The Pavilion At Ocean Point
Inspection Findings
F-Tag F0550
F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Resident 3 had no right arm and Resident 3's left arm was on his lap. Resident 3 stated there was a facility power outage on 8/6/25. Resident 3 stated he was provided with a call bell, but he could not use it because
he was not able to raise or reach using his left arm. Resident 3 stated he stayed wet until the electrical power turned on at 5:45 A.M. Resident 3 further stated he waited one hour yesterday (8/12/25) afternoon for someone to assist with the use of the urinal. Resident 3 stated he ended up being wet which made him angry and uncomfortable. During an interview on 8/13/25 at 10:10 A.M. with Certified Nurse Assistant (CNA) 1, CNA 1 stated residents' call lights should be answered immediately. CNA 1 stated residents have complained about the call light response and has been reported to the charge nurse. CNA 1 further stated if residents were left wet, they could develop rashes and bedsores. 4. Resident 4 was admitted to the facility
on [DATE REDACTED] with diagnoses including muscle weakness and acquired absence of right upper limb (arm) according to the facility's admission Record. During a review of Resident 2's MDS dated [DATE REDACTED], indicated BIMS score of 14, intact cognition. An observation and interview on 8/13/25 at 10:27 A.M. was conducted with Resident 4. Resident 4 was in bed and stated she waited an hour and a half for brief change. Resident 4 stated she could not recall the date and time but felt helpless having to wait too long. An interview was conducted on 8/13/25 at 10:31 A.M. with Licensed Nurse (LN) 1. LN 1 stated call light response should be as soon as possible. During an interview on 8/13/25 at 19:39 A.M. with CNA 2, CNA 2 stated call lights should be answered as soon as possible, at least between 10 to 20 minutes. CNA 2 stated residents could develop a rash and skin redness if left wet too long. 5. A review of the facility's minutes for the Resident Council meeting titled, Quality of Life Questions [QOL] was conducted. The QOL dated 5/20/25 indicated, 8.
Is your call light answered timely? Sometimes not during Noc [night]. The QOL dated 6/17/25 indicated, 8.
Is your call light answered timely? No. The QOL dated 7/15/25 indicated, 8. Is your call light answered timely? No PM.An interview was conducted on 8/20/25 at 9:32 A.M. with the Director of Nursing (DON). The DON stated he expected staff to respond to residents' call lights as soon as possible. Stated he expected CNAs to conduct rounding on the floors, inquire what the resident's need was and address accordingly.
Stated leaving a resident wet was unacceptable because the resident can develop moisture associated dermatitis (MASD- skin damage caused by prolonged exposure to moisture), excoriation and pressure injury (bedsore). The DON further stated it was very uncomfortable laying or sitting on something wet. A
review of the facility's policy and procedure (P&P) titled, Resident Rights, dated January 1, 2012, was conducted. The P&P indicated, Residents have freedom of choice, as much as possible how they wish to live their everyday lives.Employees are to treat all residents with kindness, respect and dignity ad honor the exercise of residents' rights. A review of the facility's P&P titled, Communication-Call System, dated January 1, 2012, was conducted. The P&P indicated, Nursing Staff will answer call bells promptly.adaptive call bell will be provided to resident per resident's needs.
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THE PAVILION AT OCEAN POINT in SAN DIEGO, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAN DIEGO, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THE PAVILION AT OCEAN POINT or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.