Health inspection·June 3, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to notify the attending physician of an abuse allegation for one of two sampled residents (Resident 1) reviewed for abuse. As a result, the attending physician was not aware of the abuse allegation placing Resident 1 at risk for further abuse. In addition, there was a potential for Resident 1 to not have appropriate safe interventions and physician evaluation. Findings: On 5/20/25 at 8:30 A.M., an unannounced onsite visit at the facility was conducted related to an abuse allegation. Resident 1 (R1) was admitted to the facility on [DATE] with diagnoses including [NAME] cell carcinoma (skin cancer) according to the facility's Face Sheet. During an observation and interview on 5/20/25 at 8:32 A.M. with Resident 1, Resident 1 was in bed leaning towards the left side of the bed near the bed rail. Resident 1 stated he had a concern with certified nurse assistant (CNA) 3. Resident 1 stated CNA 3 was, Rough while turning him in bed. During an interview on 5/20/25 at 9:46 A.M. with licensed nurse (LN) 1, LN 1 stated a resident's complaint about a CNA being rough was considered an abuse allegation. LN 1 stated abuse allegations were reported to the Director of Nursing (DON), Administrator, the resident's attending physician and the family. A concurrent record review and interview was conducted on 5/20/25 at 10 A.M. with the Charge Nurse (CN). The CN reviewed Resident 1's progress notes in the electronic medical record (EMR). The CN stated there was no documentation that Resident 1's attending physician was notified regarding the abuse allegation. During an interview with the DON on 5/20/25 at 10:25 A.M., the DON stated she did not find documentation regarding physician notification of the abuse allegation. During an interview with the DON on 6/13/25 at 10:18 A.M., the DON stated it was important for a resident's physician to be aware of an abuse allegation for the physician to evaluate the resident to ensure there was no physical or psychosocial harm to the resident. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 555144 Printed: 05/15/2026 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2025 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)