Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 St. Pauls Health Care Center during CMS and state inspections, most recent first.
Two residents experienced inadequate monitoring and documentation of nutrition and hydration needs. One resident with stroke-related deficits, dysphagia, and severe cognitive impairment began pocketing food and coughing during meals, but the RD did not complete a new nutritional assessment, the IDT did not address the change in condition, and the care plan was not updated with interventions, contrary to facility policy. Another resident with severe protein-calorie malnutrition and dysphagia, who could only take liquids by spoon per speech therapy, received thickened liquid nourishments but had very low and partially undocumented fluid intake over several days, while CNAs only recorded fluids at meals and not during med passes or nourishments, despite policy requiring full fluid documentation and reporting of low intake.
A resident with dementia and dysphagia, who had severe cognitive impairment, lost her dentures and had not received replacements because the facility conditioned payment for new dentures on her representative signing a waiver releasing the facility from responsibility for prior lost or damaged items. The Administrator stated the facility believed the loss was the resident’s fault, and the dentist was instructed not to proceed with scheduled dental impressions until the waiver was signed, leading to a canceled appointment and delay. The SSD acknowledged that requiring the waiver delayed the process and placed the resident in the middle of the dispute, while the DON stated the resident had the right to have dentures replaced and to eat preferred food textures without being required to sign such a waiver, contrary to the facility’s own resident rights policy.
A resident with dysphagia, severe cognitive impairment, and dependence for meals was observed being fed breakfast by a CNA while the resident’s dentures remained in a cup on the nightstand, and no oral or denture care was provided beforehand. The CNA reported not knowing the resident wore dentures and continued feeding without placing them. An LN stated dentures should have been in place before eating to allow chewing and avoid choking, and the DON stated dentures were expected to be in before every meal to support adequate intake and prevent choking or aspiration. Facility policies required denture care before breakfast and at bedtime and directed staff to assist residents with denture care.
Two residents with cognitive impairments were found to be uncomfortable in their shared room due to a persistent cold draft from a vent, despite the thermostat being set at 74°F. One resident stayed under a thick blanket, while the other wore a jacket in bed and reported feeling cold. Staff and maintenance confirmed the draft and acknowledged the room was not homelike or comfortable, with air from the vent measured at 60°F. Facility policy requires comfortable temperatures, but this was not achieved for these residents.
A resident with urinary incontinence and significant urological diagnoses experienced pain, swelling, and embarrassment after a CNA from a staffing agency improperly applied two incontinence briefs, with the inner brief folded and a hole cut for the penis, causing constriction and injury. The incident was discovered during morning care, leading to hospital evaluation and a diagnosis of paraphimosis. The CNA admitted to using this unsafe practice routinely, and the facility's investigation confirmed the actions constituted neglect and violated facility policy.
A registry CNA provided continence care without verified competency, resulting in improper application of incontinence briefs that caused swelling, pain, and psychosocial harm to a resident with urinary tract conditions. The facility lacked documentation of competency validation, did not provide orientation or training to registry staff, and could not produce a relevant skills checklist or policy for registry staff use.
A resident with a history of cancer and a pathological fracture was repeatedly given Percocet, a controlled substance, without a valid physician's order after admission. Multiple nurses administered the medication, which had been discontinued, using a handwritten controlled drug record lacking essential labeling. The facility's medication administration policy was not followed, and the errors were discovered during a narcotic count.
A resident with a history of cancer and bone fracture brought a bottle of previously prescribed narcotics into the facility, which was not properly labeled or stored. The medication was kept in the medication cart and administered without a valid physician's order, and the controlled drug record was incomplete. Additionally, a discontinued blister pack of oxycodone remained in the cart with active medications, leading to a near medication error. Staff interviews confirmed that facility policies for labeling and storage of controlled substances were not followed.
A resident with a history of skin cancer reported rough handling by a CNA, which was considered an abuse allegation. Although facility policy required immediate notification of the attending physician, interviews and record review confirmed that the physician was not notified of the incident, and there was no documentation of such notification.
The facility did not maintain required documentation of past employment history, references, or qualifications for certain staff, including a CNA, due to inconsistent practices and lack of a written policy. During a survey following a resident's concern, it was found that reference checks were not mandatory and records were missing, especially for long-term employees.
