Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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.
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 August 2026) and official state health department websites.