Health inspection·December 9, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to provide a homelike environment for two of four sampled residents (Resident 1 and 2), when it did not maintain a comfortable temperature in one resident room.This failure had the potential to make residents uncomfortable.Findings:Record review of Face Sheet indicated Resident 1 was admitted on [DATE] with diagnoses which included: Dementia (severe cognitive decline affecting memory, thinking, language, and daily function, caused by damaged brain cells), Alzheimer's Disease (a progressive brain disorder, the most common form of dementia, causing severe memory loss, thinking, and behavioral problems that interfere with daily life), and Muscle Weakness.Record review of Resident 1's Minimum Data Set (MDS-assessment tool used in nursing homes) section C, Cognitive Patterns indicated a Brief Interview for Mental Status (BIMS) score of 3 indicating Resident 1 has severe cognitive impairment.Record review of Face Sheet indicated Resident 2 was admitted with diagnoses which included: Dementia, Malnutrition (lack of proper nutrition), Major Depressive Disorder (serious mental illness causing persistent sadness, loss of interest in activities, and impacting how you feel, think, and act, significantly interfering with daily life for at least two weeks), and Muscle weakness.Record review of Resident 2's MDS section C, Cognitive Patterns indicated a BIMS score of 10 indicating Resident 2 has moderate cognitive impairment.On 12/9/25 at 10:57 A.M., an observation and interview with Resident 1 was conducted. Resident 1 was observed sleeping. Resident 1 was arousable only to a loud voice. Resident 1 was observed with thick fleece blanket over her head. Resident 1 was alert, but hard of hearing (HOH), Resident 1 was able to answer questions translated by Spanish speaking staff, Unit Clerk 1 (UC). Resident 1 stated she was not cold under the thick blanket, but did not want to come out from under the blanket. Resident 1's room felt drafty with a cool breeze coming from the vent directly above her head. An observation of Resident 1's room thermostat indicated it was set at 74 degrees Fahrenheit (F-measure of temperature).On 12/9/25 at 11:10 A.M., an observation and interview with Resident 2 was conducted. Resident 2 was observed sitting in bed with her jacket on. Resident 2 was alert and able to answer questions via Spanish translator, UC. Resident 2 stated that she felt cold, and that a wind was coming from the vent making her cold. Resident 2 stated that .she preferred to be warmer and would like it if we could warm up the room for her.On 12/9/25 at 11:20 A.M., an interview with CNA 1 was conducted. CNA 1 stated that Resident 1 typically stayed under the blanket while in the room and could be cold at times. CNA 1 stated that Resident 1' daughter wrote on the board not to change the temperature on the thermostat and to leave it set at 74 F.On 12/9/25 at 11:50 A.M., a concurrent observation and interview with Maintenance Supervisor (MS) was conducted. MS stated that they check the room temperatures weekly. MS's then measured the temperature of air vents above resident's bed with a laser thermometer at 60 degrees F. MS measurement of temperatures of surface temp of Resident's 1's and 2's beds was 72 degrees. MS acknowledged the cool draft (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 2 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 12/09/2025 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)