Federal inspectors cited the facility on August 12, 2025, following a complaint inspection.
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The resident, identified in inspection records only as Resident D, had a medical history that made the delay particularly serious.
That finding sits at the center of a federal complaint inspection completed August 11, 2025, at the skilled nursing facility on the San Francisco Peninsula.
Federal inspectors who visited Avir at Beaumont on August 12, 2025, found it harder to dismiss.
The resident affected was one of few.
The citation affected a small number of residents, according to the inspection report filed August 11, 2025.
That last duty, the one most directly tied to whether a resident actually gets to a doctor, is where inspectors found the breakdown.
The resident, identified in inspection records only as Resident 1, was on a pureed diet.
The inspection, conducted August 12, 2025, stemmed from a complaint.
The transfer should not have been attempted the way it was.
It was 10:22 on a Monday morning.
CMA R worked six days after her certification expired.