St. Pauls Health Care Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

swollen. CNA 1 stated Resident 1 stated he was upset with her for informing the charge nurse. CNA 1 stated Resident 1 appeared embarrassed and did not want to talk about who put the briefs on that way.

During an interview on 9/3/25 at 11:05 A.M., LN 1 stated on the morning of 8/3/25 CNA 1 notified him she was concerned about Resident 1's brief placement. LN 1 stated he observed CNA 1 remove Resident 1's outer brief and saw a folded brief with a hole cut through the middle and Resident 1's meatus sticking through the hole. LN 1 stated Resident 1's penis appeared swollen and discolored and the opening was so tight it was acting like a rubber band. Resident 1 was guarded during the physical assessment. LN 1 stated

the practice of putting a resident in two briefs was not acceptable and was considered a form of neglect. LN 1 stated there was visible skin breakdown where the brief was restricting the tip of the penis. LN 1 stated

the person who placed Resident 1 in the briefs was identified as the overnight (NOC) CNA from registry (a staffing agency). During an interview on 9/4/25 at 4:20 P.M., the nurse administrator (NA) stated she had completed the internal investigation of the alleged abuse involving Resident 1 and found that NOC CNA was responsible for double briefing the resident. NA stated double briefing should never be done because it increases the risk of skin breakdown. NA stated it was the facility's policy to never double brief residents and all CNAs were expected to be competent and implement best practices. The NA stated registry staff should complete their competencies before coming to work on the floor. NA stated she was unable to find any type of documentation that verified NOC CNA's competencies were completed before working at the facility. NA acknowledged Resident 1 experienced psychosocial harm from embarrassment and reported pain as well as potential for injury because NOC CNA applied two briefs in an unsafe manner. NA stated

the facility was unable to guarantee the safety of their residents if standards of care were not being met. A

review of the facility document titled, Allegation of Abuse - 5 day summary report, dated 8/7/25, indicated .Summary of Incident: On August 3, 2025, at approximately 11:45 AM, Charge RN [CN] was notified by CNA [1] that Resident [1] was found to be double briefed during routine morning care. One brief was placed correctly, while the second had a hole cut in the center through which the penis was pulled, causing constriction. This resulted in swelling and discoloration of the meatus, and the resident reported discomfort.

Follow up investigation. August 5, 2025. CNA [NOC CNA] (Night Shift, Registry) was interviewed. He admitted to applying two briefs in the described manner and stated that this was part of his routine practice with residents he considered heavy wetters. He acknowledged having used this technique in other faculties.

The facility's investigation substantiated that improper continence care had occurred, constituting neglect.

The CNA's actions resulted in physical harm to the resident and were inconsistent with regulatory standards, resident rights, and facility protocols.the deviation from accepted practices posed a risk to resident safety and dignity. Conclusion: After a thorough investigation was conducted, it was determined to be a substantiated case of neglect based on deviation from standard care practice. A review of the facility policy titled, Abuse and Neglect - Clinical Protocol, approved March 2025, indicated, Policy Statement. 2.

Neglect, as defined at 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 5. Along with staff and management, the physician will help identify situations that might constitute or could be construed as neglect; for example. failure to provide incontinence care Cross Reference: see F-F726

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Pauls Health Care Center

235 Nutmeg Street San Diego, CA 92103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

NOC CNA's competencies were completed before working at the facility. NA acknowledged Resident 1 experienced psychosocial harm from embarrassment and reported pain as well as potential for injury because NOC CNA applied two briefs in an unsafe manner. NA stated the facility was unable to guarantee

the safety of their residents if standards of care were not being met. A record review of the facility submitted

a skills checklist provided by the registry company from a different long-term care provider not connected to

the facility. The skills check list was signed by the NOC CNA on 8/20/25, after the CNA had been terminated from the facility on 8/5/25. Additionally, the check list was incomplete and for an unrelated long-term care facility and provided no evidence of assessment or supervisory validation signatures for each competency. The facility did not provide a policy on the utilization of registry staff upon request.

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