Bayshire Torrey Pines Post-Acute

Inspectors wroteBased on interview and record review the facility failed to implement a toileting schedule according to a resident's care plan intervention for one of three residents reviewed for care planning (Resident 1). This deficient practice had the potential for Resident 1 not to receive appropriate care, treatment, and interventions for fall prevention. Resident 1 was re-admitted to the facility on [DATE] with diagnoses including difficulty walking, muscle weakness and respiratory failure with hypoxia (a condition where the lungs fail to adequately exchange oxygen, leading to low oxygen in the blood) according to the facility's admission Record. An interview on 3/25/26 at 9:42 A.M. with Licensed Nurse (LN) 1 was conducted. LN 1 stated Resident 1 had a fall incident, was sent out to the hospital and has not returned to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a baseline care plan for two of 43 sampled residents (Resident 1 and Resident 3) with actual pressure ulcers. This deficient practice had the potential to delay the necessary person-centered care needed to prevent negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess an actual pressure ulcer on admission, provide appropriate treatment and preventative measures according to standards of practice to prevent further progression of a pressure ulcer for one of 43 sampled residents (Resident 1) at risk for pressure ulcers. This failure resulted in a delay of Resident 1's stage III pressure ulcer to be appropriately staged during an initial admission assessment and proper treatment for continous care necessary to prevent the worsening of the pressure ulcer.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. Opened food items had no use by date. 2. Food items with mold in it. 3. Employees' personal belongings were stored inappropriately in a food preparation area. 4. Boxes on top of the ice machine. These findings had the potential to expose the facility's residents to unsafe and unsanitary food practices that could lead to widespread foodborne illnesses.

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure it followed professional standards of practice when a gastrostomy tube (GT-tube inserted through the belly to bring nutrition and medications directly to the stomach) placement and residual (the amount of liquid drained from a stomach following administration of nutrition) was not checked before medication administration for one resident (20). This failure had the potential for causing complications related to GT health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care to one of two residents (Resident 96), reviewed for Activities of Daily Living (ADL, activities related to personal care) for dependent residents. As a result, Resident 96 was at risk for skin injury and infection.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a dressing for a peripherally inserted central catheter (PICC- a long, thin, flexible tube inserted into a vein that allows delivery of medications) was changed in a timely manner for one resident (151). This failure had the potential to increase the risk of infection to Resident 151.

Inspectors wroteBased on interview and record review, the facility failed to indicate the appropriate indication for the use of anticoagulant (blood thinner) medication for one of two residents (Resident 22), reviewed for unnecessary medications. This had the potential for unnecessary medication use and had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interviews, and record review, the facility failed to indicate the appropriate use of anti-anxiety (medication used for worry and fear) medications and communicated the target behavioral monitoring for the use of anti-anxiety medication among staff members, for one of five residents reviewed for unnecessary psychotropic (mind-altering) medications (Resident 96). This failure had the potential for unnecessary psychotropic medication use, its side effects, and a decline for residents psychological and mental well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection control practices when a urinary catheter (a tube inserted into the bladder to aid in urine flow) bag and dignity bag (a bag used to cover and conceal contents inside) was lying on the floor for one of two residents reviewed for urinary catheter care (Resident 95). This failure had the potential for cross contamination (spread of germs and bacteria) and infection.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures when the facility failed to conduct a comprehensive investigation of allegations of inappropriate comments that involved one resident (Resident 1). This failure had the potential for allegations of inappropriate behavior to not be fully investigated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received foods in measured amounts when standardized recipes were not followed for residents receiving pureed diets. This failure had the potential for residents to have decreased nutrition and possible weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety was maintained in the kitchen according to facility policy when multiple food items were not dated or were dated in the future; and no received on or use by date was noted. These deficient practices had the potential to cause foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat a resident with dignity when a Certified Nursing Assistant (CNA 1) stood while assisting with breakfast (Resident 108). This failure had the potential to cause Resident 108 a loss of self-esteem and/or self-worth.

