235 Nutmeg Street, San Diego, CA 92103 (opens Google Maps) · San Diego County · (619) 239-8687· 59 certified beds · avg 53 residents/day · certified since Sep 25, 1991 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
New to these records? How to read an inspection report →
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5 · how star ratings work →
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and quality measures from resident assessments and claims.
▲ Actual harm, isolated · May 11, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Jun 9, 2026 (Deficient, Provider has date of correction)
Showing the latest 3 of 58 inspection findings. Open the full record below to read every finding.
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint F-0600
The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint F-0656
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint F-0684
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 11, 2026 | ▲ G · Actual harm, isolated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint · F-0600 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint · F-0656 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684 |
| Feb 7, 2026 | E · Potential for more than minimal harm, pattern | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint · F-0692 |
| Feb 7, 2026 | D · Potential for more than minimal harm, isolated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint · F-0550 |
| Feb 7, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint · F-0677 |
| Dec 9, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584 |
| Sep 4, 2025 | D · Potential for more than minimal harm, isolated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint · F-0600 |
| Sep 4, 2025 | D · Potential for more than minimal harm, isolated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint · F-0726 |
| Jun 26, 2025 | E · Potential for more than minimal harm, pattern | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. · F-0565 |
| Jun 26, 2025 | E · Potential for more than minimal harm, pattern | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. · F-0605 |
| Jun 26, 2025 | E · Potential for more than minimal harm, pattern | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · F-0656 |
| Jun 26, 2025 | E · Potential for more than minimal harm, pattern | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755 |
| Jun 26, 2025 | E · Potential for more than minimal harm, pattern | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · F-0756 |
| Jun 26, 2025 | E · Potential for more than minimal harm, pattern | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · F-0757 |
| Jun 26, 2025 | E · Potential for more than minimal harm, pattern | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · F-0761 |
| Jun 26, 2025 | E · Potential for more than minimal harm, pattern | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880 |
| Jun 26, 2025 | D · Potential for more than minimal harm, isolated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · F-0552 |
| Jun 26, 2025 | D · Potential for more than minimal harm, isolated | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · F-0557 |
| Jun 26, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · F-0628 |
| Jun 26, 2025 | D · Potential for more than minimal harm, isolated | The facility did not make sure care was delivered by qualified people following each resident's written care plan — the individualized document that spells out exactly what care that resident is supposed to receive. · F-0659 |
| Jun 26, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · F-0686 |
| Jun 26, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · F-0688 |
| Jun 26, 2025 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689 |
| Jun 26, 2025 | D · Potential for more than minimal harm, isolated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · F-0759 |
| Jun 26, 2025 | D · Potential for more than minimal harm, isolated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Jun 26, 2025 | D · Potential for more than minimal harm, isolated | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. · F-0865 |
| Jun 10, 2025 | E · Potential for more than minimal harm, pattern | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint · F-0760 |
| Jun 10, 2025 | D · Potential for more than minimal harm, isolated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint · F-0761 |
| Jun 3, 2025 | D · Potential for more than minimal harm, isolated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint · F-0580 |
| Jun 3, 2025 | D · Potential for more than minimal harm, isolated | The facility was not properly licensed, or did not operate in compliance with federal, state, and local laws, regulations, and accepted professional standards. · from a complaint · F-0836 |
| May 2, 2025 | D · Potential for more than minimal harm, isolated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint · F-0760 |
| Jun 20, 2024 | E · Potential for more than minimal harm, pattern | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689 |
| Apr 7, 2023 | E · Potential for more than minimal harm, pattern | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · F-0656 |
| Apr 7, 2023 | E · Potential for more than minimal harm, pattern | The facility did not have enough staff with the right skills to meet the mental and behavioral health needs of its residents, such as those living with dementia or depression. · F-0741 |
| Apr 7, 2023 | E · Potential for more than minimal harm, pattern | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · F-0758 |
| Apr 7, 2023 | E · Potential for more than minimal harm, pattern | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · F-0838 |
| Apr 7, 2023 | E · Potential for more than minimal harm, pattern | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · F-0867 |
| Apr 7, 2023 | E · Potential for more than minimal harm, pattern | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880 |
| Apr 7, 2023 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' personal and medical information private and confidential. · F-0583 |
| Apr 7, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584 |
| Apr 7, 2023 | D · Potential for more than minimal harm, isolated | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · F-0676 |
| Apr 7, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684 |
| Apr 7, 2023 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689 |
| Apr 7, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · F-0695 |
| Apr 7, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · F-0699 |
| Apr 7, 2023 | D · Potential for more than minimal harm, isolated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · F-0759 |
| Apr 7, 2023 | D · Potential for more than minimal harm, isolated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Mar 29, 2019 | D · Potential for more than minimal harm, isolated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · F-0552 |
| Mar 29, 2019 | D · Potential for more than minimal harm, isolated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · F-0686 |
| Mar 29, 2019 | D · Potential for more than minimal harm, isolated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · F-0725 |
| Mar 29, 2019 | D · Potential for more than minimal harm, isolated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755 |
| Mar 29, 2019 | D · Potential for more than minimal harm, isolated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · F-0759 |
| Mar 29, 2019 | D · Potential for more than minimal harm, isolated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · F-0761 |
| Mar 29, 2019 | D · Potential for more than minimal harm, isolated | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. · F-0800 |
| Mar 29, 2019 | D · Potential for more than minimal harm, isolated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Mar 29, 2019 | D · Potential for more than minimal harm, isolated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880 |
| Mar 29, 2019 | D · Potential for more than minimal harm, isolated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. · F-0883 |
Citations from standard inspections stayed about the same across the last two inspection cycles (15 → 18).
