Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sequoias San Francisco Convalescent Hospital during CMS and state inspections, most recent first.
Food-contact surfaces were found dirty and in poor repair throughout the kitchen, including heavily scored cutting boards with embedded residue, muffin pans with dried buildup, bulk-food bins with residue inside, an industrial can opener with soil on the blade and base plate, and ice machines with visible residue on internal parts. Staff confirmed several items were not clean to sight, noted the can opener should be cleaned after each use, and acknowledged that utensils and equipment stored in the dish room could not be assumed clean because cockroaches were present; a sous chef was also observed using a skillet from the dish room for resident food without additional cleaning or sanitization.
Improper Storage of Grease and Open Dumpster Lids: Kitchen staff left an uncovered pot of used cooking grease/oil stored on the floor under the 3-compartment sink, and it remained out overnight instead of being discarded after meal service. Surveyors also observed compost and recycle dumpsters at the loading dock with lids open, including food waste and food residue in the containers. V1EC stated the lids should be closed due to pest concerns, and the pest control manager confirmed recent pest sightings in the building and kitchen.
QAPI program failed to effectively include FANS. Surveyors found kitchen issues with pests, sanitation, and equipment maintenance, while staff interviews showed kitchen audits were inconsistent, not always done in the kitchen, and not thorough. The RD stated the kitchen safety and sanitation QAPI project had no strategy for improvement, no data to track progress, and was not quantifiable.
Kitchen equipment was not maintained in safe operating condition when the dishmachine was leaking and the floor in the dish room was very wet, with water also dripping from the clean side of the machine. Staff confirmed the leak had been present for a long time and had not been reported. In addition, a light cover under a vent hood was missing, leaving the bulb exposed, and the MM stated he was aware of the missing cover and was looking for one.
Unsanitary kitchen and nourishment room conditions were observed throughout the food service areas, including dirty and damaged walk-in cooler and freezer floors, broken tile and caulking, dirty ceilings, vents, fans, racks, carts, drainpipes, conduit, electrical boxes, and a sprinkler head. Surveyors also observed rodent droppings in multiple kitchen and nourishment room locations and cockroaches in the dish room while the floor was very wet and the dishmachine was leaking.
Pest Control Program Failed to Eliminate Cockroaches and Rodents: Surveyors found multiple German cockroaches in the kitchen dish room, rodent droppings throughout the kitchen and in the Health Center nourishment room, and live mice in the kitchen and atrium dining area. Staff observed pests on dish racks, the dish machine, floors, and walls, while food debris, used grease, leaks, moisture, open trash bins, missing door sweeps, and holes in walls/ceilings created conditions for pest activity. Pest control reports documented repeated mice/cockroach sightings and recommendations for trapping and sealing entry points, but leadership did not timely address the activity or fully review the vendor’s structural recommendations.
A resident was allowed to self-administer an inhaler and nasal spray without a completed self-administration assessment, resulting in the resident administering an incorrect dosage of nasal spray. The facility's policy requires an IDT assessment and physician's order for self-administration, which was not documented. The resident had mild cognitive impairment and was observed self-administering medications since admission from an Independent Living floor.
A medication error rate of 7.41% was observed in a facility when two residents received eye drops without the LVN following the proper procedure of pressing the thumb over the inner canthus to prevent systemic absorption. The errors involved Thera Tears and Timolol eye drops, and the Nurse Manager confirmed the LVN's non-compliance with the facility's policy.
Food-Contact Equipment Not Kept Clean
Penalty
Summary
Food-contact surfaces in the kitchen were not kept clean or in good repair, as shown by multiple observations of cutting boards, muffin pans, bulk-food bins, an industrial can opener, and ice machines with residue buildup, scoring, and other soil accumulations. Surveyors observed 21 cutting boards stored on a rack in the dishmachine room that were significantly scratched and notched, with embedded black and yellow residue and flaking surface coating. Two additional cutting boards in the food preparation/tray-line area were also significantly scored with black residue embedded in the surface, and facility staff confirmed they were not clean to sight. Surveyors also observed three muffin pans with yellow and dark brown dried residue, three bulk-food bins with brown, yellow, and orange residue on the inside surfaces, and an industrial can opener with rough gray matter on the blade and dried brown residue on the base plate and seam. Staff confirmed the residue on the pans, bins, and can opener, and stated the can opener should be cleaned after each use. The bulk-food bins held food thickener, flour, and brown rice, and when the residue inside the bins was wiped with a damp towel, it transferred to the towel. Two ice machines also had visible residue. One had pink and yellow residue on the evaporator cover and pink residue on the plastic frame above the evaporator plate, along with sticky rough residue above the ice bin; another had yellow residue on the inside surface along the top frame of the evaporator plate and in the plastic trough tray below it. Staff stated the ice machine was cleaned quarterly by an outside vendor and that there was no monitoring between services. In addition, the DON stated he could not say all utensils and equipment stored on dish room racks were clean because cockroaches were present, and a sous chef was observed taking a skillet from the dish room and using it to cook for a resident without any additional cleaning or sanitization despite several cockroaches being observed in the area.