Inspectors wroteBased on interview and record review, the facility failed to develop and transmit Discharge Minimum Data Set (MDS, a comprehensive assessment and care screening tool) assessments for two of two residents reviewed for Resident Assessment (Residents 5, 8). This failure resulted in Resident 5 and 8's discharge status not being communicated to the Centers for Medicare and Medicaid (CMS) as required, and had the potential to result in delayed quality measurements from the data.

Inspectors wroteBased on observation, interview and record review, the facility failed to utilize urine collection containers (UCC) in a safe, clean manner for two of two residents reviewed for Environment of Care. This failure had the potential to cause urinary tract infections (UTIs).

Inspectors wroteBased on interview and record review, the facility failed to ensure the acceptable standard of care for the blood pressure medication was followed for one of two sampled residents. This failure had the potential to affect Client 1 ' s quality of life, health and well- being.

Inspectors wroteBased on interview and record review, the facility failed to provide regular showers to two of two sampled residents (1, 2). As a result, Resident 1 and Resident 2 were placed at an increased risk of skin infections.

Inspectors wroteBased on observations, staff interviews, and facility document reviews, the facility failed to ensure the management and oversight of food and nutrition service operations was maintained with a qualified full-time dietitian or nutrition professional who met the requirements as specified in established state (California Code, Health and Safety Code - HSC § 1265.4) standards and federal standards, which include an onsite, qualified, full-time dietetic services supervisor (DSS) or food service manager (FSM); and a Dietitian employed full or part-time. The lack of oversight of dietetic and food services by a full-time DSS or FSM, resulted in the kitchen staff not having adequate oversight, tools, and training to develop the skills to carry out the Food and Nutrition Services in a competent, safe, and sanitary manner, particularly when the dietitian was part-time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department when: 1. A [NAME] (CK 1) and two diet aides (DA) 1 and DA 2 did not use standardized recipes and therapeutic menus in the kitchen to prepare and plate resident meals. 2. A [NAME] (CK 2) and a diet aide (DA 3) did not use a therapeutic menu or guide to prepare pureed meals and thickened drinks. 3. A [NAME] (CK 4) did not obtain or document the final cooking temperatures of prepared food for two months. 4. A Diet Aide (DA 2) did not correctly plate meals for residents on therapeutically prescribed carbohydrate-controlled (CCHO) diets. 5. A [NAME] (CK 3) did not know how to calibrate a food thermometer. 6. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the use of standardized recipes and therapeutic menus approved by a Registered Dietitian were used for skilled nursing home residents on therapeutic diets. This practice led to residents receiving meals did not match their physician ordered diet, or medical condition, which had the potential to compromise their nutrition status and other health consequences such as choking or death. Cross references:

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received foods that retained nutritive value and were served at an appetizing temperature when: 1. Standardized recipes and therapeutic menus were not followed for residents receiving pureed diets. 2. Holding temperatures on the tray line and resident test tray were below acceptable range and three residents complained of cold food. This failure had the potential to result in decreased intake and further compromise the nutritional status of 38 residents receiving therapeutic diets from the facility's kitchens. 1. During an observation and interview in the main kitchen on 2/27/23 at 3:36 PM, CK 2 was preparing shredded barbeque chicken for pureed resident meals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a meal span of less than fourteen (14) hours between a substantial evening meal and breakfast the following day. This failure had the potential to increase hunger and negatively affect the nutrition status of 38 residents who consume meals at the Skilled Nursing facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy when: 1. A white powdered substance was stored in the main kitchen unlabeled and undated in a large plastic bin. 2. Breadcrumbs were opened and undated with no cover or closure device. 3. The walk-in refrigerator and satellite kitchen refrigerator had multiple TCS (time/temperature control for food safety foods- meats, dairy, pasta, etc.) foods that were stored uncovered, unlabeled, and/or undated. 4. The temperature of milk stored in the satellite kitchen refrigerator was 44.8F when tested. 5. A dirty rag with brown stains was on tray with nine 8 oz. glasses of juice on it in the satellite kitchen reach-in refrigerator. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a kitchen garbage bin was kept clean and free of debris. This failure had the potential to promote an unsanitary environment that harbors pests and expose to unsafe conditions.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure two ice machines and the skilled nursing facility (SNF) kitchen dish machine were maintained in a safe, operating, and fully functioning manner, according to the manufacturer's guidelines and standards of practice. These failures had the potential to expose 38 residents to unsafe, unsanitary ice, which could lead to foodborne illnesses and further compromise their health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure when: 1. Nursing staff were competent and knowledgeable about the proper disinfection of shared glucometers (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to the manufacturer's instructions and accepted professional standards of practice and administration of nebulizer treatment (a liquid medicaine to help control breathing problems). Four out of Four nursing staff in three out of three nursing stations, did not know about the appropriate disinfectant product to use and/or the allowance of wet time (the amount of time disinfectants need to remain wet on surfaces to properly disinfect) when disinfecting shared glucometers. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a system of receipt and disposition of Controlled Substances (CS- a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) were established and implemented when: 1. The facility did not have a system in place in sufficient detail to accurately reconcile disposition of all controlled drugs. 2. The facility did not have a system in place to accurately periodically reconcile controlled drugs and account for controlled drugs for two out of two sampled residents (Residents 20, 555). These failures increased the risk for loss and/or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of a Controlled Substance.

