Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 The Sequoias during CMS and state inspections, most recent first.
Surveyors found that a carton of orange juice, four cartons of apple juice, and a paper cup wrapped in plastic were stored in a refrigerator without expiration dates, use by dates, or labels. The Registered Dietitian confirmed that all refrigerated food should be labeled and dated, in accordance with facility policy and CMS guidance.
A resident transitioning from Medicare Part A to LTC did not receive the required Skilled Nursing Facility Beneficiary Notice of Non-Coverage (SNFABN), despite the issuance of a Notice of Medicare Non-Coverage (NOMNOC) to the family. The Social Worker confirmed the SNFABN was not completed, resulting in the resident not being properly informed of potential financial liability for non-covered services.
A resident with advanced dementia and high fall risk experienced 10 unwitnessed falls, yet the care plan was not reviewed or revised by the interdisciplinary team as required. Despite interventions like floor mats and a private caregiver, the care plan lacked input from the resident's representative and was not updated after repeated incidents, contrary to facility policy.
During a review of controlled medication records, surveyors found that nursing staff signed out narcotics from the CDR for two residents but failed to document administration on the eMAR as required. Interviews with the DON and an LVN confirmed that the facility's process and policy require documentation on both records, but this was not completed for several doses of Oxycodone and Tramadol given as PRN for pain management.
The facility did not ensure proper implementation of its antibiotic stewardship program, as the IP failed to notify physicians when two residents did not meet McGeer criteria for antibiotic use and did not track antibiotic use for another resident. Antibiotics were administered without qualifying symptoms or appropriate monitoring, contrary to facility protocols.
The facility failed to ensure safe food storage by keeping a garlic oil container beyond its use-by date in the refrigerator. During an observation, both the Director of Dining Services and the Executive Chef acknowledged the expired product should have been discarded, as per facility policy and CMS and FDA guidelines, to prevent potential foodborne illnesses.
A facility failed to communicate a physician's recommendation to avoid using a Hoyer lift for a resident with a fracture, leading to a delay in informing direct caregivers. The recommendation was not documented in the endorsement report book until nearly 48 hours later, and a CNA was only informed that the resident was on bedrest. The facility also lacked a policy on shift-to-shift endorsement.
The facility failed to ensure a clean and homelike environment by improperly storing washbasins on bathroom floors and having gaps in window screens. Washbasins used for personal hygiene were found on the floor in four rooms, and window screens in two rooms had gaps, potentially allowing pests inside. The facility's policies did not adequately address these issues.
The facility failed to transmit the MDS for a resident in a timely manner and did not complete and transmit the MDS for another resident, violating contractual agreements with the State and CMS. The MDS Nurse confirmed these issues during an interview and record review. Additionally, the facility lacked a policy for tracking and timely transmission of MDSs, submitting an incomplete document from a CMS manual instead.
A facility failed to accurately code a resident's MDS assessment regarding restraints, as the resident was incorrectly marked as restrained. The MDS Nurse was unsure why the assessments were coded this way and planned to correct and resubmit them. Additionally, the facility lacked a proper policy for accurate MDS coding, providing only pages from a CMS manual without essential policy elements.
A resident in a LTC facility was observed with her leg bent under her wheelchair due to refusing footrests, believing they would tip her chair. An LVN confirmed this behavior was not documented in her care plan, violating the facility's policy requiring comprehensive care plans for all residents.
A facility failed to monitor a resident for adverse side effects or behavioral changes while on Ambien, a hypnotic medication for insomnia. Despite the care plan requiring monitoring every shift, no evidence of such monitoring was found. Interviews with staff confirmed the absence of documentation regarding sleeping patterns or behaviors, contrary to the facility's policy on psychotherapeutic medication management.
A medication labeling discrepancy was identified in an LTC facility when an LVN dispensed Prednisone for a resident. The medication labels did not match the physician's order in the EMR, indicating a different dosage. The LVN acknowledged the discrepancy and noted the absence of a dosage change sticker. The DON and pharmacist confirmed the need for labels to match the EMR and for a change of direction sticker to prevent medication errors.
The facility failed to transmit PBJ data to CMS on time due to the MDS Nurse lacking access to the CMS website, which delayed submission past the deadline. Additionally, the facility's PBJ data transmission policy was incomplete, missing key elements like objectives, responsibilities, and purpose.