A resident with a history of bullous pemphigoid received the wrong wound treatment when a nurse mistakenly applied crushed methadone tablets instead of the prescribed topical metronidazole. The error occurred after the nurse failed to locate the correct medication and did not properly verify the medication label, contrary to facility policy requiring the five rights of medication administration.
The facility failed to conduct post-fall assessments and update care plans for four residents, each with a history of falls and high fall risk scores. Despite incidents of falls, no new interventions were documented, and the facility's policy lacked guidance on post-fall procedures.
Failure to Monitor and Document Nutrition and Hydration Needs for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to effectively monitor and evaluate nutrition and hydration needs for two residents. One resident with hemiplegia, aphasia, dysphagia, and severe cognitive impairment was dependent on staff for all ADLs. Although the MDS indicated no swallowing disorders, a CNA later reported that toward the end of the resident’s stay he was not interested in food, was congested, choked sometimes while eating, and began pocketing food and coughing. The RD confirmed that on a specific date the resident had a change in condition and was noted to be pocketing food during meals, which the RD stated placed the resident at risk for not meeting food and fluid intake and for aspiration. Despite this documented change in condition, the RD stated there was no evidence that the IDT met to discuss the resident’s change in dietary needs, and no new nutritional assessment was completed. The resident’s care plan did not reflect the pocketing of food, and no new interventions were implemented to address this change. This inaction occurred despite the facility’s written policy on Resident Hydration and Prevention of Dehydration, which required the dietitian to assess residents more often as necessary per resident need, initiate intake and output monitoring when potential inadequate intake or signs of dehydration were observed, and update the care plan with documented resident response to interventions. The second resident had diagnoses including severe protein-calorie malnutrition and dysphagia and was cognitively intact, requiring supervision for eating. A restorative nursing assistant observed that this resident received a thickened liquid nourishment as part of a scheduled nourishment pass but appeared to consume less than half. The RD stated that speech therapy had determined the resident could only consume liquids with a spoon, placing the resident at higher risk for dehydration, and that the resident required a specific daily fluid range to be adequately hydrated. Record review showed the resident’s documented fluid intake on one day was 236 ml, with no documented fluid intake for the following two days, and the RD stated the resident did not meet minimum fluid intake requirements during that period. The DON acknowledged that CNAs were only documenting fluid intake during meals and not during med passes or nourishments, despite facility policy requiring aides to provide, encourage, and document intake of bedside, snack, and meal fluids and to report intake of less than 1200 ml/day to nursing staff.
Resident Rights Violated by Conditioning Denture Replacement on Waiver
Penalty
Summary
The facility failed to honor a resident’s rights when it conditioned replacement of lost dentures on the resident’s representative signing a waiver. The resident, who had dementia, dysphagia, and a BIMS score of 3 indicating severe cognitive impairment, had her dentures reported lost on 1/24/26. A dental referral was made on 1/26/26, but the dentures had not been replaced by the time of the survey. The resident’s responsible party reported that the facility agreed to pay for replacement dentures only if she signed a waiver releasing the facility from responsibility for any lost, missing, or damaged items prior to and up to 2/6/26, and she was not comfortable signing it. The Administrator stated the facility determined it was the resident’s fault that the dentures were lost and therefore provided the waiver and release for the responsible party to sign. The dentist reported being scheduled to take dental impressions at the facility but stated he was instructed by the facility not to come until the responsible party signed the waiver. The responsible party confirmed the dentist did not arrive for the scheduled appointment and that she had not signed the waiver. The Social Services Director acknowledged that the facility required the waiver to be signed before proceeding with dental impressions and that the appointment on 2/10/26 was canceled because the responsible party refused to sign. The Social Services Director stated that requiring the waiver delayed the process for the resident to receive new dentures and that the resident was put in the middle of the situation. The DON stated the waiver was not satisfactory and that the resident had the right to have dentures replaced and to eat preferred food textures without being required to sign a waiver. The facility’s Resident Rights policy stated residents have the right to exercise their rights without interference, coercion, discrimination, or reprisal from the facility.
