Health inspection·May 12, 2023

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that irregularities in the Pharmacy Medication Regimen Review (MRR-a systematic evaluation of medication therapy) for one of three sampled residents (Resident 23) were acted upon when there was no evidence the attending physician reviewed and documented if actions had been taken to address the identified irregularities (includes use of medications without adequate monitoring, in excessive doses, and/or in presence of adverse consequences) for MRR dated April 2023 in response to the pharmacist's recommendations. This deficient practice had the potential risk for harm by causing adverse consequences related to medication therapy. Findings: Resident 23 was admitted on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, Alzheimer's disease (a progressive disease beginning with mild memory loss), and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). Review of Resident 23's Minimum Data Set (MDS- an assessment tool) dated 4/13/23 indicated, Resident 23's cognition is moderately impaired. Review of Resident 23's Physician Orders for 5/11/23 indicated, Resident 23 was on Mirtazapine (antidepressant) 15 milligram (mg) at bedtime for depression manifested by (m/b) inability to sleep/insomnia, Lorazepam (medication used to treat anxiety) 0.5 mg every 8 hours as needed for anxiety m/b agitation and/or verbalization of belief that staff may be taking things from her room, Seroquel 25 mg twice daily and Quetiapine [generic] 50 mg daily at 2:00 PM (an antipsychotic medication that treats several kinds of mental health conditions) for vascular dementia with behavioral disturbance m/b agitation, paranoia and hallucinations. Review of MRR dated 4/1/23 indicated, no response from the physician. In a concurrent interview on 5/11/23 at 10:54 AM, Registered Nurse (RN) 2 said, the pharmacist comes to do the medication review, and has a binder of the monthly individualized report. RN 2 stated, If the physician responds, he makes a note and signs it. During an interview on 5/12/23 at 9:54 AM, the Director of Nursing stated, We don't have it, when asked for the physician's response to the pharmacist-reported irregularities on Resident 23's MRR dated 4/1/23. During an interview on 5/12/23 at 10:46 AM, the Consultant Pharmacist (CP) said, MRR is done monthly and a formal note to the physician is written for recommendations that are appropriate at the time of review. The CP stated, Yes, it is expected the physician needs to see it (MRR) and elect what to do. Review of Resident 23's physician notes dated 4/11/23 and 5/5/23, did not indicate identified irregularities in the MRR dated 4/1/23 has been reviewed and what action has been taken to address it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 2 of 13 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 05/12/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of facility policy titled, Medication Regimen Review with effective date of 11/28/16, indicated, .7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR, or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 7.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it . Event ID: Facility ID: 056071 If continuation sheet Page 3 of 13 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 05/12/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 23) reviewed were free from unnecessary psychotropic medication (drugs that affect brain activities associated with mental processes and behavior) when: 1. Resident 23 received Seroquel (Quetiapine [generic] - an antipsychotic medication to treat severe mental disorder in which thought, and emotions are so weak that contact is lost with external reality) without appropriate indication, patient centered non-pharmacological approaches, and adequate behavior monitoring; 2. There was no evidence Gradual Dose Reduction (GDR - a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for Seroquel use was attempted; 3. Care plan did not reflect specific target behavior to be monitored for the use of Seroquel; 4. There was no rationale indicated when Lorazepam (medication used to treat anxiety) PRN was used for more than 14 days, and there was no duration of therapy indicated in the physician's order. These deficient practices had the potential to result Resident 23 to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis. For short-term adjunctive use while addressing underlying cause(s) of severe symptoms. In patients without a clinically significant response after an adequate trial (e.g., up to 4 weeks), taper and withdraw therapy. Only continue in patients with demonstrated benefit; attempt to taper and withdraw at regular intervals (e.g., within 4 months of initiation). [https://online.