A list of the most recent deficiencies for Bayshire Torrey Pines Post-Acute. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-11 | 2024-02-10 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-01-11 | 2024-02-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-01-11 | 2024-02-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-11 | 2024-02-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-11 | 2024-02-10 | N |
| Use approved construction type or materials. | Fire Safety | 2024-01-17 | 2024-02-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-17 | 2024-02-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-17 | 2024-02-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-17 | 2024-02-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-25 | 2024-01-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-02 | 2023-11-16 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-08 | 2023-05-19 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-08 | 2023-04-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-08 | 2023-04-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-08 | 2023-04-20 | N |
| 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. | Health | 2023-03-08 | 2023-04-20 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-03-08 | 2023-04-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-08 | 2023-04-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-08 | 2023-04-20 | 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 | 2023-03-08 | 2023-04-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-08 | 2023-04-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-08 | 2023-04-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-08 | 2023-04-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-08 | 2023-04-20 | 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 | 2023-03-08 | 2023-04-20 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-03-08 | 2023-04-20 | 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 | 2023-03-08 | 2023-04-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-08 | 2023-04-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-08 | 2023-04-20 | N |
| 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. | Health | 2023-03-08 | 2023-04-20 | N |
| 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. | Health | 2023-03-08 | 2023-04-20 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-03-08 | 2023-04-20 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-03-08 | 2023-04-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-03-08 | 2023-04-20 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-03-08 | 2023-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-08 | 2023-04-20 | N |
| Dispose of garbage and refuse properly. | Health | 2023-03-08 | 2023-04-20 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-03-08 | 2023-04-20 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2023-03-08 | 2023-04-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-08 | 2023-04-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-08 | 2023-04-20 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-03-08 | 2023-04-20 | N |
| Keep all essential equipment working safely. | Health | 2023-03-08 | 2023-04-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-03-14 | 2023-04-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-14 | 2023-04-04 | 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 | 2023-03-14 | 2023-04-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-14 | 2023-04-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-03-14 | 2023-04-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-14 | 2023-04-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-14 | 2023-04-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-14 | 2023-04-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-14 | 2023-04-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-14 | 2023-04-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-14 | 2023-04-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-14 | 2023-04-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-14 | 2023-04-04 | N |
| Respond appropriately to all alleged violations. | Health | 2023-02-23 | 2023-03-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-23 | 2023-03-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-16 | 2023-03-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-09 | 2022-09-02 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-25 | 2019-08-27 | N |
| 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. | Health | 2019-07-25 | 2019-08-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-25 | 2019-08-27 | N |
| 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. | Health | 2019-07-25 | 2019-08-27 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-07-25 | 2019-08-27 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-07-25 | 2019-08-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-25 | 2019-08-27 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-07-31 | 2019-08-21 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-07-31 | 2019-08-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-31 | 2019-08-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-31 | 2019-08-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-31 | 2019-08-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-31 | 2019-08-21 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-07-31 | 2019-08-21 | N |