Failure to Provide Denture Care and Denture Use Prior to Meal Service
Penalty
Summary
The facility failed to ensure oral care and denture use were provided before breakfast for one resident who required assistance with activities of daily living. The resident had diagnoses including dysphagia following a stroke and type 2 diabetes, and an MDS assessment showed a BIMS score of 8, indicating severe cognitive impairment, with a documented need for substantial assistance with oral hygiene. Physician orders indicated the resident was dependent with all meals. During observation, the resident was sitting up in bed being fed breakfast by a CNA, while an open denture cup containing dentures was on the nightstand. The CNA stated she did not know the resident wore dentures and had not provided oral or denture care prior to breakfast, and she continued feeding the resident without placing the dentures in the resident’s mouth. In an interview, an LN stated the resident should have been assisted with placing dentures in the mouth before eating breakfast and that it was important for the resident to wear dentures while eating to chew food and avoid choking. In a telephone interview, the DON stated her expectation was that dentures were placed in the resident’s mouth prior to every meal so residents could consume an adequate amount of food and the texture they like, and stated, "We don't want them to choke or aspirate." Review of the facility’s “Dentures, Cleaning and Storing” policy indicated denture care was to be provided before breakfast and at bedtime, and residents were to be encouraged to keep dentures in their mouths as much as possible. The “Dental Services” policy indicated direct care staff would assist residents with denture care, including removing, cleaning, and storing dentures.
Failure to Maintain Comfortable Room Temperature for Cognitively Impaired Residents
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for two residents with cognitive impairments when it did not ensure an appropriate room temperature. One resident, with severe dementia and Alzheimer's disease, was found sleeping under a thick fleece blanket with the blanket pulled over her head, and only responded to a loud voice. The room felt drafty, with a cool breeze coming from a vent directly above her head, and the thermostat was set at 74°F per the resident's daughter's instructions. The second resident, with moderate cognitive impairment, malnutrition, and major depressive disorder, was observed sitting in bed wearing a jacket and reported feeling cold due to a wind from the vent, expressing a preference for a warmer room. Staff interviews confirmed that both residents often appeared cold in their room, with one typically staying under a blanket and the other wearing a coat in bed. The maintenance supervisor measured the air coming from the vent at 60°F and the bed surfaces at 72°F, acknowledging that the draft could be uncomfortable. Both the maintenance supervisor and licensed nurse agreed that the room was not homelike or comfortable for the residents at the time. Facility policy requires maintaining comfortable temperatures between 71°F and 81°F, and the Director of Nursing confirmed that the room temperature was not homelike and could have negatively affected the residents' mood and health.
Improper Double Briefing by CNA Causes Physical and Psychosocial Harm
Penalty
Summary
A facility failed to ensure that a resident received continence care in accordance with professional standards, resulting in improper application of incontinence briefs. Specifically, a certified nursing assistant (CNA) from a staffing agency applied two incontinence briefs to a resident, with the inner brief folded and a hole cut in the center through which the resident's penis was pulled. This method caused constriction, swelling, and pain to the resident, who had a medical history of prostatic hyperplasia with lower urinary tract symptoms and obstructive and reflux uropathy. The improper application was discovered during morning care by another CNA, who found the resident in pain and with visible swelling and discoloration of the penis. The resident was subsequently assessed by a licensed nurse, who confirmed the improper placement of the briefs and noted that the opening in the inner brief was so tight it acted like a rubber band, causing further swelling and skin breakdown. The resident was sent to the emergency room, where he was diagnosed with paraphimosis, a condition where the foreskin becomes trapped behind the head of the penis, leading to swelling and pain. The resident also experienced psychosocial harm, including embarrassment and reluctance to discuss the incident. Interviews with facility staff and review of documentation revealed that the CNA responsible for the double briefing admitted to using this technique routinely with residents he considered "heavy wetters" and had done so in other facilities. The facility's investigation substantiated that the CNA's actions constituted neglect, as they deviated from accepted standards of care and facility policy, which explicitly prohibits double briefing due to the risk of skin breakdown and harm. The facility was unable to verify that the registry CNA had completed required competencies before working on the floor.