[NAME].com/lco/action/doc/retrieve/docid/patch_f/7598 accessed on 5/22/23]. According to the American Geriatrics Society (AGS) based on the Beers Criteria® (AGS Beers Criteria Guidelines for Healthcare Professionals to help improve the safety of prescribing medications for older adult) for Potentially Inappropriate Medication (PIM) Use in Older Adults 2023, .Quetiapine .Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. The recommendation is to strongly avoid the use of this medication . Findings: Resident 23 was admitted on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, Alzheimer's disease (a progressive disease beginning with mild memory loss), and vascular (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 4 of 13 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 05/12/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels of the brain) with agitation. Review of Resident 23's Minimum Data Set (MDS- a care area assessment and screening tool), dated 4/13/23, indicated, Resident 23's cognition was moderately impaired. Residents Affected - Few 1. During an observation and concurrent interview on 5/8/23 at 9:39 AM, Resident 23 was in her wheelchair watching television, smiling and in good spirits. Resident 23 said she loved staying in the facility, it felt like being home. Resident 23 was also observed on multiple occasions: on 5/8/23 at 12:30 PM, and on 5/9/23 at 10:22 AM, during which she did not exhibit any types of behaviors. During an interview on 5/8/23 at 12:36 PM, Certified Nursing Assistant (CNA) 1 said, Resident 23 was combative but usually nice, when asked what behavioral disturbance Resident 23 manifested. During an interview on 5/11/23 at 2:17 PM, CNA 2 said, at times Resident 23 would say, My mom was here earlier. CNA 2 stated, I think that's her hallucination. During an interview on 5/11/23 at 2:29 PM, Registered Nurse (RN) 1 said, behaviors manifested by Resident 23 were: sometimes she's in the hallway and wants to go out or would say that she doesn't want the medications. RN 1 further said, hallucinations as manifestation of behavioral disturbance was generalized because different people have different manifestations of hallucination (auditory or visual). RN 1 stated, Monitoring of hallucination should be specific to see if medication is effective. Review of current physician's orders included: Seroquel 25 milligram (mg) by mouth twice daily (BID) with a start date of 1/8/23, and Quetiapine 50 mg daily at 2:00 PM with a start date of 4/9/23, both for vascular dementia with behavioral disturbance manifested by (m/b) agitation, paranoia, and hallucinations. The orders did not indicate what specific target behaviors were to be monitored. 2. Review of Resident 23's medication administration record (MAR) indicated: - Seroquel 25 mg three times a day was administered from 1/1/23 to 1/7/23 - Seroquel 25 mg BID was administered from 1/8/23 to 5/11/23 - Quetiapine 50 mg daily was administered from 1/8/23 to 5/10/23 During a concurrent interview and record review on 5/12/23 at 9:54 AM, with the Director of Nursing (DON), the Pharmacy Services Report April 2023 with an attachment titled Note to Attending Physician/Prescriber printed 4/1/23 was reviewed. The Note to Attending Physician/Prescriber indicated, .If appropriate, please consider a GDR at this time. If not appropriate, please document rationale for contraindication . The DON said, there was no documentation the physician acted upon the pharmacist's recommendation for GDR and stated, We don't have it. During an interview on 5/12/23 at 10:46 AM, the Consultant Pharmacist (CP) said, MRR is done monthly and a formal note to the physician is written for recommendations that are appropriate at the time of review. CP stated, Yes, it is expected the physician needs to see it (MRR) and elect what to do. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 5 of 13 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 05/12/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 23's physician notes dated 4/11/23 and 5/5/23, did not indicate pharmacist's recommendation for GDR, identified in the MRR printed 4/1/23, has been reviewed and what action has been taken to address it. 3. During a concurrent interview and record review on 5/11/23 at 10:54 AM, with RN 2, Resident 23's care plan for psychotropic drugs was reviewed. The care plan did not indicate behaviors to be monitored for the use of Seroquel. RN 2 said, the care plan should reflect the overall care provided to the resident. RN 2 stated, Resident 23's care plan was not individualized, there was no behavior monitoring indicated, only observe for side effects for the use of Seroquel. 