Health inspection·November 22, 2024

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete medication self-administration assessment for one resident out of four residents (Resident 15) observed during medication administration of inhaler and nasal spray, when no documentation that Resident 15 can self-administer medication. Residents Affected - Few This failure resulted in Resident 15 given the wrong dose of nasal spray. FINDINGS: During the medication administration observation on 11/19/24 at 9:20 a.m.,, for Resident 15, Licensed Nurse (LVN) 2 was observed preparing and administering (6) oral medications. LVN 2 pulled out Fluticasone propionate 50 mcg/ actuation nasal spray 1 spray both nares twice a day for postnasal drip, Trelegy Ellipta 100 mcg-62.5 mcg-25 powder for inhalation I puff inhalation once a day for Emphysema. LVN 2 handed Fluticasone bottle to resident, per LVN 2, resident does it herself. Resident shook the bottle and sprayed 2 sprays on the right nose and 2 sprays on the left nose. LVN 2 came out of the washroom and asked resident, how many sprays did you do Resident stated, 2 they don't work anyway. LVN 2 handed the inhaler to resident, reminded to take deep breath, resident pushed the inhaler button once, handed the inhaler back to LVN 2. Resident rinsed her mouth with water provided by LVN 2. A review of Resident 15's clinical record indicated, admitted on [DATE] with diagnoses including: Emphysema(a lung disease that makes it difficult to breathe), Atrial Fibrillation(irregular heartbeats). During an interview on 11/19/24 at 10: 30 a.m., with Resident 15, per Resident 14, I give it to myself, I gave 2 sprays they don't even work, maybe I don't need it. Resident stated she used to give this spray to herself. During an interview on 11/19/24 at 11 a.m.,, with LVN 2, per LVN 2, resident has been giving herself the inhaler and nasal spray since she has been admitted to the SNF. She came from the Independent Living floor. Don't remember completing the self-administration assessment form. During a concurrent interview and record review with on 11/20/24 at 10:15 AM, NM, per NM, there is a process for self- administration of medication. Resident request to self administer and IDT will meet and document result from the assessment form, if the resident is capable of doing her own medication. MD will have to be involved and IDT will need to care plan. needs pharmacy approval. Per NM, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 056071 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 11/22/2024 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)