Failure to Validate Competency of Registry CNA Resulting in Harm from Improper Continence Care
Penalty
Summary
The facility failed to ensure that nursing staff, specifically a night shift certified nursing assistant (CNA) from a staffing agency, were competent to provide continence care for a resident. The CNA did not have documented competency validation before working on the floor and was identified as having improperly applied incontinence briefs, resulting in double briefing. The inner brief had a hole cut through the center with the resident's penis pulled through, which was too tight and caused swelling, pain, and discoloration. The resident, who had a history of prostatic hyperplasia and obstructive uropathy, required hospital evaluation due to these injuries. Interviews with staff confirmed that registry CNAs did not receive formal orientation, training, or facility-specific policy information before starting work, and there was no practice of shadowing or skills checklist completion for registry staff. Record review showed that the only skills checklist available was from a different facility, completed after the CNA had already been terminated, and was incomplete with no supervisory validation. The facility was unable to provide documentation verifying the CNA's competencies or a policy on the use of registry staff. The nurse administrator acknowledged that without competency validation, the facility could not guarantee resident safety, and the resident experienced psychosocial harm and pain as a result of the improper continence care provided by the unverified CNA.
Unordered Administration of Controlled Substance Due to Medication Verification Failures
Penalty
Summary
The facility failed to prevent multiple significant medication errors involving the administration of a controlled substance without a valid physician's order. A resident with a diagnosis of malignant neoplasm of the bone and a pathological fracture of the left humerus was admitted with a prescription for Percocet from the hospital, but this order was discontinued by the facility nurse practitioner upon admission. Despite this, the resident's bottle of Percocet was kept in the controlled drug storage drawer, and the medication was administered to the resident on nine separate occasions by five different nurses, without a corresponding physician's order or pharmacy approval. Interviews and record reviews revealed that the nurses did not verify the medication against the active physician's orders or the medication administration record (MAR) before administering Percocet. One nurse admitted to not knowing that Percocet was different from oxycodone and did not check the medication against the order. The controlled drug record (CDR) used to document the administration of Percocet was handwritten and lacked essential labeling information, which contributed to repeated errors. The MAR did not include an administration history or directions for the Percocet that was given. The facility's policy required verification of a physician's order and confirmation of the medication name and dose with the MAR prior to administration, especially for narcotics. However, these procedures were not followed, resulting in the administration of a controlled substance without proper authorization or documentation. The errors were discovered during a routine narcotic count, which revealed discrepancies in the controlled drug record and missing pills from the resident's supply.
Improper Labeling and Storage of Controlled Substances
Penalty
Summary
The facility failed to ensure proper labeling and storage of controlled substances for a resident with a diagnosis of malignant neoplasm of the bone and a pathological fracture of the left humerus. Upon admission, the resident brought a bottle of previously prescribed narcotics, which was taken by staff. However, the medication was not properly labeled or stored according to facility policy and professional standards. The bottle of oxycodone/acetaminophen (Percocet) brought from outside was kept in the medication cart and administered without a valid physician's order, and the controlled drug record (CDR) for this medication was handwritten, missing essential information such as dose, time, and route of administration. During a medication cart audit, a blister pack of discontinued oxycodone 10mg tablets was found stored with active controlled medications in the cart. The order for this medication had been stopped, but the medication remained accessible for over a month. A licensed nurse reported nearly making a medication error by almost administering the discontinued 10mg tablet instead of the currently ordered 5mg tablet. The nurse acknowledged that discontinued medications should not remain in the cart, as this increases the risk of administration errors. Interviews with staff, including the MDS coordinator, licensed nurses, and the DON, confirmed that the facility did not follow its own policies regarding the labeling and storage of controlled substances. The DON acknowledged that the Percocet brought from outside should not have been stored with active medications and that the CDR should not have been handwritten or missing required information. The facility's policy requires that all medications be labeled with the resident's name, medication name, dose, route, and other essential details, and that discontinued medications be removed or destroyed per pharmacy instructions.
