementation of bed rail care plans for 28 of 35 residents (Residents 1, 3, 4, 5, 6, 7, 8, 10, 11, 12, 20, 13, 14, 15, 16, 17, 18, 19, 21, 23, 24, 25, 27, 139, 138, 140, 141 and 142). During review of the facility's user manual for the Assist Bar, undated, it indicated under section 2 Safety, 2.1 General Guidelines .Proper patient assessment and monitoring, and proper maintenance and use of equipment is required to reduce the risk of entrapment .To avoid injury . always maintain and inspect equipment per the instructions in this manual. Under section 2.2 Intended use, it indicated, The purpose of the Assist Bar is to provide the resident a grab bar in which they can use to assist themselves from a sitting position to standing while exiting a long-term care bed. Clinical staff must decide whether a resident would benefit from the use of this aid. Under section 5 Usage, indicated, To avoid patient entrapment from use of assist bar .only use the assist (up) position while attending to the resident. Return the assist bar to the storage (down) position when unattended. Under section 7 Maintenance, it indicated, 7.1 Cleaning and Care .maintenance and cleaning procedures should be conducted initially, between users, on a regular schedule and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sequoias San Francisco Convalescent Hospital 1400 Geary Blvd San Francisco, CA 94109 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm During review of the Policy and Procedure titled, Side Rails/Assist Bars dated 06/19 indicated, Procedure .3. Nursing staff .shall assess the need for assist bar upon admission, quarterly and when indicated . An assessment form and informed consent will be completed by nursing staff. 4. Nursing staff shall document initial assessment in the medical record and develop a care plan Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sequoias San Francisco Convalescent Hospital 1400 Geary Blvd San Francisco, CA 94109 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to maintain an account of all controlled drugs when the facility was not able to provide evidence of documentation of accounting of receipt and disposition of discontinued controlled substance (is generally a drug or chemical whose manufacture, possession, or use is regulated by a government; a prescription from a licensed physician [medical doctor] is needed to acquire these medications). This deficient practice had the potential for drug diversion. Findings: During medication room observation and concurrent interview with the Nurse Manager 1 (NM 1) on [DATE] at 1:40 PM, the storage for discontinued controlled substance medications contained the following: 14 Temazepam capsules - medication to treat sleep problem; 17 Clonazepam tablets - medication to treat anxiety (excessive fear and worrying); eight Triazolam tablets - medication to treat sleep problem; nine Zoldipem tablets - medication to treat sleep problem. NM 1 stated, when the controlled substance medications are discontinued the nurses give them to me. We do not have any kind of form to log the controlled substance medication that was given to me. During an interview with the Director of Nursing (DON) on [DATE] at 1:30 PM, the DON stated, No, I don't deal with that [discontinued controlled substance medications], you have to talk to the Nurse Manager [NM 1]. During a review of the facility policy and procedure titled, Disposal/Destruction of Expired or Discontinued Medications, Effective Date [DATE], indicated, Disposal of Controlled Substance Medications, 13. The facility should record destruction of controlled substances on: 13.1 Medication Disposition/Destruction Form; . 13.3 Medication Destruction Log Book. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sequoias San Francisco Convalescent Hospital 1400 Geary Blvd San Francisco, CA 94109 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on observation, interview and record review, the facility failed to ensure medications were properly labeled and stored when: 1. 75 suppositories used to treat nausea (feeling of an urge to vomit) and vomiting were found without labeling. 2. The temperature of the refrigerator containing vaccines was not monitored. This failure had the potential to dispense medication without a physician order and decrease the effectiveness of the vaccines. Findings: 1. During the medication room observation and concurrent interview with Nurse Manager 1 (NM 1) on 8/26/19, at 2:10 PM, 48 unlabeled promethazine suppositories, and 27 unlabeled prochlorperazine suppositories were found in one of one medication refrigerator in one of one medication room. NM 1 acknowledged the suppositories were not labeled and stated, Those are house supplies, we don't label them. During an interview with the Director of Nursing (DON) on 8/28/19 at 2:10 PM, DON stated, we do not have a specific policy for labeling. That's all we have, 2. During the medication room observation and concurrent interview with NM 1 on 8/27/19 at 2:15 PM, the temperature of the refrigerator containing 12 Prevnar 13 vaccine (used for prevention of pneumonia [a potentially serious lung disease]) and two Purified Protein Derivative (PPD, used for skin testing to determine if a person has tuberculosis [TB]) was not monitored. NM 1 acknowledged the finding and stated, I didn't know the temperature of the refrigerator containing vaccines has to be monitored twice a day. Review of the facility policy and procedure titled, Storage and Expiration Dating of Medications, Biological's, Syringes and Needles, dated 10/2016, indicated, .Facility should ensure that medications and biological's were stored at their appropriate temperature according to the United States Pharmacopeia guidelines for temperature ranges. Facility staff should monitor of vaccines twice a day . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 6 of 6