Improper Storage of Grease and Open Dumpster Lids
Penalty
Summary
The facility failed to ensure used fat and oil drained from cooking equipment was covered and discarded in a way that prevented attraction of pests. During a concurrent observation in the kitchen on 2/9/26 at 10:33 AM, an uncovered large pot that was about 50% filled with black liquid and floating particles was stored on the floor under the 3-compartment sink. Brown, greasy-looking liquid was observed dripping down the outside of the pot. V1DD verified that the contents were used grease/oil from cooking and stated the contents were dumped daily. During an interview on 2/10/26 at 4:06 PM, V1DD stated the pot of cooking grease under the 3-compartment sink was not dumped at the end of the night on 2/8/26, so it remained out overnight, and that the pot of grease should be discarded after each meal service. On 2/13/26 at 4:52 PM, two dumpsters at the loading dock were observed with lids open; the compost dumpster contained bags of food waste and the recycle dumpster contained recyclables including opened food cans with food residue inside. V1EC stated the dumpster lids should be closed because of the risk of attracting pests, and V2PCMM confirmed there were recent pest sightings in the building and kitchen.
QAPI Program Did Not Effectively Include Food and Nutrition Services
Penalty
Summary
The facility failed to ensure there was an effective, comprehensive, data-driven QAPI program that included the Food and Nutrition Services (FANS) Department. The report states that this failure had the potential to result in not identifying issues and making system improvements in the FANS department, with possible contamination of food, food borne illness, and/or decreased quality of food for 39 residents who received food from the kitchen out of a census of 39. During the recertification survey, multiple kitchen issues were identified, including pests, cleanliness and sanitation concerns, and maintenance of equipment concerns. Review of facility policies showed the QAPI plan included Food Services and that the Qualified Dietitian was to meet regularly with the Food and Nutrition department and maintain a written record of those activities. However, interviews showed the audits were not being done consistently or thoroughly: the Dining Safety Assessment was completed monthly but not necessarily in the kitchen each month, kitchen audits were only done quarterly, and the last kitchen audit did not thoroughly check all areas. The Registered Dietitian stated she thought the audits should be done more frequently and more thoroughly, and also stated there was no strategy developed for improving identified issues and no data to track improvement. She further stated the kitchen safety and sanitation QAPI project was not quantifiable.
Kitchen Equipment Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to maintain kitchen electrical and mechanical equipment in safe operating condition when the dishmachine had leaking parts and a light cover under a vent hood was missing. Review of facility policies showed that essential equipment repairs were to be initiated by Maintenance within 24 hours and that proper maintenance of the physical plant and all equipment in the department was the responsibility of the Director in cooperation with Maintenance. The 2022 Federal Food Code was also cited as requiring equipment to be maintained in a state of repair. During observation in the kitchen, the dishmachine was in use and the dish room floor was very wet. A later observation showed a pipe under the dishmachine leaking, and water dripping from the counter on the clean side of the dishmachine. The Executive Chef confirmed the drainpipe was leaking and thought there was a crack in the counter where water was getting through. The Director of Dining Services stated the dishmachine had been leaking for a long time but had not been reported. In a separate observation, multiple lights under a vent hood were seen over cooking equipment, and one light cover was missing so the bulb was exposed. The Director of Dining Services stated maintenance had been informed of the missing hood light cover, and the Maintenance Manager stated he was aware of the missing cover and was looking for one.
Unsanitary kitchen and nourishment room conditions with pest activity
Penalty
Summary
Sanitary environmental conditions in the kitchen and nourishment room were not maintained. Surveyors observed multiple areas that were not in good repair and/or not clean, including walk-in cooler floors, kitchen tile flooring, baseboards, ceilings, walls, vents, fans, metal storage racks, a metal rolling cart, caulking around the 3-compartment sink, a walk-in freezer door, a walk-in refrigerator door gasket, the outer surface of a drainpipe under the 3-compartment sink, equipment wheels, conduit, electrical boxes, and a sprinkler head in the walk-in refrigerator. The report states these conditions had the potential to provide harborage for pests and/or contaminate equipment and/or food containers used for eating for 39 residents out of a census of 39. During observations in the kitchen, surveyors found residue, gaps, and deterioration in several food service areas. In walk-in refrigerator 1, there was dark brown and yellow residue along the edges of the metal floor, a gap between the floor and baseboard, raised floor areas, and a baseboard pulled away from the wall. In walk-in refrigerator 2, metal floor panels were not flush and there were gaps with brown residue along the walls and baseboard. In walk-in freezer 3, dried expanded foam was present along the floor surface and the floor was uneven with gaps between the metal floor panels and the floor. Outside freezer 2, broken tiles, missing grout, jagged caulking, and debris were observed. The baseboard near the service elevator was cracked, chipped, jagged, and had dark brown residue. The ceiling throughout the kitchen was discolored and had brown spattered residue and black fuzzy residue, with bent grid framework creating gaps. Missing wall tile and a visible hole were observed behind a food storage rack. Vents and fans throughout the kitchen had dusty or fuzzy residue, including a vent in the dry food storeroom that had black residue between the slats and residue falling onto the rack below. Storage racks, a metal cart, the 3-compartment sink caulking, the refrigerator door caulking and gasket, drainpipes under the sink, fryer wheels, rolling cart wheels, conduit, electrical boxes, and a sprinkler fixture all had visible residue or deterioration. Rodent droppings were observed in the nourishment room and throughout the kitchen food preparation and storage areas, and cockroaches were observed in the dish room on the floor, walls, dishmachine, and racks while the dish room floor was very wet and the dishmachine was leaking.
