Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Zuckerberg San Francisco General Hosp & Trauma Snf during CMS and state inspections, most recent first.
The facility failed to maintain food safety standards, with observations of grease and debris build-up in the kitchen, rust residue in an ice machine, and improper handwashing by a Food and Nutrition Services employee. These deficiencies contravened facility policies and FDA guidelines, posing risks of contamination and foodborne illness.
The facility failed to create comprehensive care plans for two residents. One resident, prescribed Citalopram for depression, lacked a person-centered care plan for the medication. Another resident with ESRD did not have specific interventions in their care plan despite attending regular dialysis sessions. Staff confirmed the absence of these care plans, which are required by facility policy.
The facility failed to obtain consent and monitor targeted behaviors for psychotropic medications in two residents. One resident was prescribed Wellbutrin for amphetamine use disorder without consent or behavioral monitoring, while another was on Celexa for depression without specific behavioral monitoring. Staff interviews revealed misunderstandings about consent requirements, and the facility's policy on informed consent and monitoring was not followed.
A resident did not receive proper pharmaceutical services when an RN failed to rotate insulin glargine injection sites, administering it in the same area on consecutive days. This was against facility policy and manufacturer's guidelines, which require site rotation to prevent skin and tissue issues.
The facility failed to remove an expired vial of Tuberculin Purified Protein Derivative (Tubersol) from the medication refrigerator. The vial, opened on June 17, 2024, lacked a discard date and was stored beyond its 28-day expiration period. RNs confirmed the expiration and acknowledged the need for disposal, in line with the facility's policy on medication storage.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, impacting 15 out of 15 sampled residents. Observations revealed a significant build-up of grease, grime, debris, and food crumbs on the floors of the building 5 kitchen, particularly under the shelves in the dry storage area and beneath the cooking ranges. The Executive Chef acknowledged the difficulty in cleaning under the stationary cooking equipment and admitted that the floors had not been mopped as required. Additionally, the kitchen refrigerator floor was littered with fallen vegetables. These conditions contravened the facility's cleaning policy, which mandates regular cleaning to prevent the accumulation of dust, dirt, and food particles, as well as the FDA Federal Food Code requirements. Further deficiencies were noted with an ice machine in the building 5 kitchen, which had rust-colored residue on the bottom ledge of the ice bin, posing a contamination risk. The facility's policy requires ice machines to be maintained in a visibly clean condition, aligning with FDA guidelines to prevent microorganism accumulation. Additionally, a Food and Nutrition Services employee failed to follow proper handwashing procedures during tray line operations. After picking up an item from the floor, the employee changed gloves without washing hands, contrary to the facility's policy and FDA Food Code, which stipulates handwashing before glove changes. These lapses in food safety practices had the potential to lead to pest infestations or foodborne illnesses, endangering the health and safety of medically compromised residents.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which included measurable objectives and specific interventions. Resident 14, who was admitted with diagnoses including seizure disorder and depression, was prescribed Citalopram (Celexa) for depression. However, there was no individualized, person-centered care plan developed for the use of this medication. During a review, a registered nurse confirmed the absence of a care plan for Celexa, acknowledging its importance for guiding the care team in understanding the resident's goals of care. Similarly, Resident 7, who was admitted with diagnoses including diabetes and end-stage renal disease (ESRD), did not have specific interventions outlined in their care plan for managing ESRD. This resident attended dialysis sessions three times a week and had a left upper arm fistula for dialysis access. A licensed vocational nurse confirmed that the care plan lacked specific interventions for ESRD, despite the resident's regular dialysis schedule. The facility's policy requires that all clinical issues and triggered care assessment areas be reviewed during interdisciplinary team meetings to determine necessary care plans, but this was not adhered to in these cases.
Failure to Obtain Consent and Monitor Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. For Resident 227, there was no consent or monitoring of targeted behaviors for the use of Wellbutrin, an antidepressant prescribed for amphetamine use disorder. Despite the resident being cognitively intact, the facility did not obtain consent for the medication, as confirmed by RN 1 and the Clinical Pharmacist. The facility's failure to monitor targeted behaviors was acknowledged during interviews with staff, who incorrectly believed that consent was not needed because the medication was not prescribed for depression. For Resident 14, who was readmitted with diagnoses including seizure disorder and depression, there was a lack of specific behavioral monitoring for the use of Celexa, another antidepressant. Although the resident's records indicated monitoring for signs and symptoms of depression, RN 4 admitted that there was no specific target behavior identified for monitoring. The facility's policy required informed consent and specific behavioral monitoring for psychotropic medications, but these were not adequately implemented for Resident 14. The deficiencies in both cases could result in the unnecessary use of psychotropic medications, which may negatively affect the residents' well-being. The facility's failure to obtain consent and conduct specific behavioral monitoring for psychotropic medications was a violation of their policy and the State Operations Manual guidelines, which require such measures regardless of the medication's indication for use.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for a resident, identified as Resident 79, by not rotating the injection sites for insulin glargine, a medication used to treat diabetes. During a medication administration observation, a registered nurse (RN) administered the insulin injection at the back of the resident's left upper arm on two consecutive days. This was contrary to the facility's policy and the manufacturer's prescribing information, which both emphasize the importance of rotating injection sites to prevent skin and fatty tissue irritation. The review of Resident 79's Medication Administration Record (MAR) revealed that the insulin glargine was administered in the same area on multiple occasions, specifically in the right lower abdomen for three consecutive days and then in the left upper arm for two consecutive days. The RN acknowledged the oversight during an interview and confirmed that the injection sites should have been rotated. The facility's policy and the manufacturer's guidelines both highlight the risk of lipodystrophy and localized cutaneous amyloidosis if injection sites are not rotated, which was not adhered to in this case.
Expired Medication Not Removed from Storage
Penalty
Summary
The facility failed to ensure the removal of expired medications, specifically an opened vial of Tuberculin Purified Protein Derivative (Tubersol), which was stored in the medication refrigerator beyond its expiration date. During an observation of the medication room, a vial of Tubersol with an opened date of June 17, 2024, was found without a discard date. Registered Nurse (RN) 1 stated that the medication is good for 28 days once opened, while RN 3 confirmed that the medication expired on July 15, 2024. RN 2 also read the opened date as June 17, 2024, and acknowledged that it should be discarded. The facility's policy, titled 'Pharmaceutical Services: Guidelines for Storage and Delivery of Medications,' last revised in December 2023, indicated that all multi-dose injectable vials, including vaccines and insulins, are good for a maximum of 28 days after opening and should be labeled with a discard after date. This oversight had the potential to compromise the integrity and effectiveness of the drug and lead to inaccurate test results.
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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) |
|---|---|---|---|---|
| California Pacific Medical Ctr- Davies Campus Hosp | 1.4 mi | ★★★★★ | 11 | 0 |
| Hayes Convalescent Hospital | 2.1 mi | ★★★★★ | 2 | 0 |
| San Francisco Health Care | 2.1 mi | ★★★★★ | 5 | 0 |
| Central Gardens Post Acute | 2.1 mi | ★★★★★ | 0 | 0 |
| Jewish Home & Rehab Center D/p Snf | 2.2 mi | ★★★★★ | 16 | 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.