Camino Healthcare: Antibiotic Doses Missed - CA
The resident, who uses a wheelchair and has a spinal fracture and urinary retention, was prescribed cephalexin 500 milligrams four times daily to treat his UTI. But medication records show he missed the 5 p.m. dose on August 20, both the 1 p.m. and 5 p.m. doses on August 21, and the 5 p.m. and 9 p.m. doses on August 22 because he was out of the facility.
Federal inspectors found the facility had clear policies requiring staff to dispense medications and explain proper administration to residents before they leave on pass. The policy, dated December 2023, specifically states that "resident medications will be dispensed and explained to the resident representative to include instructions on when and how the medications are to be taken."
None of that happened.
Licensed Vocational Nurse 2 told inspectors during a September 10 interview that if a resident was scheduled for important medications while on pass, "the nurse would have to notify the doctor to obtain an order to allow the resident to take the medication while they are away from the facility." The nurse said education should be given to the resident on proper administration, and the medication record includes an option to mark that the resident took medication while away on pass.
But when reviewing the resident's medication administration record for August, the nurse confirmed the antibiotic "was not given at the scheduled times because Resident 1 was out of the facility." No doctor was contacted. No medication was dispensed. No education was provided.
The resident's medical records show he was admitted with multiple serious conditions including vertebral fractures and paraplegia. His July assessment confirmed he was cognitively intact with full decision-making capacity and could communicate effectively with staff and family.
The missed antibiotic doses occurred during treatment for a urinary tract infection, a potentially serious condition for someone with urinary retention and spinal cord injuries. Licensed Vocational Nurse 2 acknowledged to inspectors that "it was important to take antibiotics when they are scheduled because you want the bacteria to be killed and the infection to be gone."
Interrupting antibiotic treatment can allow bacterial infections to worsen or develop resistance to medication. For residents with compromised urinary systems, untreated UTIs can lead to kidney infections or sepsis.
The facility's medication administration record documented each missed dose with the notation that the resident was "out of the facility," but staff took no steps to ensure continuity of treatment. The resident's pass privileges continued despite the ongoing antibiotic course.
Federal inspectors found the violation represented a failure to meet professional standards of quality care. While classified as causing minimal harm, the deficiency created potential for actual harm given the importance of consistent antibiotic treatment for active infections.
The resident's cognitive abilities and communication skills meant he could have been educated about taking medication during passes. His decision-making capacity was documented in multiple assessments, including an April history and physical that confirmed his ability to understand and make healthcare decisions.
Camino Healthcare's own policies required exactly the intervention that never occurred. The December 2023 procedure manual outlined the specific steps nursing staff should follow when residents on medication leave the facility temporarily.
The inspection occurred following a complaint and focused on medication management practices. Inspectors reviewed the resident's complete medical record, including face sheets, assessments, physician orders, and medication logs spanning multiple months.
Licensed Vocational Nurse 2's interview revealed staff understood both the clinical importance of uninterrupted antibiotic treatment and the facility's policy requirements. The nurse explained the proper procedure for handling medications during passes and acknowledged the medication record system included options for documenting off-site administration.
The resident continues living at the facility, where his conditions require ongoing medical management including wheelchair mobility and treatment for urinary retention. His vertebral fracture and paraplegia make him dependent on facility staff for medication administration and healthcare coordination.
Five missed antibiotic doses over three days represented a significant gap in prescribed treatment for an active infection in a medically vulnerable resident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Camino Healthcare from 2025-09-10 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
CAMINO HEALTHCARE in HAWTHORNE, CA was cited for violations during a health inspection on September 10, 2025.
But medication records show he missed the 5 p.m.
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.