Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bayshire Torrey Pines Post-acute during CMS and state inspections, most recent first.
A resident with difficulty walking, muscle weakness, and respiratory failure with hypoxia had a documented fall, after which the IDT added interventions including a toileting schedule to the fall and bowel/bladder care plans to reduce unassisted ambulation to the bathroom. EMR review showed the CNA toileting program task, directing staff to assist with toileting before and after meals and PRN, was only documented on two days, and the DON confirmed there was no documentation of an ongoing toileting schedule after the fall. CNAs reported that the resident was not on a toileting schedule and instead got up unassisted when needing the bathroom, contrary to the care-planned interventions and the facility’s comprehensive, person-centered care plan policy.
The facility failed to initiate a baseline care plan within 48 hours for two residents with pressure ulcers. One resident had a pressure ulcer identified upon readmission, but the care plan was delayed by three days. Another resident's pressure ulcer was noted during admission, but treatment orders were delayed by six days. Interviews revealed that waiting for the wound RN to stage ulcers contributed to these delays, contrary to facility policy requiring timely assessment and care planning.
A resident with a history of stroke and cognitive deficits was readmitted with an open area on the coccyx. The facility failed to stage the pressure ulcer promptly, delaying the care plan initiation by three days. This delay in assessment and treatment was contrary to the facility's policy, which required timely evaluation and care planning to prevent ulcer progression.
The facility was found to have several deficiencies in kitchen sanitation and food safety practices. Opened food items lacked use-by dates, and moldy strawberries were found in the refrigerator. Employees' personal belongings were improperly stored in the food preparation area, and boxes were placed on top of the ice machine, posing contamination risks. The CDM and RD acknowledged these issues, emphasizing the importance of proper labeling, storage, and sanitation to prevent health risks to residents.
A facility failed to follow professional standards when a nurse administered medications through a gastrostomy tube (GT) without checking its placement and residual for a resident with gastrostomy status. The nurse admitted to forgetting these critical steps, which are necessary to prevent complications. The Director of Nursing confirmed the expectation for all nurses to perform these checks.
A resident with generalized muscle weakness and fluctuating decision-making capacity did not receive proper nail care, resulting in long, split fingernails with debris underneath. Despite the resident's expressed desire for nail trimming, staff failed to address this need, as confirmed by interviews with a CNA and LN. The facility's policy required staff to maintain residents' grooming and hygiene, which was not adhered to in this case.
A resident with pelvic osteomyelitis had a PICC line dressing that was not changed in a timely manner, increasing the risk of infection. The dressing, dated from the hospital discharge, had not been changed according to the facility's policy, which requires changes every 7 days. The DON confirmed the oversight.
A facility failed to specify the indication for the use of apixaban, an anticoagulant, for a resident with peripheral vascular disease and atrial fibrillation. The physician's order lacked clarity on whether the medication was intended for A-fib or PVD. The Director of Nursing confirmed that licensed nurses should verify and clarify medication orders with the attending physician, as per facility policy.
A facility failed to manage anti-anxiety medication for a resident, leading to a deficiency. The resident was prescribed clorazepate for psychosis without a proper diagnosis. Staff interviews revealed no behavioral monitoring was conducted, and the licensed nurse admitted to entering the order incorrectly. The DON emphasized the need for correct medication indications, aligning with the facility's policy against unnecessary medication use.
A resident's urinary catheter bag and dignity bag were found lying on the floor, contrary to infection control practices. The resident, who had a history of benign prostatic hyperplasia and chronic urinary retention, expressed discomfort. Observations showed a licensed nurse jumping over the bags, and interviews with staff confirmed the bags should not be on the floor to prevent infection.
A facility failed to follow its abuse policy when a resident made inappropriate sexual comments to a CNA. The DON admitted that the investigation was not documented, and the Administrator acknowledged the incident was not classified as abuse, leading to a deficiency.
Failure to Implement Care-Planned Toileting Schedule for Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned toileting schedule for a resident identified as being at risk for falls. The resident was re-admitted with diagnoses including difficulty walking, muscle weakness, and respiratory failure with hypoxia. Following a fall on 3/12/26, an IDT post-accident/fall review documented that the resident was found on the floor near the bathroom door after a family member called a nurse. The IDT documented existing and new interventions, including placing the bed in the lowest position with the call light and personal items within reach, using a bed alarm, frequent rounding, and initiating a toileting schedule to reduce unassisted ambulation to the bathroom. The resident’s fall care plan, initiated on 3/10/26, identified the resident as at risk for falls related to generalized weakness and specified a toileting schedule to reduce unassisted ambulation to the bathroom, with a start date of 3/16/26. A bowel/bladder incontinence care plan initiated on 3/13/26 also included a toileting program to establish voiding/bowel patterns. Review of the resident’s EMR CNA task list showed a toileting program task directing staff to assist with toileting before and after meals as tolerated and PRN, but documentation of this task was only present on 3/18/26 and 3/19/26. The DON confirmed that the check marks indicated toileting was provided only on those two days and that there was no documentation of a toileting schedule following the fall incident. CNA 1, who was regularly assigned to the resident, reported that the resident had episodes of getting up unassisted specifically to go to the bathroom. CNA 4, assigned to the resident on the 2 p.m. to 10 p.m. shift, stated the resident was not on a toileting schedule and instead woke up whenever he needed to use the bathroom. The facility’s policy on comprehensive, person-centered care plans requires the IDT, with the resident and representative, to develop and implement a care plan that describes the services to be furnished, but the care-planned toileting schedule was not implemented as written for this resident.
