Pavilion at Ocean Point: Call Light Delays Leave Residents Wet - CA
Resident 3 told inspectors about the August 6th power outage at The Pavilion at Ocean Point. With his left arm resting on his lap and lacking the mobility to raise or reach the call button, he had no way to summon help. He stayed wet until the facility's electrical power returned nearly six hours later.
The problems extended beyond the emergency. Just days before the inspection, Resident 3 waited a full hour for assistance with a urinal on August 12th. He ended up wet again, leaving him angry and uncomfortable.
His experience wasn't isolated.
Resident 4, who has muscle weakness and is missing her right arm, waited an hour and a half for a brief change during the inspection week. She couldn't recall the exact date and time but described feeling helpless during the prolonged wait.
"Call lights should be answered as soon as possible, at least between 10 to 20 minutes," CNA 2 told inspectors. The aide acknowledged that residents left wet too long could develop rashes and skin redness.
CNA 1 was more direct about the consequences. If residents were left wet, they could develop rashes and bedsores, the aide explained. CNA 1 also revealed that residents had complained about call light response times, and these complaints had been reported to the charge nurse.
The facility's own resident council meetings documented the ongoing problems. In May, residents answered "Sometimes not during night" when asked if call lights were answered timely. By June, the response was simply "No." July brought the same answer: "No PM."
Licensed Nurse 1 told inspectors that call light response should happen "as soon as possible," but the standard appeared more aspirational than operational.
Director of Nursing acknowledged the severity of delayed responses during his August 20th interview with inspectors. He expected staff to respond to call lights immediately and conduct regular rounding to address residents' needs.
Leaving residents wet was "unacceptable," he said, because prolonged moisture exposure can cause moisture associated dermatitis, excoriation, and pressure injuries. "It was very uncomfortable laying or sitting on something wet," he added.
The facility's policies supported his statements. The Communication-Call System policy, dating to 2012, required nursing staff to "answer call bells promptly" and provide adaptive call bells based on individual resident needs.
Yet Resident 3's experience revealed a fundamental breakdown in this system. During the power outage, he received a standard call bell that his physical limitations made unusable. With no right arm and limited mobility in his left, the device became worthless precisely when he needed it most.
The Resident Rights policy emphasized treating all residents "with kindness, respect and dignity." But dignity becomes hollow when residents with physical disabilities are left wet for hours because staff fail to check on them during emergencies or respond to their calls for basic care.
Both residents affected had significant physical limitations. Resident 3 had no right arm. Resident 4 suffered from muscle weakness and was missing her right upper limb. These disabilities made them particularly vulnerable to delayed care responses, yet the facility's systems failed to account for their specific needs.
The inspection found that few residents were affected by the call light delays, and the harm level was classified as minimal. But for Resident 3 and Resident 4, the impact was immediate and personal. One spent hours in wetness during a power outage. The other waited 90 minutes for a basic dignity need while feeling helpless.
The facility had clear policies requiring prompt call light responses and adaptive equipment for residents with special needs. Staff understood the medical risks of leaving residents wet. Resident council meetings had documented complaints for months.
Despite this knowledge and these policies, residents continued waiting. Resident 3's experience during the power outage crystallized the problem: when systems fail, the most vulnerable residents suffer first and longest.
The inspection occurred on August 13th, just one week after the power outage that left Resident 3 wet until dawn.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Pavilion At Ocean Point from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
THE PAVILION AT OCEAN POINT in SAN DIEGO, CA was cited for violations during a health inspection on August 13, 2025.
Resident 3 told inspectors about the August 6th power outage at The Pavilion at Ocean Point.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.