Torrey Pines Post Acute and Rehabilitation

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 27, 2021

  Based on observation, interview, record review and document review, the facility failed to prevent a resident fall when it failed to ensure the resident's wheelchair was securely latched to the transportation van prior to transit for 1 of 25 sampled residents (Resident 8). Findings include: Resident 8 (R8) was admitted on [DATE], with diagnoses including [CONDITION(S)] and dementia. A Licensed Progress Note dated 08/10/2020, revealed R8 had a fall incident in the transportation van while being transported back to the facility from a medical appointment. Upon return to facility, the resident was assessed for injuries, physician and responsible party were notified and the resident was transferred to the hospital. […]

• No harm, potential for more than minimal, widespreadF812May 10, 2024

  Based on observation, interview and document review, the facility failed to ensure food items stored inside the stand-alone cooler and freezer were labeled, dated, and not expired; containers for juice machine were stored according to manufacturer instruction; items in the unit nourishment rooms were labeled, dated, and not expired. The deficient practice posed a potential risk to safety and health standards which could lead to contamination, inadequate storage, and place residents at risk of foodborne illness. […]

• No harm, potential for more than minimal, widespreadF563Feb 23, 2022

  Based on observation, interview, record review, and document review the facility failed to ensure indoor visitation was allowed for residents. Findings include: On 02/16/2022 at 2:09 PM, during the resident council meeting the residents verbalized indoor visitation at the facility had not been allowed for approximately 18 months due to the pandemic. On 02/18/2022 at 11:41 AM, the Infection Preventionist (IP) indicated visitation was allowed in the southwest activity room which could accommodate one family at a time for a maximum duration of one hour. The IP explained visits were scheduled with social services and family members would proceed to a designated outdoor area after being screened by the receptionist. […]

• No harm, potential for more than minimal, widespreadF805Feb 23, 2022

  Based on observation, meal test, interview, and document review, the facility failed to ensure a pureed diet was prepared in a manner to meet the required modified texture for 4 of 4 residents with difficulty chewing or swallowing (Resident 30, 33, 55, and 56). Findings include: On 02/17/2022 at 11:45 AM, a meal tray line observation was conducted with the Kitchen Manager, a cook, and two dietary aids. The pureed diet included pureed Brussels sprouts and pureed pork chops. The pureed pork had visible pieces of meat. The pureed diet was tested , and it was confirmed the meals were not thoroughly grounded or blended to provide a safe consistency and texture for residents at risk of choking or silent aspiration. […]

• No harm, potential for more than minimal, widespreadF812Feb 23, 2022

  Based on observation, interview, and document review, the facility failed to ensure the kitchen was clean, walls were in a good repair with no holes, utensils were kept in sanitary condition, and food was stored in a manner to prevent cross-contamination and food-related illness. Findings include: On [DATE] in the morning, an inspection of the kitchen was conducted with the Food Service Manager. The following issues were observed: A bleach solution bucket was placed under the meal preparation table close to a packet of ready-to-eat pastry. A toaster with food debris. The top surface of a steamer was visibly soiled with grease and dust. The exhaust vent over the stove was visibly soiled with grease and dust, including the tips of two fire suppression sprinklers. […]