St. Pauls Health Care Center
235 Nutmeg Street, San Diego, CA 92103
St. Pauls Health Care Center is a nursing home in San Diego, California. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionAugust 12, 2026 (2 months ago)
- Health citations since April 7, 202359 (California average 50)
- Fines in the past three years1, $29,179 in total
- CMS flagsCMS abuse icon
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CMS flags
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Fine
CMS changed the fine from May 11, 2026 from $44,890 to $29,179.
Health inspection on August 12, 2026
11 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 11 citations
Citation F0732. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on September 21, 2026.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 21, 2026.
CMS has cited this home for F0812 3 times since 2023.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on September 21, 2026.
CMS has cited this home for F0552 2 times since 2025.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on September 21, 2026.
CMS has cited this home for F0628 2 times since 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on September 21, 2026.
CMS has cited this home for F0656 4 times since 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on September 21, 2026.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 21, 2026.
CMS has cited this home for F0689 4 times since 2023.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on September 21, 2026.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on September 21, 2026.
CMS has cited this home for F0695 2 times since 2023.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on September 21, 2026.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 21, 2026.
CMS has cited this home for F0880 3 times since 2023.
Fire safety inspection on August 12, 2026
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation E0006. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on September 3, 2026.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on September 3, 2026.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on September 3, 2026.
CMS has cited this home for K0353 2 times since 2023.
Citation K0741. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on September 3, 2026.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on September 3, 2026.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on September 3, 2026.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on September 3, 2026.
CMS has cited this home for K0363 2 times since 2023.
CMS update of July 29, 2026
CMS abuse icon
CMS added its abuse icon to this home.
Health inspection on May 11, 2026
3 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
118 of 1,165 California homes (10%) got a citation at the actual harm level in 2026.
CMS fine of $29,179 on May 11, 2026.
Show the 3 citations
Citation F0600. Severity G: actual harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on June 9, 2026.
CMS has cited this home for F0600 2 times since 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on June 9, 2026.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 9, 2026.
CMS has cited this home for F0684 2 times since 2023.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
Health inspection on February 7, 2026
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0692. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on March 6, 2026.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on March 6, 2026.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on March 6, 2026.
CMS update of January 14, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Health inspection on December 9, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 19, 2025.
CMS has cited this home for F0584 2 times since 2023.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Health inspection on September 4, 2025
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on October 4, 2025.
Citation F0726. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 4, 2025.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Health inspection on June 26, 2025
18 citationsCMS lists this as a standard inspection.
Show the 18 citations
Citation F0565. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on July 26, 2025.
Citation F0605. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on July 26, 2025.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 26, 2025.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on July 26, 2025.
Citation F0756. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on July 26, 2025.
Citation F0757. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on July 26, 2025.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 26, 2025.
CMS has cited this home for F0761 2 times since 2025.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 26, 2025.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on July 26, 2025.
Citation F0557. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
CMS lists it as corrected on July 26, 2025.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on July 26, 2025.
Citation F0659. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care by qualified persons according to each resident's written plan of care.
CMS lists it as corrected on July 26, 2025.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on July 26, 2025.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 26, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 26, 2025.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on July 26, 2025.
CMS has cited this home for F0759 2 times since 2023.
Citation F0812. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 26, 2025.
Citation F0865. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have a plan that describes the process for conducting QAPI and QAA activities.
CMS lists it as corrected on July 26, 2025.
Fire safety inspection on June 26, 2025
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on July 18, 2025.
CMS has cited this home for K0918 2 times since 2023.
Health inspection on June 10, 2025
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0760. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on July 3, 2025.
CMS has cited this home for F0760 2 times since 2025.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 3, 2025.
Health inspection on June 3, 2025
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on July 3, 2025.
Citation F0836. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 3, 2025.
Health inspection on May 2, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on May 18, 2025.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
Health inspection on June 20, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 20, 2024.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.9 to 4.1 hours per resident per day.
Health inspection on April 7, 2023
15 citationsCMS lists this as a standard inspection.
Show the 15 citations
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on May 5, 2023.
Citation F0741. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
CMS lists it as corrected on May 5, 2023.
Citation F0758. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 5, 2023.
Citation F0838. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 5, 2023.
Citation F0867. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on May 5, 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 5, 2023.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on May 5, 2023.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 5, 2023.
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on May 5, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 5, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 5, 2023.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on May 5, 2023.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on May 5, 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on May 5, 2023.
Citation F0812. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on May 5, 2023.
Fire safety inspection on April 7, 2023
10 citationsCMS lists this as a standard inspection.
Show the 10 citations
Citation K0111. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
CMS lists it as corrected on May 16, 2023.
Citation K0343. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
CMS lists it as corrected on May 16, 2023.
Citation K0771. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
CMS lists it as corrected on May 16, 2023.
Citation K0346. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
CMS lists it as corrected on May 16, 2023.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on May 16, 2023.
Citation K0354. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on May 16, 2023.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on May 16, 2023.
Citation K0700. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
CMS lists it as corrected on May 16, 2023.
Citation K0711. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on May 16, 2023.
Citation K0918. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on May 16, 2023.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (619) 239-8687
- Last standard health inspection
- August 12, 2026 (2 months ago)
- Certified beds
- 59
- Residents per day, on average
- 49
- Ownership type
- Non profit - Corporation
- Legal business name
- St Paul's Episcopal Home INC
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
More health citations than the California average (59 vs 50).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- ST PAUL'S EPISCOPAL HOME INC5% or greater direct ownership interest · 100% · since 01/01/1980
- ELLENICH, RONALDOperational/managerial control · not applicable · since 10/20/2025
- LUKAS, SOPHIAOperational/managerial control · not applicable · since 02/20/2023
- MCHALE, MICHAELOperational/managerial control · not applicable · since 04/11/2022
- RAJPER, SALEEMOperational/managerial control · not applicable · since 01/26/2026
Show 1 more
- VIEU, GEORGEOperational/managerial control · not applicable · since 04/17/2023
Questions
When was St. Pauls Health Care Center last inspected?
CMS lists August 12, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does St. Pauls Health Care Center have?
CMS lists 59 health citations since April 7, 2023. CMS also calls these deficiencies.
Has St. Pauls Health Care Center been fined?
CMS lists 1 fine in the past three years, $29,179 in total.
What is the CMS star rating of St. Pauls Health Care Center?
Its CMS overall star rating is 2 of 5.
Is St. Pauls Health Care Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.
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