St. Pauls Health Care Center
St. Pauls Health Care Center in SAN DIEGO, CA — inspection on September 4, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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
checklist provided by the registry company from a different long-term care provider not connected to
unrelated long-term care facility and provided no evidence of assessment or supervisory validation
staff upon request.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.