Delayed Care Planning for Pressure Ulcers
Penalty
Summary
The facility failed to initiate a baseline care plan for two residents with actual pressure ulcers within 48 hours of admission, as required. Resident 1 was readmitted with a history of cerebral infarction and had a pressure ulcer on the coccyx identified during the admission skin assessment. However, the pressure ulcer care plan was not initiated until three days after admission, which was a delay in providing necessary care. The admission nurses did not stage the pressure ulcer, waiting instead for the wound MD, which contributed to the delay. Resident 3 was admitted with a history of malnutrition and had a pressure ulcer on the coccyx noted during the admission assessment. Despite this, no treatment orders were made for the pressure ulcer until six days after admission. The care plan for the pressure ulcer was initiated three days after admission, which was not within the required 48-hour timeframe. This delay in care planning could have contributed to the worsening of the pressure ulcer. Interviews with the MDS nurse and the DON revealed that the facility's practice of waiting for the wound RN to stage pressure ulcers led to delays in care planning. The facility's policy required assessment for pressure injury risk factors within eight hours of admission, but the failure to include pressure ulcers in the baseline care plan within 48 hours was a deficiency. The DON emphasized the importance of clear initial assessments and timely care planning to prevent worsening of pressure ulcers.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to accurately assess and provide timely treatment for a pressure ulcer on a resident upon admission. The resident, who had a history of cerebral infarction and moderate cognitive deficits, was readmitted to the facility with an open area on the coccyx. The admission nurse noted the wound but did not stage it, as the facility's practice was to wait for the wound MD to do so. This delay resulted in the absence of a pressure ulcer care plan within the required 48-hour timeframe, which is crucial for preventing the worsening of the ulcer. The Director of Nursing acknowledged the importance of including an actual pressure ulcer in the admission assessment and baseline care plan to prevent further complications. The facility's policy required an assessment for pressure injury risk factors within eight hours of admission, but this was not adhered to. The lack of immediate staging and care planning led to a delay in appropriate treatment, as the wound was not properly addressed until three days after admission when the wound RN initiated the care plan.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the kitchen, as observed during a survey. Several opened food items in the walk-in refrigerator, including sweet and sour basting sauce, grated carrots, salsa, noodle soup, and tomato soup, lacked use-by dates. The Certified Dietary Manager (CDM) acknowledged the importance of labeling food items to prevent serving expired foods to residents. Additionally, two packs of strawberries with mold were found in the refrigerator, which the CDM admitted should have been inspected to ensure freshness. The Registered Dietician (RD) confirmed that the expectation was for dietary staff to label and inspect food items to prevent health risks to residents. Further observations revealed that employees' personal belongings, such as a cellphone, keys, and a speaker, were improperly stored in the food preparation area, posing a risk of food contamination. The CDM and RD both stated that personal items should be kept in designated lockers to prevent contamination. Additionally, two boxes of Styrofoam products were found on top of the ice machine, which the CDM acknowledged should not have been there, as it could lead to debris falling into the ice machine and creating mold. The RD emphasized the need for the ice machine to be clear to maintain sanitation.
Failure to Verify GT Placement and Residual Before Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding the administration of medications through a gastrostomy tube (GT) for Resident 20. Resident 20, who was admitted with a diagnosis that included gastrostomy status, was observed during a medication administration process. A licensed nurse (LN 1) was responsible for administering medications to Resident 20. During the procedure, LN 1 detached the GT from the nutrition feeding tube, flushed it with water, and proceeded to administer medications without checking the GT placement and residual. LN 1 later acknowledged forgetting to perform these checks, which are crucial steps outlined in the facility's policy to prevent complications such as aspiration pneumonia. The Director of Nursing confirmed that it is expected for all nurses to verify GT placement and residual before administering medications.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care to a resident, identified as Resident 96, who was dependent on staff for personal care due to generalized muscle weakness. Upon observation, Resident 96's fingernails were found to be long, split, and had brown materials underneath, which the resident expressed discomfort about. The resident indicated that no staff had asked if she wanted her nails trimmed, despite her desire for them to be cut short. The clinical records showed that Resident 96 had fluctuating capacity to make medical decisions and required assistance for hygiene and grooming, as noted in her care plan. Interviews with facility staff, including a CNA and an LN, confirmed that the resident's fingernails were not properly maintained, posing a risk of self-injury and potential infection. The CNA acknowledged that they should have checked the resident's nails, while the LN noted that assessing and maintaining nail hygiene was part of their responsibilities. The Director of Nursing stated that the facility's expectation was for staff to ensure residents' nails were cleaned and trimmed as part of their hygiene care. The facility's policy on Activities of Daily Living supported the need for providing necessary services to maintain good grooming and personal hygiene for residents unable to perform these tasks independently.
