Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
15’23
1’24
26’25
17’26
59 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Aug 12, 2026 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Aug 12, 2026 | D · potential | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Routine |
| Aug 12, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Aug 12, 2026 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Aug 12, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Aug 12, 2026 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Aug 12, 2026 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Aug 12, 2026 | F · potential | Post nurse staffing information every day. | Routine |
| Aug 12, 2026 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Aug 12, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Aug 12, 2026 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| May 11, 2026 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| May 11, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| May 11, 2026 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Feb 7, 2026 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Feb 7, 2026 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| Feb 7, 2026 | E · potential | Provide enough food/fluids to maintain a resident's health. | Complaint |
| Dec 9, 2025 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Complaint |
| Sep 4, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Sep 4, 2025 | D · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Complaint |
| Jun 26, 2025 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Jun 26, 2025 | D · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Routine |
| Jun 26, 2025 | E · potential | Honor the resident's right to organize and participate in resident/family groups in the facility. | Routine |
| Jun 26, 2025 | E · potential | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Routine |
| Jun 26, 2025 | D · potential | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Routine |
| Jun 26, 2025 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Jun 26, 2025 | D · potential | Provide care by qualified persons according to each resident's written plan of care. | Routine |
| Jun 26, 2025 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Jun 26, 2025 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Jun 26, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Jun 26, 2025 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jun 26, 2025 | E · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Jun 26, 2025 | E · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Routine |
| Jun 26, 2025 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jun 26, 2025 | E · potential | 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. | Routine |
| Jun 26, 2025 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jun 26, 2025 | D · potential | Have a plan that describes the process for conducting QAPI and QAA activities. | Routine |
| Jun 26, 2025 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Jun 10, 2025 | E · potential | Ensure that residents are free from significant medication errors. | Complaint |
| Jun 10, 2025 | D · potential | 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. | Complaint |
| Jun 3, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Jun 3, 2025 | D · potential | Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Complaint |
| May 2, 2025 | D · potential | Ensure that residents are free from significant medication errors. | Complaint |
| Jun 20, 2024 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 7, 2023 | D · potential | Keep residents' personal and medical records private and confidential. | Routine |
| Apr 7, 2023 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Apr 7, 2023 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Apr 7, 2023 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Apr 7, 2023 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Apr 7, 2023 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Apr 7, 2023 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Apr 7, 2023 | D · potential | Provide care or services that was trauma informed and/or culturally competent. | Routine |
| Apr 7, 2023 | E · potential | Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Routine |
| Apr 7, 2023 | E · potential | 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. | Routine |
| Apr 7, 2023 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Apr 7, 2023 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Apr 7, 2023 | E · potential | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Routine |
| Apr 7, 2023 | E · potential | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Routine |
| Apr 7, 2023 | E · potential | Provide and implement an infection prevention and control program. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
St. Pauls Health Care Center
235 Nutmeg Street, San Diego, CA 92103 · (619) 239-8687
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555144
- Certified beds
- 59
- Legal owner
- St Paul's Episcopal Home INC
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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