Failure to Label and Date Food Items in Refrigerator
Penalty
Summary
Surveyors observed that a carton of orange juice, four cartons of apple juice, and a paper cup wrapped in plastic were stored inside the pantry refrigerator without expiration dates, use by dates, or labels. During an interview conducted at the time of observation, the Registered Dietitian confirmed that all food stored in the refrigerator should be labeled with expiration or use by dates. Review of the facility's policy indicated that all food items must be covered, labeled, and dated, and that foods past their use by, sell by, or best by dates should be discarded. Additionally, CMS guidance requires staff to inspect, properly store, and label all food and beverages upon receipt and during storage. The lack of labeling and dating on these items constituted a failure to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Failure to Provide Required Beneficiary Notice Upon Change in Medicare Coverage
Penalty
Summary
The facility failed to provide an Advanced Beneficiary Notice (ABN) to a resident who was discharged from Medicare Part A coverage to long-term custodial care. During a review of records and an interview with the Social Worker, it was found that although a Notice of Medicare Non-Coverage (NOMNOC) was issued and signed by the resident's family member, the required Skilled Nursing Facility Beneficiary Notice of Non-Coverage (SNFABN) was not completed for the resident. The Social Worker acknowledged that the SNFABN was not used and stated awareness that it is required for long-term residents. This omission occurred when the resident transitioned from Medicare-covered services to custodial care, and the facility did not inform the resident of potential financial liability for services not covered under Medicare/Medicaid or the facility's per diem rate, as required by CMS guidance.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to review and revise the care plan for a resident after 10 incidents of unwitnessed falls, despite the resident being identified as high risk for falls. The resident, who was admitted with diagnoses including Peripheral Vascular Disease, pain in the left leg, cognitive communication deficit, and generalized anxiety disorder, had a history of moderate to advanced dementia and required total care. The care plan for falls was initiated, and interventions such as floor mats and a private caregiver during the day were in place. However, the care plan did not reflect input from the resident's representative, and there was no evidence that the plan was updated or revised after repeated falls, as required by facility policy and procedure. Observations and interviews revealed that staff were aware of the resident's frequent falls, particularly at night, and that the resident exhibited anxiety and confusion. The facility's fall risk assessments consistently indicated a high risk, and the resident's cognitive assessment was incomplete, with no BIMS summary score documented. Despite these findings and the facility's policy requiring the interdisciplinary team to update the care plan after falls, the care plan remained unchanged after multiple incidents, and the required comprehensive assessment and team review were not documented.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure that controlled medications were fully accounted for, as evidenced by discrepancies found during a random audit of controlled medication use for two out of four sampled residents. In both cases, nursing staff signed out controlled medications from the Controlled Drugs Records (CDR) but did not document the administration of these medications on the Electronic Medication Administration Record (eMAR). Specifically, for one resident with an order for Oxycodone 5 mg as needed for pain, the CDR indicated that doses were signed out on two occasions, but there was no corresponding documentation on the eMAR or in the nursing progress notes to confirm administration. For another resident with orders for Tramadol 25 mg and 50 mg as needed for pain, the CDR showed that doses were signed out on four occasions, but again, there was no documentation on the eMAR to indicate administration. Interviews with the Director of Nursing (DON) and a Licensed Nurse (LVN1) confirmed that the facility's process requires documentation of controlled medication administration on both the CDR and the eMAR. The DON and LVN1 verified that the required documentation was missing for the identified instances. Review of the facility's policy indicated that the licensed nurse is responsible for charting the date and time of each administered medication, including PRN medications, on the eMAR. The lack of documentation resulted in inaccurate accountability of controlled medications for the affected residents.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the Infection Preventionist (IP) not consistently following established protocols for antibiotic use and monitoring. Specifically, the IP did not communicate or provide notification to the primary medical doctor when residents' symptoms did not meet the McGeer criteria for antibiotic use. For two residents, antibiotics were prescribed and administered despite the absence of qualifying symptoms, and there was no documentation of physician notification or further guidance sought. In one case, a resident received a full course of antibiotics for a urinary tract infection (UTI) without presenting any UTI symptoms, and in another, a resident was given antibiotics for pneumonia despite lacking respiratory symptoms, with only weakness, lethargy, and a change in level of consciousness noted. Additionally, the IP failed to track antibiotic use for one resident who was prescribed Methenamine for UTI prevention, omitting this information from the antibiotic use monitoring spreadsheet. The facility's policy required the IP to review antibiotic utilization and notify providers of findings inconsistent with appropriate use, but this process was not followed. These actions and omissions resulted in antibiotics being prescribed and administered without proper indication or monitoring, as required by the facility's antibiotic stewardship protocols.