Failure to Notify Physician of Abuse Allegation
Penalty
Summary
The facility failed to notify the attending physician of an abuse allegation involving a resident who was admitted with a diagnosis including skin cancer. During an unannounced onsite visit, the resident reported to surveyors that a CNA had been rough while turning him in bed, which was considered an abuse allegation by facility staff. Interviews with the licensed nurse and the charge nurse confirmed that such allegations should be reported to the Director of Nursing, the administrator, the resident's attending physician, and the family. However, a review of the resident's electronic medical record and interviews with the charge nurse and DON revealed there was no documentation that the attending physician had been notified of the abuse allegation. The facility's policy and procedure on reporting and investigating abuse, neglect, exploitation, or misappropriation required immediate notification of the attending physician when abuse is suspected. Despite this policy, both the charge nurse and DON confirmed that there was no evidence of physician notification in this case. The DON acknowledged the importance of physician awareness to ensure the resident's safety and proper evaluation, but the required notification did not occur.
Failure to Maintain Employee Qualification and Reference Documentation
Penalty
Summary
The facility failed to comply with state regulations requiring the maintenance of complete information regarding employees' past employment and qualifications. During an unannounced onsite visit related to an abuse allegation, it was discovered that the facility did not have records of past employment history, references, or qualifications for certain employees, including a certified nurse assistant (CNA) who had been employed for over 20 years. Interviews with the Director of Nursing, Human Resources staff, and the HR Manager revealed that reference checks were not consistently performed or documented, and there was no written policy mandating such checks. The transition from paper to electronic records in 2018 further contributed to the lack of available documentation for long-term employees. A resident who was admitted with a diagnosis of skin cancer expressed concerns about the CNA in question. The facility was unable to provide any policy or procedure regarding employment verification or reference checks when requested by surveyors. Staff interviews indicated that background and reference checks were only completed if specifically requested by managers, and there was no standardized process in place to ensure compliance with regulatory requirements for employee qualification documentation.
Medication Error: Wrong Drug Applied to Wound
Penalty
Summary
A medication error occurred when a licensed nurse administered the wrong medication to a resident with a history of bullous pemphigoid, a rare skin condition causing large fluid-filled blisters. The resident, who was cognitively intact, had a physician's order for topical metronidazole to be applied to a wound on the right arm. Instead, the nurse mistakenly applied crushed methadone tablets to the wound after failing to locate the prescribed medication in the treatment cart. The error was discovered when the nurse returned to the medication cart and realized the incorrect medication had been used. Interviews and record reviews revealed that the nurse did not properly verify the medication label or follow the facility's policy requiring the five rights of medication administration. The facility's policies specify that medications must be administered according to prescriber orders and that the label should be checked three times to ensure accuracy. The nurse acknowledged the mistake and stated that she should have checked the drug name, dose, resident's name, frequency, time, and route before administration.
Failure to Conduct Post-Fall Assessments and Update Care Plans
Penalty
Summary
The facility failed to complete post-fall assessments and implement resident-centered fall preventive measures for four residents, leading to a potential risk of repeated fall incidents. Resident 1, who was admitted with gait and mobility issues, experienced a fall resulting in a hip fracture. Despite being identified as a high fall risk, no post-fall assessment was conducted, and no new interventions were documented in the care plan to prevent further falls. Resident 2, diagnosed with unsteadiness and muscle weakness, was found on the floor after a fall. Although marked as a fall risk, the facility did not complete a post-fall assessment or update the care plan with new preventive measures. Similarly, Resident 3, with Parkinsonism and mobility abnormalities, had multiple falls without subsequent assessments or care plan updates. Resident 4, who has hemiplegia following a cerebral infarction, attempted an unsupervised transfer and fell. Despite a high fall risk score, no post-fall assessment was conducted, and the care plan was not updated. The facility's policy lacked guidance on completing post-fall assessments and documenting preventive measures, contributing to these deficiencies.
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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 Diego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Balboa Nursing & Rehabilitation Center | 0.6 mi | ★★★★★ | 11 | 0 |
| Mission Hills Post Acute Care | 1 mi | ★★★★★ | 0 | 0 |
| Hillcrest Heights Healthcare Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Golden Hill Post Acute | 2.6 mi | ★★★★★ | 54 | 0 |
| Villa Coronado D/p Snf | 2.8 mi | ★★★★★ | 0 | 0 |
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