The Pavilion at Ocean Point
3202 Duke Street · San Diego, CA · 92110 · 6192244141
133 certified beds For profit - Limited Liability company Chain: Pacific Healthcare Holdings
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Staffing levels are well below research benchmarks for safe care.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | none |
Inspection citations (83 in the current record)
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Potential for harm · D September 17, 2025 · found via complaint
Ensure each resident receives an accurate assessment.
Corrected October 8, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 13, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected September 12, 2025 · Resident Rights
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Potential for harm · D July 31, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected August 29, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 31, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 29, 2025 · Quality of Life and Care
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Potential for harm · D June 24, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected July 17, 2025 · Resident Rights
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Potential for harm · D June 24, 2025 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected July 17, 2025 · Resident Rights
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Potential for harm · D April 15, 2025 · found via complaint
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected April 20, 2025 · Resident Rights
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Potential for harm · D October 24, 2024
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected November 21, 2024 · Resident Rights
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Potential for harm · D October 24, 2024
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected November 21, 2024 · Resident Rights
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Potential for harm · D October 24, 2024
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected November 21, 2024 · Resident Rights
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Potential for harm · D October 24, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected November 21, 2024 · Resident Rights
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Potential for harm · D October 24, 2024
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected November 21, 2024 · Resident Rights
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Potential for harm · D October 24, 2024
Ensure each resident receives an accurate assessment.
Corrected November 21, 2024 · Resident Assessment and Care Planning
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Potential for harm · D October 24, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected November 21, 2024 · Resident Assessment and Care Planning
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Potential for harm · D October 24, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected November 21, 2024 · Resident Assessment and Care Planning
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Potential for harm · D October 24, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected November 21, 2024 · Quality of Life and Care
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Potential for harm · D October 24, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected November 21, 2024 · Pharmacy Service
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Potential for harm · D October 24, 2024
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected November 21, 2024 · Pharmacy Service
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Potential for harm · D October 24, 2024
Ensure medication error rates are not 5 percent or greater.
Corrected November 21, 2024 · Pharmacy Service
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Potential for harm · D October 24, 2024
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected November 21, 2024 · Pharmacy Service
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Potential for harm · D October 24, 2024
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected November 21, 2024 · Nutrition and Dietary
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Potential for harm · D October 24, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected November 21, 2024 · Nutrition and Dietary
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Potential for harm · D October 24, 2024
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected November 21, 2024 · Administration
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Potential for harm · E October 24, 2024
Provide and implement an infection prevention and control program.
Corrected November 21, 2024 · Infection Control
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Potential for harm · D October 24, 2024
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected November 21, 2024 · Environmental
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 2, 2026 | Payment Denial | 5 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 055322 · certified since December 1, 1969. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.