The Pavilion at Ocean Point: Call Light Failures - CA
These are two of the residents described in a complaint inspection conducted August 13, 2025, at The Pavilion at Ocean Point in San Diego. Federal inspectors cited the facility for failing to answer call lights in a reasonable amount of time, leaving residents sitting in their own waste while staff knew the problem existed and had for months.
Resident 3, who has muscle weakness, told inspectors he had waited roughly an hour the previous afternoon for someone to help him use a urinal. Nobody came in time. He ended up wet, which he described as making him angry and uncomfortable.
Resident 4 had been admitted to the facility with muscle weakness and the acquired absence of her right arm. She was in bed when inspectors spoke with her on the morning of August 13. She said she had waited an hour and a half for a brief change. She couldn't recall the exact date and time it happened, but she remembered how it felt. She told inspectors she felt helpless having to wait too long.
The certified nursing assistants inspectors interviewed did not dispute that the waits were a problem. CNA 1 said call lights should be answered immediately, that residents had complained about response times, and that those complaints had been reported to the charge nurse. CNA 1 said directly that residents left wet could develop rashes and bedsores. CNA 2 said call lights should be answered within 10 to 20 minutes at most, and that prolonged wetness causes rash and skin redness.
The Director of Nursing, interviewed on August 20, said he expected staff to respond as soon as possible and expected CNAs to round on floors and address residents' needs. He said leaving a resident wet was unacceptable. He named the specific consequences: moisture associated dermatitis, excoriation, pressure injuries. He said it was very uncomfortable laying or sitting on something wet.
None of that is disputed. What the inspection record shows is that management knew all of this and the problem continued anyway.
The clearest evidence came not from the residents' rooms but from the facility's own Resident Council meeting minutes. In a section titled Quality of Life Questions, residents were asked the same question across three consecutive monthly meetings: Is your call light answered timely?
In May 2025, the answer was: sometimes not during the night shift.
In June 2025, the answer was: no.
In July 2025, the answer was: no, in the evening.
The August inspection came one month after that third consecutive complaint. The facility's own records documented a pattern stretching back at least to spring. Residents had raised it formally, in writing, through the process the facility itself created for them to report concerns. The call light response did not improve.
The facility's call system policy, dated January 1, 2012, states that nursing staff will answer call bells promptly. Its resident rights policy, also dated 2012, states that employees are to treat all residents with kindness, respect and dignity.
Resident 4, one arm, waiting alone in bed for ninety minutes, told inspectors she felt helpless. That word appears once in the inspection report, in her own account of what it was like to need something and have no way to get it.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
THE PAVILION AT OCEAN POINT in SAN DIEGO, CA was cited for violations during a health inspection on August 13, 2025.
These are two of the residents described in a complaint inspection conducted August 13, 2025, at The Pavilion at Ocean Point in San Diego.
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.