All bars start at zero. Exact values and supporting details remain below.
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 10 | 0 | D |
| 2023 | 15 | 0 | E |
| 2024 | 1 | 0 | E |
| 2025 | 26 | 0 | E |
| 2026 | 6 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
How to file a complaint about care →
1 fine totaling $44,890.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
| Date | Type | Amount / length |
|---|---|---|
| May 11, 2026 | Fine | $44,890 |
What these staffing numbers mean →
All bars start at zero. Exact values and supporting details remain below.
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.03 | 4.31 | 3.95 | top 14% in California; top 13% in the U.S. |
| Registered Nurse hours | 0.98 | 0.61 | 0.69 | top 12% in California; top 17% in the U.S. |
| Weekend total nurse staffing | 4.56 | 3.90 | 3.50 | top 12% in California; top 11% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.61 | 0.51 | 0.48 | top 21% in California; top 22% in the U.S. |
| Total nursing staff turnover (%) | 62.5 | 36.7 | 45.8 | bottom 2% in California; bottom 13% in the U.S. |
| RN turnover (%) | 40.0 | 38.1 | 42.9 | bottom 47% in California; top 46% in the U.S. |
Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.78, RN 0.93, weekend 4.34.Comparing with Medicare Care Compare? Care Compare shows the raw figure (4.78 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 4/5.
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
Quality measures rating: 3/5 · long-stay residents: 5/5 · short-stay residents: 2/5
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for St. Pauls Health Care Center. CMS inspection and staffing records do not tell us what this home will charge you.
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Understand who pays for care · How we handle price evidence · Report an incorrect price
How to read ownership records →
Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| St Paul's Episcopal Home INC | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/1980 |
| Dekieffer, Kitty | Individual | Corporate Director | NOT APPLICABLE | 06/23/2025 |
| Dekieffer, Kitty | Individual | Trustee of the SNF | NOT APPLICABLE | 06/23/2025 |
| Edd, Patrick | Individual | Corporate Director | NOT APPLICABLE | 06/23/2025 |
| Edd, Patrick | Individual | Trustee of the SNF | NOT APPLICABLE | 06/23/2025 |
| Ellenich, Ronald | Individual | Corporate Officer | NOT APPLICABLE | 01/26/2026 |
| Ellenich, Ronald | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/20/2025 |
| Ellenich, Ronald | Individual | ADP of the SNF | NOT APPLICABLE | 02/06/2026 |
| Greiner, Philip | Individual | Corporate Director | NOT APPLICABLE | 06/23/2025 |
| Greiner, Philip | Individual | Trustee of the SNF | NOT APPLICABLE | 06/23/2025 |
| Gross, Dan | Individual | Corporate Director | NOT APPLICABLE | 06/23/2025 |
| Gross, Dan | Individual | Trustee of the SNF | NOT APPLICABLE | 06/23/2025 |
| Keller, Mary | Individual | Corporate Director | NOT APPLICABLE | 06/23/2025 |
| Keller, Mary | Individual | Trustee of the SNF | NOT APPLICABLE | 06/23/2025 |
| Lukas, Sophia | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/20/2023 |
| Lukas, Sophia | Individual | Corporate Officer | NOT APPLICABLE | 02/20/2023 |
| Lukas, Sophia | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/20/2023 |
| Lukas, Sophia | Individual | ADP of the SNF | NOT APPLICABLE | 02/20/2023 |
| Marusiak, David | Individual | Corporate Director | NOT APPLICABLE | 06/23/2025 |
| Marusiak, David | Individual | Trustee of the SNF | NOT APPLICABLE | 06/23/2025 |
Showing 20 of 32 parties CMS has on file for this facility; 12 are not displayed. The full list is in the CMS Ownership dataset.
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Balboa Nursing & Rehabilitation Center | 0.6 mi | San Diego, CA | ★★★★☆ | 3/5 | |
| Mission Hills Post Acute Care | 1.0 mi | San Diego, CA | ★★★★☆ | 3/5 | |
| Hillcrest Heights Healthcare Center | 1.3 mi | San Diego, CA | ★★★★★ | 4/5 | |
| Golden Hill Post Acute | 2.6 mi | San Diego, CA | ★★★☆☆ | 3/5 | |
| Villa Coronado D/P SNF | 2.8 mi | Coronado, CA | ★★★★★ | 5/5 | |
| Arroyo Vista Nursing Center | 3.5 mi | San Diego, CA | ★★★★★ | 4/5 | |
| The Pavilion at Ocean Point | 3.7 mi | San Diego, CA | ★★☆☆☆ | 2/5 | |
| The Shores Post-Acute | 4.2 mi | San Diego, CA | ★★★☆☆ | 3/5 | |
| Helen Bernardy Center D/P SNF | 4.7 mi | San Diego, CA | ★★★★★ | 5/5 | |
| Kearny Mesa Convalescent and Nursing Home | 4.7 mi | San Diego, CA | ★★★★★ | 5/5 | |
| University Care Center | 4.8 mi | San Diego, CA | ★★★★★ | 4/5 | |
| Brighton Place San Diego | 4.8 mi | San Diego, CA | ★☆☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
CMS records place this facility in San Diego, CA — 83 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.
Listed by facility name — not a ranking. Homes already in the table above are not repeated here.
Facility data as of CMS processing date 2026-08-01. CCN 555144.
May we use Google Analytics cookies to measure visits and pages viewed? Optional — every feature works without them. Privacy details