St. Pauls Health Care Center
235 Nutmeg Street · San Diego, CA · 92103 · 6192398687
59 certified beds Non profit - Corporation
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
- No federal fines or payment denials in CMS’s 3-year window.
The composite number cleared 70 points, but Recommended is gated: inspection record below the Recommended bar. That rule is part of the published method.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
66% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 4 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 4.56 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.83 | 0.55–0.75 |
| Weekend hours / resident-day | 4.00 | ≈ weekday level |
| Nursing turnover / year | 66% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (55 in the current record)
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Potential for harm · D February 7, 2026 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected March 6, 2026 · Resident Rights
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Potential for harm · D February 7, 2026 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected March 6, 2026 · Quality of Life and Care
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Potential for harm · E February 7, 2026 · found via complaint
Provide enough food/fluids to maintain a resident's health.
Corrected March 6, 2026 · Quality of Life and Care
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Potential for harm · D December 9, 2025 · found via complaint
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.
Corrected December 19, 2025 · Resident Rights
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Potential for harm · D September 4, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected October 4, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D September 4, 2025 · found via complaint
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.
Corrected October 4, 2025 · Nursing and Physician Services
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Potential for harm · D June 26, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected July 26, 2025 · Resident Rights
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Potential for harm · D June 26, 2025
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected July 26, 2025 · Resident Rights
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Potential for harm · E June 26, 2025
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected July 26, 2025 · Resident Rights
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Potential for harm · E June 26, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected July 26, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 26, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected July 26, 2025 · Resident Rights
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Potential for harm · E June 26, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 26, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 26, 2025
Provide care by qualified persons according to each resident's written plan of care.
Corrected July 26, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 26, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected July 26, 2025 · Quality of Life and Care
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Potential for harm · D June 26, 2025
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.
Corrected July 26, 2025 · Quality of Life and Care
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Potential for harm · D June 26, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 26, 2025 · Quality of Life and Care
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Potential for harm · E June 26, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected July 26, 2025 · Pharmacy Service
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Potential for harm · E June 26, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected July 26, 2025 · Pharmacy Service
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Potential for harm · E June 26, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected July 26, 2025 · Pharmacy Service
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Potential for harm · D June 26, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected July 26, 2025 · Pharmacy Service
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Potential for harm · E June 26, 2025
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.
Corrected July 26, 2025 · Pharmacy Service
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Potential for harm · D June 26, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected July 26, 2025 · Nutrition and Dietary
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Potential for harm · D June 26, 2025
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected July 26, 2025 · Administration
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Potential for harm · E June 26, 2025
Provide and implement an infection prevention and control program.
Corrected July 26, 2025 · Infection Control
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Potential for harm · E June 10, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected July 3, 2025 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 555144 · certified since September 25, 1991. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.