Inspectors wroteBased on record review, and interview, the facility failed to ensure four of four sampled residents (Residents 547, 245, 3, 25) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 547 was administered clonazepam (medication that works in brain to help with anxiety) without an appropriate end date. 2. Resident 245 was administered alprazolam, no resident specific behavioral interventions were attempted or implemented prior to initiation and/or during use of alprazolam. 3. Resident 3 was administered trazodone (medication for depression) without appropriate clinical justification for dose increase and no resident specific behavioral interventions were attempted or implemented prior to initiation and/or during use of trazodone. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Facility Assessment (process used by facilities to assess the needs of its resident population and required resources to provide the care and services the residents need) addressed the dietary aides' training and competencies in order to provide food and nutrition services in a competent and safe manner. This failure placed 38 of the 38 residents in the facility, who received food from the licensed kitchen, at risk for food-borne illness, (illness caused by food contaminated with bacteria, viruses, or toxins) and not meeting the nutritional needs of the residents. (Refer to F-801)

Inspectors wroteBased on interview and document review, the facility Medical Director failed to ensure dietary policies and procedures and the Facility Assessment (process used by facilities to assess the needs of its resident population and required resources to provide the care and services the residents need) policy were implemented, when dietary staff did not prepare the residents' meals in accordance with the physician's orders. This failure placed 38 of the 38 residents in the facility, who received food from the licensed kitchen, at risk for food-borne illness, (illness caused by food contaminated with bacteria, viruses, or toxins) and not meeting the nutritional needs of the residents. (Refer to F-801 and F-838)

Inspectors wroteBased on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining, and improving safety and quality in nursing homes) did not identify areas of improvement in the facility's dietary services, when dietary staff did not prepare the residents' meals in accordance with the physician's orders. In addition, the facility's QAPI program policy and procedure did not clearly describe all the elements required in accordance to the federal regulation. This failure placed 38 of the 38 residents in the facility, who received food from the licensed kitchen, at risk for food-borne illness, (illness caused by food contaminated with bacteria, viruses, or toxins) and not meeting the nutritional needs of the residents. [...]

Inspectors wrote9. During a staff interview on 2/27/23 at approximately 8:20 am, IDON 1 (Interim Director of Nursing) identified the quarantine/isolation area as the three rooms at the end of the first hallway. IDON1 stated the Red Zone (isolation area) had COVID precautions in place for the residents with COVID 19 (dangerous viral infection) diagnoses. During observation on 2/27/23 at 9:09 am, the first hallway was observed to have a Red Zone laminated sheet attached to a post in front of the two Northeast (NE) rooms. In addition, three partially filled isolation carts, along with instruction sheets for donning Personal Protection Equipment (PPE), that included gowns, gloves, and mask, were observed outside of Resident 348, 349, and 350's rooms. Red Zone signs observed outside of Resident's 348 and 349's rooms. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a qualified Infection Preventionist (IP- a person who coordinated the handling of facility's infection control practices) was employed full time. As a result, the facility did not have a full time IP overseeing infection control practices for all the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform an interdisciplinary team (IDT, staff from different department who coordinates the residents care), assessment, and obtain a physician order for one of 39 residents (Resident 25) when multiple prescribed topical creams were found in a blue container on top of resident's bedside table. This failure had the potential for unsafe and improper administration of the topical cream medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address resident's needs and preferences for two of 12 sampled residents (345, 549) when: 1. Resident 549's call light was not within reach. 2. Resident 345's preferred time for administration of her medications were not honored as requested. These failures had the potential for resident's needs not being met. In addition, failure to honor the preferred time of medication administration resulted to Resident 345's refusals of medications and feelings of frustration and low self-worth.