4. During a review of Resident 23's clinical record, the following were found: - The Physician Orders for 5/11/23 indicated, .Lorazepam 0.5 mg (milligram) 1 tab (tablet) by mouth every 8 hours as needed (PRN) for anxiety . with a start date of 10/4/22 and no stop date indicated. - The MAR for 1/2023 indicated, .Lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed for anxiety . and was administered on January 3 and 15, 2023. - The MAR for 2/2023 indicated, .Lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed for anxiety . and was administered on February 22, 2023. - The MAR for 3/2023 indicated, .Lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed for anxiety . and was administered on March 22, 2023. - The MAR for 4/2023 indicated, .Lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed for anxiety . and was administered on April 16 and 19, 2023. - The MAR for 5/2023 indicated, .Lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed for anxiety . and was administered on May 3 and 8, 2023. During an interview on 5/12/23 at 10:46 AM, CP said, for PRN psychotropic medications, he goes through the resident's medications twice or three times to evaluate, and for the medication to not stay on the resident's profile, only 10-14 days. The CP then writes a formal note to the physician for recommendations that are appropriate at the time of review. Review of facility policy titled, Psychotherapeutic Medication Management Program last revised on 6/21, indicated, .A. Physician Responsibilities .2. The psychotherapeutic medication order shall include the following information: Manifestations of the disorder and/or specific behavioral targets treated i.e., auditory hallucinations, hitting others, refusing to eat, etc. 4. The physician shall review the monthly psychotherapeutic summary and determine if the resident should remain on the same dose, or an adjustment should be made .G. Interdisciplinary Team .1. The resident's interdisciplinary care plan shall include the reason for the drug and describe the behaviors the drug was prescribed to treat . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 6 of 13 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 05/12/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a 7.69% error rate when two medication errors out of 29 opportunities were observed during a medication pass when: Residents Affected - Few 1. Resident 10 received Symbicort (medication used to treat asthma and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) was not in accordance with the manufacturer's instructions for use. 2. Resident 42 received Metoprolol (medication used to treat high blood pressure, chest pain, and heart failure) not in accordance with the physician's order. These failures resulted in medications given not in accordance with the physician's order and manufacturer's instructions for use that may affect the residents' clinical conditions. Findings: 1. During a medication pass observation on 5/9/23 at 9:28 AM, Registered Nurse (RN) 1 prepared Resident 10's Symbicort 160 microgram (mcg)-4.5 mcg/actuation HFA aerosol inhaler. RN 1 did not shake the inhaler prior to administering two puffs by mouth. During an interview on 5/9/23 at 9:31 AM, RN 1 acknowledged that he did not shake the inhaler before administering the medication, and stated, Yeah, I should shake before giving. Review of Symbicort instructions for use indicated, .Shake your Symbicort inhaler well for 5 seconds right before each use . 2. During a medication pass observation on 5/9/23 at 9:41 AM, RN 1 was observed preparing eight medications for Resident 42. Included in the medications was Metoprolol Succinate ER (Extended Release) 25 milligram (mg). RN 1 checked Resident 42's vital signs (clinical measurements, specifically heart rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and had a heart rate of 59 beats per minute. Then, RN 1 proceeded to give the eight medications to Resident 42. During an interview on 5/9/23 at 9:46 AM, RN 1 read Resident 42's heart rate on the monitor as 59 and acknowledged that the resident took all medications. RN 1 stated, Yes, all eight. During a concurrent interview and record review on 5/10/23 at 12:35 PM, with RN 1, Resident 42's electronic medication administration record (eMAR) dated 5/9/23 was reviewed. The eMAR indicated, a physician's order for Metoprolol Succinate ER 25 mg tablet once daily for hypertension, hold for SBP (systolic blood pressure - measures the pressure in the arteries when the heart beats) less than 100 or HR (heart rate) less than 60. RN 1 read the physician's established parameters and acknowledged that the medication was administered on 5/9/23 with Resident 42's HR at 59. RN 1 stated, I should have held the medication. RN 1 said, Resident 42's heart rate might go down and can cause loss of consciousness. Review of facility policy titled, Medication Administration revised on 2/18, indicated, .B. Holding Medications .2. The following criterion must be met in order to hold ordered medications .For cardiovascular drugs, BP or pulse outside MD established parameters . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 7 of 13 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 05/12/2023 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 and/or medical supplies were properly labeled and stored. There were four expired nasal swabs, two packets of expired supplement powder, six packets of expired food thickener in Atrium medication cart. Also, there were boxes of expired insulin syringes, 18 expired electrocardiogram (ECG/EKG - records the electrical signal from the heart to check for different heart conditions) electrodes (sticky patches placed on the chest to record the heart's electrical signals), one canister of expired Sani-Cloth Purple Wipes, six expired intravenous (IV) catheters (a flexible tube inserted to a vein to administer fluids or medications), two expired IV start kit, two expired CADD (Continuous Ambulatory Delivery Device -a small, battery-operated pump that can be used to send fluids, medication, and chemotherapy as an intravenous infusion) administration sets, five dressing change trays, five expired foam dressings, 21 expired syringe tip caps, 12 expired needleless connectors (device that allow quick access to the infusion line, ensuring a secure connection), 41 expired female luer lock caps (connect to all syringe tips in place of a dispensing tip), 18 expired duoderm dressings (indicated for the management of lightly exuding wounds), one expired IV connecting tubing, two expired hypodermic safety needles (medical tool which enters the skin, a very thin, hollow tube with one sharp tip), two expired angiocaths (thin hollow tubes that allow the introduction of contrast dyes into various areas of the body for diagnostic purposes) and an expired vacutainer safety lok blood collection set (a sterile closed system for drawing blood from difficult veins) found in the medication storage room. This deficient practice had the potential to cause unsafe and/or inappropriate storage and administration of medications to residents. Findings: 1. During an observation on 5/9/23 at 10:35 AM, with Registered Nurse (RN) 3, there were four nasal swabs in the third drawer from the top, on the left side of the Atrium Medication Cart. The swabs indicated an expiration date of 1/31/22. During a concurrent interview, RN 3 said, the swabs were used for respiratory pathogen panel (checks for virus, bacteria, or other organism that causes an illness in the respiratory tract). RN 3 stated, It should not be there, should be discarded. During an observation on 5/9/23 at 10:35 AM, with RN3, there were two JUVEN (brand name) supplement powder with an expiration of 12/1/21 and six packets of SIMPLY THICK (brand name) food thickener with an expiration of 8/4/22, in the fourth drawer from the top, on the left side of the Atrium Medication Cart. During a concurrent interview, RN 3 said, the food thickener is used to thicken thin liquids for residents on nectar thick diet. RN 3 stated, It should not be in the cart. 2. During an observation of the Medication Storage Room on 5/9/23 at 10:52 AM, with RN 3, the following were found: A box of insulin syringes (110 pieces) with an expiration date of 12/31/22; 18 ECG/EKG electrodes with an expiration date of July 2017; A canister of Sani-Cloth purple wipes with an expiration date of April 2023; IV catheters with different expiration dates: one on 11/30/21, four on 2022, and one on 1/31/23; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 8 of 13 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 05/12/2023 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 Two IV start kit with an expiration date of 2022 Level of Harm - Minimal harm or potential for actual harm Two CADD administration sets with an expiration date of 2022 Dressing change trays with different expiration dates: two on 2022, and three on 2/19/23; Residents Affected - Some Five Allevyn (brand name) dressing with an expiration date of July 2022; Syringe tip caps with different expiration dates: 14 on 12/2021 and 7 on 2/2023; 12 Needleless connectors with different expiration dates: 6/2022, 8/2022, and 11/2022; Female Luer Lock caps with different expiration dates: three on 2020, 19 on 2/2021, and 19 on 11/2022; Duoderm