Expired Garlic Oil in Kitchen Refrigerator
Penalty
Summary
The facility failed to maintain safe and sanitary conditions for food storage in the kitchen, as evidenced by the presence of a garlic oil container in the refrigerator that was beyond its use-by date. During an observation and interview with the Director of Dining Services (DoDS) and the Executive Chef (EC), it was confirmed that the garlic oil was expired and should have been discarded. Both the DoDS and EC acknowledged the oversight and agreed that the expired product should have been removed from storage. The facility's policy and procedure on food storage, as well as guidance from the Centers for Medicare and Medicaid Services (CMS) and the U.S. Food and Drug Administration (FDA), emphasize the importance of discarding food past its expiration date to prevent contamination and ensure food safety. The failure to adhere to these guidelines and procedures posed a potential risk for foodborne illnesses among residents, as unsafe food handling practices can expose them to pathogens.
Failure to Communicate Physician's Recommendation
Penalty
Summary
The facility failed to ensure timely communication of a physician's recommendation regarding the care of a resident who had a fracture of unknown origin. The physician assessed the resident and recommended that staff refrain from using a Hoyer lift, as it was likely the cause of the fracture. However, this recommendation was not documented in the endorsement report book until almost 48 hours later, leading to a delay in communication to all direct caregivers. During an interview, a CNA assigned to the resident stated that they were only informed that the resident was on bedrest and were not told about the specific recommendation to avoid using the Hoyer lift. Additionally, the facility was unable to provide a policy regarding shift-to-shift endorsement, and the policy they did provide did not contain any guidance on reading and passing on physician's notes and recommendations to the next shift.
Deficiencies in Environmental Maintenance and Hygiene Practices
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by two specific issues. Firstly, during observations on two separate days, washbasins were found stored on the bathroom floors in four different rooms. These washbasins are used for personal hygiene, including cleaning residents' bodies and private areas. The Staff Development Nurse acknowledged that staff were trained to use these washbasins for such purposes and confirmed that they should not be stored on the floor. The facility's policy on cleaning and disinfecting non-critical resident-care items did not address the proper storage of washbasins. Secondly, window screens in two rooms were observed to have gaps between the window opening and the outer frame, which could potentially allow flying pests into the residents' living spaces. The facility's policy on scheduled maintenance, which includes a checklist for external grounds inspections, indicated that window screens should be checked during weekly inspections. However, the gaps in the window screens suggest that this aspect of the maintenance policy was not adequately followed.
Failure to Transmit and Complete MDS Timely
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) for one resident in a timely manner and did not complete and transmit the MDS for another resident. This failure violated the facility's contractual agreement with the State and the Centers for Medicare & Medicaid Services (CMS). During an interview and record review, the MDS Nurse confirmed that the MDS for one resident was transmitted late and the MDS for another resident was incomplete. Additionally, the facility was unable to provide a policy that governs the tracking and timely transmission of MDSs. The document submitted by the facility was an excerpt from a Resident Assessment Instrument (RAI) manual and lacked essential policy elements such as general information, purpose, policy, and procedure, and did not address the system for tracking MDS due dates and submissions.
Inaccurate MDS Coding for Restraints
Penalty
Summary
The facility failed to accurately code a resident's Minimum Data Set (MDS) assessment, specifically regarding the use of restraints. This deficiency was identified for one of the twelve sampled residents, referred to as Resident 10. The MDS assessments dated November 14, 2023, and February 14, 2024, incorrectly indicated that Resident 10 was restrained. However, during an observation and interview on May 22, 2024, Resident 10 stated he was never restrained, and there were no signs of restraints in his room or on his wheelchair or bed. The MDS Nurse acknowledged the error and expressed uncertainty about why the assessments were coded as such, indicating a need for correction and resubmission. Additionally, the facility was unable to provide a policy regarding the accurate coding of MDS data. Instead, they submitted pages from a Resident Assessment Instrument (RAI) manual published by CMS, which lacked essential policy elements such as general information, purpose, policy, and procedure. The document also did not address how the MDS nurse should gather and verify data through observation, record reviews, or staff/resident interviews before coding a resident's MDS.
