Cycle 1
Health 2024-11-22 · Fire 2024-11-22
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
San Francisco, CA
Sequoias San Francisco Convalescent Hospital
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
1400 Geary Blvd, San Francisco, CA
(415) 922-9700
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
33
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1969-06-18
CMS approved date
Coverage
Medicare
Participation flags
Staffing
Hours and turnover
RN hours / resident day
2.06
Registered nurse staffing
LPN hours / resident day
0.20
Licensed practical nurse staffing
Aide hours / resident day
3.21
Nurse aide staffing
Weekend hours
4.74
Weekend nurse staffing
RN turnover
13%
Annual RN turnover
Total nurse turnover
29%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.3
0.5 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
1.6
1.6 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 66.4% |
98.5%
32.1 pts worse
|
93.4%
27 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.5% |
98.2%
11.7 pts worse
|
95.5%
9 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.3% |
1.6%
5.7 pts worse
|
3.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.0% |
4.1%
1.9 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
13.7%
1 pts worse
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 2.3% |
14.2%
11.9 pts better
|
16.7%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.8% |
11.0%
0.2 pts better
|
16.3%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.2% |
10.7%
13.5 pts worse
|
14.9%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
1.0%
1.8 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
1.2%
1.8 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.7% |
10.9%
15.8 pts worse
|
19.8%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
4.7%
2.9 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 45.6% |
94.0%
48.4 pts worse
|
81.7%
36.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.9% |
93.2%
2.3 pts worse
|
79.7%
11.2 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-12 · Fire 2023-05-12
7 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2019-08-30 · Fire 2019-08-30
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-22
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-01-13
E · Potential for more than minimal harm
2024-11-22
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-01-13
E · Potential for more than minimal harm
2024-11-22
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2025-01-13
D · Potential for more than minimal harm
2024-11-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-01-13
C · Minimal harm
2024-11-22
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-01-13
C · Minimal harm
2024-11-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-13
C · Minimal harm
2024-11-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-01-13
C · Minimal harm
2024-11-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-13
C · Minimal harm
2024-11-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-13
F · Potential for more than minimal harm
2023-05-12
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-06-08
F · Potential for more than minimal harm
2023-05-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-08
F · Potential for more than minimal harm
2023-05-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-08
F · Potential for more than minimal harm
2023-05-12
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-06-08
E · Potential for more than minimal harm
2023-05-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-08
E · Potential for more than minimal harm
2019-08-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-10-22
D · Potential for more than minimal harm
2019-08-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-10-22
D · Potential for more than minimal harm
2019-08-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-10-22
D · Potential for more than minimal harm
2019-08-30
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-10-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-22
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-31
F · Potential for more than minimal harm
2023-05-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-10
E · Potential for more than minimal harm
2023-05-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-07-10
E · Potential for more than minimal harm
2023-05-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-05-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-05-12
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-05-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-07-10
D · Potential for more than minimal harm
2023-05-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-07-10
F · Potential for more than minimal harm
2019-08-30
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2019-11-05
E · Potential for more than minimal harm
2019-08-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-11-05
E · Potential for more than minimal harm
2019-08-30
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-11-07
Penalties and ownership
What sits behind the stars
Ownership
Sequoia Living Inc
5% Or Greater Direct Ownership Interest · Organization
Agostino, Valerie
Corporate Director · Individual
Atwood, Martha
Corporate Officer · Individual
Corriea, Richard
Corporate Director · Individual
Goddard, Glen
Operational/Managerial Control · Individual
Goddard, Glen
W-2 Managing Employee · Individual
Herman, Steven
Corporate Director · Individual
Howie, Carl
Corporate Director · Individual
Ito, Holly
Corporate Director · Individual
Jamison, David
Corporate Director · Individual
Lim, Marianne
Corporate Director · Individual
Lynn, Patricia
Corporate Director · Individual
Mayeda, Nancy
Corporate Director · Individual
Mcvey, Sarah
Corporate Officer · Individual
Sanderson, Cory
Corporate Director · Individual
Shoemake, Charles
Corporate Officer · Individual
Spaulding, Dianne
Corporate Director · Individual
Suey, Marilyn
Corporate Director · Individual
Tumbale, Terence
Operational/Managerial Control · Individual
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#3
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