dressings with different expiration dates: three on 9/2021, seven on 5/2022, and eight on 11/2022; One IV connecting tubing with an expiration date of 11/2022; Two hypodermic safety needles with an expiration date of 6/2020; Two angiocaths with an expiration date of 3/2021; and A vacutainer safety lok with an expiration date of 12/31/22. During a concurrent interview, RN 3 acknowledged the above findings. During an interview on 5/9/23 at 1:03 PM, with RN 2 and the Director of Nursing (DON), RN 2 confirmed the above findings. The DON said, the expired supplies should not be in the medication storage room and should be discarded. Review of facility policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles last revised on 4/1/22, indicated, .3. General Storage Procedures .3.4 Facility should ensure that infusion therapy products and supplies are stored .according to the manufacturer's or supplier's recommendations .3.7 Facility should ensure that .disinfectants and other household substances are stored separately from medications .19. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 9 of 13 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 05/12/2023 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure food sanitation when: Residents Affected - Many 1. Two expired 1.86 liters of chocolate caramel were found on the shelf of the canned food storage area, 2. A kitchen equipment and stove/warmer were found unclean in the plating area of the kitchen. These failures have the potential to place the residents at risk for food borne illness. Findings: 1. During the initial tour of the facility's kitchen on 5/8/23 at 9:20 am, it was observed that two 1.86 liters can of Chocolate Caramel were stored on the front of the second layer of the canned food storage shelf. During a concurrent interview with the Executive Chef (EC), Director of Dining Services and Registered Dietitian (RD), they stated that it was a mistake and an omission. They said that the cans of chocolate caramel were not supposed to be on that shelf and these were supposed to be discarded. The facility's undated policy and procedure titled the Food and Supply on page 1, indicated, Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date. 2. During observation on 5/8/23 at 9:21 am, the oven/warmer in the kitchen area was found to be dirty. When asked, the EC stated that they must order supplies to clean the equipment while the RD said they have to contact the company that made the equipment to come and loosen the parts so they can clean it. During observation on 5/11/23 at 11:00 am, the oven warmer was still not cleaned up. In a concurrent interview, the EC and RD stated that they called the company to come loosen the stove before they can clean it. The EC and RD could not say when is the appointment date/time. During a review of Area and Equipment Cleaning Policy on 5/11/23 at 2:00 pm, it indicated in the procedure: Director develops a reference manual on cleaning areas and equipments in the Food and Nutrition Services/Dinning Services, Assigns daily cleaning responsibilities in each position workflow .Management and Supervisory Personnel. Assigns weekly and special cleaning to be completed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 10 of 13 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 05/12/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2b. Resident 42 was admitted on [DATE] with diagnoses including multiple fracture (breaking) of ribs, pleural effusion (water on the lungs). Residents Affected - Some During the initial tour observation on 5/8/23, at 10:35 AM, Resident 42 was in her room sitting up on her wheelchair with oxygen concentrator (a medical device) on at one liter per minute via nasal cannula. The nasal cannula was not labeled. During a concurrent observation and interview on 5/8/23, at 10:38 AM, RN 1 checked the oxygen concentrator and the nasal cannula tubing, stated, I don't see any label. Further stated, There should be a label and change tubing every 72 hours. During an interview on 5/8/23, at 10:40 AM, DON acknowledged by stating, Yeah, we are supposed to label tubing when we put it together. During an interview on 5/9/23, at 4:05 PM, the IP stated, . the nasal cannula tubing should be dated and changed weekly. 