Failure to Develop Individualized Care Plan for Wheelchair Footrest Refusal
Penalty
Summary
The facility failed to develop an individualized care plan for a resident who refused to use footrests on her wheelchair. During an observation, the resident was seen with her left leg bent under the seat of her wheelchair and dragging it as she moved down the hallway. An interview with an LVN revealed that the resident had a history of refusing footrests due to a belief that they would tip her wheelchair. However, this behavior was not documented in the resident's care plan. The facility's policy requires that all residents have a comprehensive care plan that is periodically reviewed and revised, but this was not adhered to in the case of this resident.
Failure to Monitor Adverse Effects of Ambien
Penalty
Summary
The facility failed to ensure proper monitoring for adverse side effects or behavioral changes in a resident receiving Ambien, a hypnotic medication used to treat insomnia. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, generalized muscle weakness, and insomnia, was prescribed Ambien 5mg to be taken at bedtime. However, during interviews and record reviews, it was found that there was no evidence of monitoring for adverse side effects or behaviors associated with the use of Ambien, despite it being part of the resident's care plan. The care plan for the resident indicated that there should be monitoring for adverse side effects of the medication every shift, but this was not implemented. Interviews with the Licensed Vocational Nurse and the Infection Preventionist revealed that there was no documentation of monitoring sleeping patterns, sleeping hours, or any related behaviors since the initiation of the care plan. The facility's policy on psychotherapeutic medication management, which requires consistent monitoring for effectiveness and adverse consequences, was not followed in this case.
Medication Labeling Discrepancy in LTC Facility
Penalty
Summary
The facility failed to ensure that all medications were properly labeled, as observed with a medication cart used for a resident. The issue was identified when a Licensed Vocational Nurse (LVN) was dispensing Prednisone for a resident, and the medication label did not match the physician's order in the electronic medical record (EMR). The LVN was administering a total of 7 mg of Prednisone, which was consistent with the physician's order, but the medication labels indicated a different dosage. The Prednisone 5 mg tablet label incorrectly stated that the resident should receive 6 mg daily, and the 1 mg tablet label also indicated a dosage of 6 mg daily, which did not align with the EMR order. The LVN acknowledged the discrepancy and noted that the medication should have had a sticker indicating a dosage change, which was missing. The Director of Nursing (DON) confirmed that medication labels should match the physician's written order and that a dosage change sticker should be applied if the order changes but the medication is still usable. The pharmacist also stated that a change of direction sticker is necessary to ensure nurses follow the new order in the EMR, highlighting the potential for medication errors if labels and EMR orders are inconsistent.
Failure to Timely Transmit PBJ Data and Incomplete Policy
Penalty
Summary
The facility failed to transmit their Payroll Based Journal (PBJ) data to the Center for Medicare Services (CMS) in a timely manner, which is a requirement to ensure compliance with their contract agreement with the State and CMS. The Minimum Data Set Nurse (MDS Nurse), who was responsible for transmitting the PBJ data, did not have access to the CMS website and had to contact IT at CMS to gain access. This process took 48 hours, resulting in a missed deadline for PBJ data submission. Additionally, the facility provided an incomplete PBJ data transmission policy. The document, titled PBJ Reporting Export & Conversion Process Guide, was undated and lacked key elements of a standard policy, such as clearly stated objectives, outlined responsibilities, and a defined purpose.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 699 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Portola Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vi At Palo Alto | 5 mi | ★★★★★ | 7 | 0 |
| Atherton Park Post-acute | 5.6 mi | ★★★★★ | 3 | 0 |
| The Terraces At Los Altos Health Facility | 5.6 mi | ★★★★★ | 0 | 0 |
| Palo Alto Post-acute | 5.7 mi | ★★★★★ | 0 | 0 |
| Webster House | 6.1 mi | ★★★★★ | 0 | 0 |
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