Camino Healthcare: Missing Pass Documentation - CA
Camino Healthcare failed to track Resident 1's movements on August 22, 2025, despite federal requirements that facilities maintain detailed records when patients leave temporarily. The 67-year-old man, who uses a wheelchair due to spinal fractures and paraplegia, had doctor's orders allowing him to go out on pass.
But when inspectors reviewed his medical records three weeks later, they found a single progress note written at 11:31 p.m. stating only that he "went out on pass earlier in the day." No other documentation existed.
Licensed Vocational Nurse 1 explained the facility's standard procedure during a September 9 interview with state inspectors. Residents must sign an "out on pass binder" with departure and return times. Staff should document the destination and expected duration "so the next staff member would have that information if the resident did not return in the specified time and be able to notify the doctor and the resident's emergency contact."
The nurse reviewed both Resident 1's progress notes and the pass binder. She found nothing.
"There was no documentation to show when Resident 1 left the facility, what time he was expected to be back and where he went to," she told inspectors.
The resident's medical history shows significant vulnerabilities that make tracking his whereabouts essential. His face sheet lists diagnoses including vertebral fractures, paraplegia, and urinary retention requiring medical management. Despite these conditions, his July 15 assessment confirmed he remained cognitively intact with the capacity to understand and make decisions.
Camino Healthcare's own policy, updated in December 2023, requires nursing staff to document extensive details when residents leave temporarily. The policy mandates recording "date, time and with whom the resident left and returned to facility, medications provided, equipment loaned and quantities, location where resident will be over the course of the leave."
Staff must also note "general condition of the resident on return, changes or incidents experienced during leave, unused medications or supplies, and other significant information."
None of this documentation existed for Resident 1's August 22 outing.
The violation creates serious safety risks. Without knowing a resident's location or expected return time, staff cannot determine when to initiate emergency protocols if someone fails to return. For a wheelchair-bound patient with spinal injuries and urinary problems, delayed response could prove dangerous.
The documentation failure also prevents proper medication management. The facility's policy requires tracking any medications or medical equipment that leave with residents, ensuring continuity of care and preventing drug diversion.
Federal regulations require nursing homes to safeguard resident information and maintain complete medical records following professional standards. The missing documentation represents both a record-keeping failure and a potential safety hazard.
Inspectors found the violation during a complaint investigation on September 10, 2025. The state classified it as causing "minimal harm or potential for actual harm" affecting few residents.
But for Resident 1, the implications were clear. During the hours he spent away from the facility, no staff member could have located him in an emergency. His wheelchair, his medical needs, his planned return time remained unknown to the very people responsible for his care.
The 11:31 p.m. progress note confirming his return provided no details about his condition, any incidents during his absence, or whether he brought back unused medications or borrowed equipment. It simply acknowledged what staff already knew by then - he had left and come back.
Resident 1's case illustrates how documentation failures can compromise resident safety even when patients have decision-making capacity and medical clearance to leave temporarily. His cognitive abilities and doctor's orders gave him the right to go out on pass. The facility's responsibility was ensuring his safety through proper tracking and communication between shifts.
That responsibility went unfulfilled on August 22, leaving a vulnerable resident effectively invisible to the healthcare system meant to protect him.
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.
The 67-year-old man, who uses a wheelchair due to spinal fractures and paraplegia, had doctor's orders allowing him to go out on pass.
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.