St. Pauls Health Care Center: Falsified CNA Records - CA
Federal inspectors who visited the facility on September 4, 2025, found that the skills competency checklist submitted for a registry nursing assistant had been signed by a NOC CNA — a night-shift certified nursing assistant — on August 20, 2025. That CNA had been terminated from the facility on August 5, 2025. Fifteen days separated the termination date from the signature. Nobody caught it.
The checklist itself compounded the problem. It wasn't a St. Pauls document. It had come from a registry company and was originally used by a different long-term care provider, one with no connection to St. Pauls. The competency fields were incomplete. There were no assessment signatures. There were no supervisory validation signatures for each skill listed. What the facility had, in short, was a partial form from a different facility, signed by someone who no longer worked there, submitted as proof that a registry aide was qualified to care for residents.
When inspectors asked for the facility's policy on how it handles registry staff, the facility did not provide one.
Registry aides occupy a particular position of vulnerability in nursing home staffing. They are brought in from outside agencies to fill gaps, often on short notice, and they arrive without the institutional familiarity that permanent staff develop over time. They may not know which residents have fall risks, which have behavioral triggers, which require a specific repositioning technique. The competency checklist exists precisely because of that gap — it is the mechanism by which a facility is supposed to confirm, before a registry aide touches a single resident, that the person knows what they are doing.
At St. Pauls, that mechanism failed at every level simultaneously.
The checklist was not the facility's own. The person who signed it had no authority to sign anything on the facility's behalf. The skills it was supposed to document were not actually verified. And the facility had no written policy governing any of this that it could hand to an inspector.
Inspectors classified the violation as causing minimal harm or potential for actual harm, and noted that few residents were affected. That classification reflects the regulatory framework's assessment of documented injury. It does not mean the situation was minor. A registry aide whose competencies were never actually verified was working with residents. The paperwork designed to catch that gap had been forged, or at minimum fabricated, by someone with no standing to produce it.
The signature on the August 20 document is the detail that is hardest to explain away. An incomplete form from the wrong facility is a sloppy error. A form signed by someone who was no longer employed is something else. That CNA was terminated August 5. They signed a competency checklist for a registry aide at the facility they no longer worked for fifteen days later. Whether the signature was solicited, offered, or manufactured without the CNA's involvement, the inspection report does not say. What it does say is that the facility accepted it.
St. Pauls did not provide a staffing registry policy when asked. That absence matters. A policy would have established who is authorized to review registry credentials, what documents are required, who conducts competency assessments, and who signs off. Without a policy, each of those questions becomes a matter of whoever happened to be handling paperwork that day. On August 20, whoever that was accepted a signed document from a terminated employee and apparently asked no further questions.
The registry company that supplied the checklist was not identified in the inspection report. Whether the company was aware that the form being used originated from a different provider is not addressed. What the report establishes is that the form made it to St. Pauls, was accepted by St. Pauls, and was the basis on which a registry aide was cleared to work with residents.
The residents themselves appear only at the edges of this story — few in number, according to the inspection classification, affected in ways the report does not detail. They were cared for by someone whose qualifications rested on a document that should not have existed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St. Pauls Health Care Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 26, 2026 · Our methodology
St. Pauls Health Care Center in SAN DIEGO, CA was cited for violations during a health inspection on September 4, 2025.
That CNA had been terminated from the facility on August 5, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.