Deficiency Records for Torrey Pines Post Acute and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Torrey Pines Post Acute and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-06-29 | 2023-08-22 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-06-29 | 2023-08-22 | N |
| Develop a communication plan. | Fire Safety | 2023-06-29 | 2023-08-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-06-29 | 2023-08-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-06-29 | 2023-08-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-29 | 2023-08-22 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-06-29 | 2023-08-22 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-06-29 | 2023-08-22 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-06-29 | 2023-08-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-29 | 2023-08-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-29 | 2023-08-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-29 | 2023-08-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-29 | 2023-08-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-29 | 2023-08-22 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-06-29 | 2023-08-22 | N |
| 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. | Health | 2023-06-29 | 2023-07-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-29 | 2023-07-21 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-06-29 | 2023-07-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-29 | 2023-07-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-07-21 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-06-29 | 2023-07-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-29 | 2023-07-21 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-06-29 | 2023-07-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-29 | 2023-07-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-08 | 2022-08-12 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-17 | 2022-05-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Develop a communication plan. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Establish methods for sharing information. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2022-02-17 | 2022-04-21 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-02-23 | 2022-04-07 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-02-23 | 2022-04-07 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-02-23 | 2022-04-07 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-02-23 | 2022-04-07 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-23 | 2022-04-07 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-02-23 | 2022-04-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-23 | 2022-04-07 | N |
| Provide activities to meet all resident's needs. | Health | 2022-02-23 | 2022-04-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-23 | 2022-04-07 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-02-23 | 2022-04-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-23 | 2022-04-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-23 | 2022-04-07 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-02-23 | 2022-04-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-23 | 2022-04-07 | N |
| Dispose of garbage and refuse properly. | Health | 2022-02-23 | 2022-04-07 | N |
| Keep all essential equipment working safely. | Health | 2022-02-23 | 2022-04-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-27 | 2021-09-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-27 | 2021-09-29 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-08-27 | 2021-09-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-27 | 2021-09-29 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-27 | 2021-09-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-27 | 2021-09-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-27 | 2021-08-27 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2019-05-22 | 2019-07-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-22 | 2019-07-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-22 | 2019-07-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-05-22 | 2019-07-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-22 | 2019-07-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-05-22 | 2019-07-19 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2019-05-22 | 2019-07-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-22 | 2019-07-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-22 | 2019-07-19 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2019-05-22 | 2019-07-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-05-22 | 2019-07-15 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-05-22 | 2019-07-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-05-22 | 2019-07-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-05-22 | 2019-07-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-24 | 2019-07-09 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-05-24 | 2019-07-09 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-05-24 | 2019-07-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-24 | 2019-07-09 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-05-24 | 2019-07-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-24 | 2019-07-09 | N |
| Provide appropriate foot care. | Health | 2019-05-24 | 2019-07-09 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-05-24 | 2019-07-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-24 | 2019-07-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-24 | 2019-07-09 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-05-24 | 2019-07-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-24 | 2019-07-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-24 | 2019-07-09 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-05-24 | 2019-07-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-24 | 2019-07-09 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-05-24 | 2019-07-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-24 | 2019-07-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-24 | 2019-07-09 | N |
