The Pavilion At Ocean Point
THE PAVILION AT OCEAN POINT in SAN DIEGO, CA — inspection on August 13, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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] 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], 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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