Sequoia Transitional Care

In the surveyor’s words

From the most serious findings on record at Sequoia Transitional Care, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Jul 19, 2021

  Based on observation, interview, and record review, the facility failed to ensure safe resident smoking practices were provided for 18 of 18 sampled residents who smoked (Resident 4, Resident 7, Resident 10, Resident 12, Resident 23, Resident 27, Resident 30, Resident 42, Resident 43, Resident 49, Resident 56, Resident 72, Resident 76, Resident 79, Resident 81, Resident 83, Resident 391, and Resident 392) when: 1. One Smoking Observation/Assessment (SOA) was not completed on admission for one sampled resident (Resident 30). 2. 11 sampled residents (Resident 79, Resident 72, Resident 4, Resident 76, Resident 30, Resident 42, Resident 43, Resident 49, Resident 10, Resident 391, and Resident 392) who smoked were allowed to keep their lighters and cigarettes/cigars in their possession. 3. […]

• Actual harm, isolatedF697Jan 15, 2026

  Based on observation, interview, and record review, the facility failed to ensure that pain management interventions were safely implemented and monitored for one of thirty sampled residents (Resident 71). Specifically, licensed nurses failed to appropriately monitor and reassess the resident following administration of prescribed opioid pain medication (morphine sulfate) and failed to identify and respond to adverse effects related to pain treatment. As a result of these failures, Resident 71 experienced opioid-induced over-sedation and respiratory depression, requiring emergency transfer to a general acute care hospital (GACH), treatment for opioid overdose including administration of Narcan (reverses opioid overdose), intubation (insertion of a tube to aid in breathing) for respiratory… […]

• Actual harm, isolatedF677Apr 17, 2025

  Based on observation, interview, and record review, the facility failed to provide care and services for one of three sampled residents (Resident 1) who was high risk for falls, had history of falls, and had a diagnosis of Dementia (decline in memory and thinking, severe enough to interfere with daily life) when Resident 1 was left waiting in the room to be toileted for approximately 30 minutes. This failure resulted in Resident 1 falling, sustaining laceration (cut) to the top of the head requiring three staples (little wire), and compression fracture (a type of broken bone that can cause the spine to collapse) of T (thoracic- middle section of spine) 5 (T5- is the fifth bone of the thoracic spine located in the middle of the back). […]

• Actual harm, isolatedF684Jun 22, 2023

  Based on interview and record review, the facility failed to follow its policy and procedure (P&P) on Change in a Resident ' s Condition or Status when the facility failed to notify the physician of a non-healing bruise (an injury appearing as an area of discolored skin on the body) and blister (a small bubble on the skin filled with serum and caused by friction, burning or other damage) for one of three sampled residents (Resident 1), left lateral shin sustained after a fall incident. […]

• Actual harm, isolatedF698Jul 19, 2021

  Based on interview and record review, the facility failed to provide [CONDITION(S)] (process of purifying blood of a person whose kidneys are not working normally) care and services according to professional standards of care for one of one sampled [CONDITION(S)] resident (Resident 14) when: 1. Dressing changes were not provided to the CVC (Central Venous Catheter - a small flexible tube that is inserted into a large vein for the purpose of providing [CONDITION(S)]) [CONDITION(S)] site. 2. A care plan (CP) was not revised after Resident 14 refused [CONDITION(S)] treatments. 3. The physician was not notified when Resident 14 refused his [CONDITION(S)] treatments on 6/30/21, 7/5/21 and 7/9/21. […]