Failure to Timely Change PICC Line Dressing
Penalty
Summary
The facility failed to ensure the timely change of a dressing for a peripherally inserted central catheter (PICC) for a resident, which increased the risk of infection. Resident 151, who was admitted with a diagnosis of pelvic osteomyelitis, was observed with a PICC line dressing dated 12/1/24, indicating it had not been changed since the resident's hospital discharge. During an interview, the resident confirmed that the dressing had not been changed since the hospital. The Director of Nursing acknowledged that the dressing should have been changed on 12/8/24, according to the facility's policy, which requires IV dressings to be changed at least every 7 days.
Failure to Specify Indication for Anticoagulant Use
Penalty
Summary
The facility failed to provide a clear indication for the use of anticoagulant medication, apixaban, for a resident admitted with diagnoses of peripheral vascular disease (PVD) and atrial fibrillation (A-fib). The physician's order dated 11/9/22 indicated the use of apixaban as an anticoagulant, but did not specify whether it was intended for A-fib or PVD. This lack of specificity in the medication order was identified during a review of the resident's clinical record and an interview with a licensed nurse (LN), who acknowledged the absence of a clear indication and noted that the nurse who transcribed the order was no longer employed at the facility. The Director of Nursing (DON) confirmed that the facility's expectation was for licensed nurses to verify and clarify medication orders with the attending physician to ensure the intended use is documented. The facility's policy on medication orders, revised in 10/2018, recommended that the indication or diagnosis for medication use be included in each order. The failure to specify the indication for apixaban use had the potential for unnecessary medication use and could negatively impact the resident's well-being.
Inappropriate Use of Anti-Anxiety Medication Due to Lack of Indication and Monitoring
Penalty
Summary
The facility failed to appropriately manage the use of anti-anxiety medication for a resident, leading to a deficiency in the administration of psychotropic drugs. Resident 96 was admitted with a physician's order for clorazepate, an anti-anxiety medication, indicated for psychosis. However, the resident did not have a diagnosis of psychosis, and the indication for the medication was incorrect. Interviews with staff, including CNAs and a licensed nurse, revealed that there was no behavioral monitoring conducted for the resident, and the staff were not informed of any behaviors to observe. The licensed nurse admitted to incorrectly entering the order and acknowledged the importance of specifying the correct indication to prevent unnecessary drug use. The Director of Nursing stated that the expectation was for licensed nurses to clarify the indication of psychotropic medications and understand the disease process being treated. The facility's policy on psychotropic medication use emphasized that residents should not receive medications that are not clinically indicated for a specific condition. The lack of proper indication and monitoring for the use of clorazepate in Resident 96's case highlights a failure in communication and adherence to the facility's policy, potentially leading to unnecessary medication use and its associated risks.
Infection Control Deficiency: Catheter Bag on Floor
Penalty
Summary
The facility failed to ensure safe infection control practices for a resident with a urinary catheter. During an observation, it was noted that the catheter bag and dignity bag of a resident were lying on the floor. This was confirmed during an interview with the resident, who expressed discomfort. The resident had been admitted with a diagnosis of benign prostatic hyperplasia and chronic urinary retention, requiring a urinary catheter. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. Further observations revealed that a licensed nurse administered medication to another resident and jumped over the catheter and dignity bags on the floor, indicating a lack of adherence to infection control protocols. Interviews with the licensed nurse, the infection preventionist, and the director of nursing confirmed that the catheter bag should not be on the floor to prevent infection. The facility's policy on catheter care, dated 2001, also specified that catheter tubing and drainage bags should be kept off the floor to maintain infection control.
Failure to Investigate Inappropriate Comments
Penalty
Summary
The facility failed to implement its policies and procedures regarding the investigation of allegations of inappropriate comments made by a resident. Resident 1, who was admitted with diagnoses including visual loss and a need for assistance with personal care, was reported by a Certified Nursing Assistant (CNA) to have made inappropriate sexual comments during a shower. Despite the report, the Director of Nursing (DON) acknowledged that the investigation was not documented as required by the facility's policy. The facility's policy on abuse, neglect, exploitation, or misappropriation, revised in September 2022, mandates that all reports are thoroughly investigated and documented. However, the Administrator admitted that the incident was not classified as abuse, and the necessary documentation was not included in the resident's chart. This lack of documentation and failure to follow the established abuse policy resulted in a deficiency, as it left the potential for allegations of inappropriate behavior to not be fully investigated.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Diego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Encinitas Post-acute | 6 mi | ★★★★★ | 0 | 0 |
| Vi At La Jolla Village | 6.1 mi | ★★★★★ | 22 | 0 |
| The Springs At Pacific Regent | 6.1 mi | ★★★★★ | 0 | 0 |
| Aviara Healthcare Center | 6.5 mi | ★★★★★ | 27 | 0 |
| La Jolla Post-acute | 7.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.