Bayshire Torrey Pines Post-Acute

In the surveyor’s words

From the most serious findings on record at Bayshire Torrey Pines Post-Acute, in the surveyor’s own words.

• Immediate jeopardy, widespreadF801Mar 8, 2023

  Based 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 S 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. […]

• No harm, potential for more than minimal, widespreadF802Mar 8, 2023

  46247 Based 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 Cook (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 Cook (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 Cook (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 Cook (CK 3) did not know how to calibrate a food thermometer. 6. […]

• No harm, potential for more than minimal, widespreadF803Mar 8, 2023

  Based 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: F800, F801, F804, F809 Findings: During an interview on 2/27/23 at 8:46 AM with CK 1 in the main kitchen, CK 1 stated he was the main cook in the mornings that prepares breakfast and lunch meals for the facility's residents, including the skilled nursing facility (SNF). […]

• No harm, potential for more than minimal, widespreadF804Mar 8, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF809Mar 8, 2023

  Based 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. Cross reference F800, F804 Findings: A record review of the facilities scheduled mealtimes provided by EC on 2/27/28 indicated, breakfast was served at 7:30 A.M., Lunch was served at 11:15 A.M. and dinner was served at 4:15 P.M. On 2/27/23 at 4:45 P.M., an observation of the SNF satellite kitchen dining room was conducted. The SNF dining room did not have a main menu posted for the day, week, or month for the residents. […]