3. Resident 42 was admitted on [DATE] with diagnoses including multiple fracture (breaking) of ribs, pleural effusion (water on the lungs). During the initial tour observation on 5/8/23, at 10:35 AM, Resident 42 was in her room sitting up on her wheelchair with oxygen concentrator on at one liter per minute via nasal cannula. The humidifier (a medical device used to humidify supplemental oxygen) attached to the oxygen concentrator was not labeled. During a concurrent observation and interview on 5/8/23, at 10:38 AM, RN 1 checked the oxygen concentrator and the humidifier, stated, I don't see any label. Further stated, There should be a label and change the humidifier when it's empty. During an interview on 5/8/23, at 10:40 AM, DON acknowledged by stating, Yeah, we are supposed to label when we put it together . looking at how often we have to change it. During an interview on 5/9/23, at 4:05 PM, the IP stated, humidifier should be dated and changed daily. Review of Physician's Orders (PO) for 5/11/23 on 5/11/23, at 3:00 PM, PO indicated, .Date and change humidifier bottle - every week or when water level is low. Review of facility policy titled, Departmental (Respiratory Therapy)- Prevention of Infection revised in November 2011, indicated, .Infection Control Considerations Related to Oxygen Administration . 3. [NAME] bottle with date and initials upon opening and discard after twenty-four (24) hours. 6. Change the oxygen cannula and tubing every seven (7) days, or as needed . Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment when: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 11 of 13 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 05/12/2023 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 0880 1. Level of Harm - Minimal harm or potential for actual harm Residents 13 and 23's handheld nebulizer masks were unlabeled and uncovered while not in use. 2. Residents Affected - Some Residents 23 and 42's oxygen tubing were unlabeled. 3. Resident 42's humidifier was unlabeled. These deficient practices could potentially result in the transmission and spread of infection causing harm to the residents. Findings: 1a. Resident 13 was admitted on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD- A group of lung diseases that block airflow and make it difficult to breathe). During an observation on 5/10/23 at 12:59 PM, Resident 13 was in bed, asleep. There was a nebulizer with an attached handheld mask that was uncovered and unlabeled on the bedside table. During an interview on 5/10/23 at 1:11 PM, Registered Nurse (RN) 1 acknowledged that the nebulizer mask was unlabeled and uncovered. RN 1 stated, The mask should be covered when not in use, so bacteria won't get in. For infection control. 1b. Resident 23 was admitted on [DATE] with diagnosis that included COPD. During the initial tour observation on 5/8/23 at 9:39 AM, Resident 23 was sitting on her wheelchair while watching television. There was a nebulizer with an attached handheld mask that was uncovered and unlabeled on the bedside table During an interview on 5/8/23 at 12:41 PM, the Licensed Vocational Nurse (LVN) 1 acknowledged that the nebulizer mask was unlabeled and uncovered. LVN 1 stated, When not in use, we have to cover so dust won't contaminate it. During an interview on 5/9/23 at 4:05 PM, the Infection Preventionist (IP) said, the nebulizer should be covered when not in use and should have the resident's name on it. Review of facility policy titled, Departmental (Respiratory Therapy)-Prevention of Infection revised in November 2011, indicated, .Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol .7. Store the circuit in designated bag, marked with date and resident's name, between uses .9. Discard the administration set-up every seven (7) days . 2a. During the dining observation on 5/8/23 at 12:30 PM, Resident 23 was sitting on her wheelchair, watching television while eating her lunch. Resident 23 was on oxygen via nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) attached to a small oxygen cylinder tank. The nasal cannula was unlabeled. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 12 of 13 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 05/12/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 5/8/23 at 12:36 PM, the Certified Nursing Assistant (CNA) 1 stated, She's (Resident 23) always on oxygen, 24/7. During an interview on 5/8/23 at 12:41 PM, the Licensed Vocational Nurse (LVN) 1 said, Resident 23 is on oxygen at 1 liter/minute when out of bed. LVN 1 acknowledged that the oxygen tubing was not dated, and stated, Not labeled. During an interview on 5/9/23 at 4:05 PM, the Infection Preventionist (IP) said, the nasal cannula should be dated and changed weekly. Review of facility policy titled, Departmental (Respiratory Therapy)-Prevention of Infection revised in November 2011, indicated, .Infection Control Considerations Related to Oxygen Administration .6. Change the oxygen cannulae and tubing every seven (7) days, or as needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056071 If continuation sheet Page 13 of 13