Pest Control Program Failed to Eliminate Cockroaches and Rodents
Penalty
Summary
The facility failed to maintain an effective pest control program when surveyors observed multiple German cockroaches of varying sizes in the kitchen dish room, rodent droppings throughout the kitchen, a live mouse in the kitchen, a live mouse in the atrium dining area, and rodent droppings in the Health Center nourishment room. Surveyors also observed structural and environmental conditions that supported pest activity, including gaps and holes in walls and ceilings, missing or removed door sweeps, open trash bin lids, residue and food debris in kitchen work areas, and moisture and leaks around the dish machine and plumbing. During observations in the kitchen, surveyors and facility staff confirmed cockroaches crawling on dish racks, the dish machine, floors, and walls, and staff acknowledged that cockroach sightings had begun the week prior. A pot containing used grease/oil was left sitting on the floor under the 3-compartment sink overnight, and staff stated that used oil and food debris could contribute to pest harborage and food sources. A sous chef was observed taking a skillet from the dish room and using it for resident food preparation without additional cleaning or sanitization, despite the presence of cockroaches in the dish room. Rodent activity was also documented in multiple areas. Surveyors observed rodent droppings in dry storage, behind a refrigerator, under racks, on food storage surfaces, and in the nourishment room. A mouse was seen exiting the dry storage room, another was observed in the atrium dining area, and a mouse was later seen moving along a wall and entering through a hole under a glass dining room door. Pest control reports reviewed by surveyors documented repeated sightings of mice and cockroaches, droppings, holes, and recommendations for mass trapping, door sweeps, sealing gaps, and other structural repairs. Facility leadership and staff gave inconsistent accounts of who reviewed the pest reports and what actions were taken, and the report states that the facility did not address pest activity in a timely manner or review all pest reports, including structural recommendations, provided by the pest control company.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to complete a medication self-administration assessment for a resident who was observed self-administering an inhaler and nasal spray. During a medication administration observation, a Licensed Nurse (LVN) handed the resident a nasal spray and an inhaler, allowing the resident to self-administer these medications. The resident administered two sprays of the nasal spray in each nostril, which was not the correct dosage, as the prescribed dosage was one spray in each nostril. The LVN admitted to not completing the self-administration assessment form for the resident, who had been self-administering these medications since admission from an Independent Living floor. The resident's clinical record indicated diagnoses of emphysema and atrial fibrillation, with a Brief Interview for Mental Status (BIMS) score of 10, indicating mild cognitive impairment. The facility's policy requires an interdisciplinary team (IDT) assessment and physician's order for self-administration of medications, which was not documented in the resident's chart. The facility's policy also mandates that the resident's ability to self-administer medications be assessed and documented before approval by the IDT and the resident's physician, which was not done in this case.
Medication Administration Errors Due to Non-Compliance with Procedures
Penalty
Summary
The facility experienced a medication error rate of 7.41% during a medication administration observation, where two errors occurred out of 27 opportunities. The errors involved two residents, one of whom was administered Thera Tears eye drops incorrectly, and the other was given Timolol ophthalmic drops improperly. The Licensed Vocational Nurse (LVN) did not follow the facility's policy and procedures for administering eye drops, which included pressing the thumb over the inner canthus to prevent systemic absorption and ensure proper distribution of the medication. Resident 19, who has a history of anxiety disorder and falling, was observed receiving Thera Tears eye drops without the LVN pressing the thumb over the inner canthus. Similarly, Resident 8, diagnosed with acute kidney failure and type 2 diabetes mellitus, received Timolol eye drops without the proper technique. The Nurse Manager confirmed that the LVN did not adhere to the facility's policy and procedure, which was also acknowledged during an interview with the LVN. The facility's policy, dated 4/1/22, clearly outlines the correct procedure for administering ophthalmic drops, which was not followed in these instances.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Francisco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Central Gardens Post Acute | 0.2 mi | ★★★★★ | 0 | 0 |
| Victorian Post Acute | 0.2 mi | ★★★★★ | 0 | 0 |
| Pacific Heights Transitional Care Center | 0.6 mi | ★★★★★ | 6 | 0 |
| Laurel Heights Community Care | 0.6 mi | ★★★★★ | 0 | 0 |
| San Francisco Towers | 0.6 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.