Inspectors wroteBased on interview and record review, the facility failed to inform a resident's representative of a significant change in physical status for one of one resident (20) reviewed for hospitalization. This failure deprived resident 20's representative of the right of being informed of resident 20's change in physical condition.

Inspectors wroteBased on interview and record review, the facility failed to provide a written bed hold notice to the resident's RP (responsible party - an individual authorized by the resident to act as an official representative) upon transfer to the hospital for one of one resident (20) reviewed for hospitalization. This failure had the potential to result in Resident 20's RP being unaware of Resident 20's return to the facility after hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a comprehensive assessments for one of 12 residents (9) reviewed for resident's assessments with a significant change in condition. This failure had the potential to affect the provision of care and treatment/services to be provided to Resident 9.

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS - a screening and an assessment tool) assessment was accurately coded for one of one resident (19) reviewed for MDS accuracy. This failure had the potential to affect the care and services to be provided for Resident 19.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed and communicated to residents/residents representatives for three of 20 residents (44, 9, 19) reviewed for base-line care plan when: 1. Resident 44 did not have a completed baseline care plan created within 48 hours of admission. 2. Residents 44, 9 and 19 were not provided a written summary of their baseline care plans. As a result of this deficient practice, there was potential for lack of continuity of care and communication among nursing staff. This deficient practice also denied residents and their representatives the opportunity to participate in their care planning process.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans were revised/updated for 2 of 12 residents reviewed for care plans. (Resident 9 and Resident 19). This failure had the potential for residents not to receive the care needed to meet their individualized needs for safety, the potential for delayed care, miscommunication among caregivers, and decreased psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care to maintain good grooming and personal hygiene for 2 of 2 residents sampled for ADL care. (Resident 19 and 350). This failure resulted in Resident 19 having long and dirty fingernails and Resident 350 did not have a shower as scheduled.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services for two of two residents (Resident 549 and Resident 10) when the residents' skin condition was not monitored. This failure resulted in progression of dermatitis (inflammation of the skin) and had the potential to cause further skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate interventions to prevent pressure ulcer for one of two sampled residents (Resident 13 ) when Resident 13's heels were not floated while in bed. This failure had the potential to cause or worsen pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a timely bowel and bladder incontinence (inability to control urine and bowel movement) care for one of two sampled residents (Resident 549). This failure had the potential to cause discomfort and skin impairment to all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for one of two sampled residents (Resident 25) when the incorrect tube feeding formula (delivery of a nutritionally complete feed, containing protein, carbohydrates, fat, water, minerals and vitamins directly into the stomach). was given to there resident. As a result, the resident had the potential to not receive a nutritionally complete diet which could lead to other health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician supervised and managed the care of one of one residents (Resident 19) who was reviewed for weight loss. This failure had the potential for Resident 19's quality of life to be affected.

Inspectors wroteBased on interview and record review, the facility failed to ensure Medication Regimen Review (MRR) recommendations were communicated with the physician for 39 residents. In addition, the facility failed to keep pharmacy records of medication recommendation review. As a result, pharmacy medication recommendations were not acted upon, which could affect the medication regimen for all the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and/or labeled in accordance with current accepted professional principles and facility policies and procedures, for eleven sampled residents (Residents 28, 556, 19, 553, 551, 547, 14, 554, 551, 1) and a stock bottle of over-the-counter medication when: 1. [...]