Other·May 22, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. FRI / Complaint #: CA00565444 and #CA00564817 A deficiency was identified under the Code of Federal Regulations. The investigation was limited to the specific facility reported incident / complaint and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Health Facilities Evaluator Nurse 35626 and health Facilities Evaluator Supervisor 14185.

F675 SS=G Quality of Life CFR(s): 483.24

F675 04/09/2018 § 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KENT11 Facility ID: CA080001515 If continuation sheet 1 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555746 (X3) DATE SURVEY COMPLETED 03/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE TORREY PINES POST-ACUTE 13101 Hartfield Ave San Diego, CA 92130 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility failed to obtain orders to administer Coumadin (a blood thinner to help prevent the formation of blood clots), to 1 sampled Resident (A) for 9 days following hospitalization for the treatment of a blood clot in her left leg. Nursing failed to develop a plan of care to address ongoing assessment of the resident's affected limb. Nursing further failed to assess the resident after the resident complained of pain in her leg to certified nursing assistants (CNAs) and an occupational therapist (OT). Nursing also failed to notify the resident's physician of the change in her condition. These deficient practices resulted in Resident A developing a second blood clot in her leg, causing ischemia (restricted blood flow) to the leg leading to irreversible death of the tissue. Resident A declined amputation of her leg and ultimately died in the hospital 6 days later, having suffered extreme pain from the ischemic limb. Findings: Resident A was originally admitted to the facility on 11/7/17, from the hospital, with diagnoses to include unspecified atrial fibrillation (an irregular heart rate that may lead to blood clots), and generalized muscle weakness, per the Admission Record. According to the Minimum Data Set Assessment (a comprehensive assessment of the resident's functional capabilities), completed for Resident A on 12/11/17, Resident A scored 15 on her mental status assessment, indicating the resident was independent in her decision making. Per the same assessment, the resident's goal was to be discharged to her assisted living facility. Resident A was transferred to the hospital on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KENT11 Facility ID: CA080001515 If continuation sheet 2 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555746 (X3) DATE SURVEY COMPLETED 03/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE TORREY PINES POST-ACUTE 13101 Hartfield Ave San Diego, CA 92130 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/23/17, after she experienced fatigue and shortness of breath while ambulating with staff at the facility, according to the Pulmonary/Critical Care Medicine Admission Note. Examination of the patient in the Emergency Department revealed, "a cold and mottled (marked with spots or blotches) left leg." After a CT angiogram, (a technique used to look at blood vessels throughout the body), Resident A was diagnosed with an "intravascular thrombus in the distal left superficial femoral artery" (a blood clot in the main artery supplying blood to the lower limb). Resident A was admitted to the hospital for treatment of the affected limb. According to the Internal Medicine Progress Note, dated 12/3/17, Resident A underwent a procedure to dissolve and remove the blood clot and treatment with heparin, followed by Coumadin (medications to prevent the formation of further clots). The physician's plan for the resident was to return to the SNF for further rehab. (therapy) and to continue with the Coumadin. Resident A was transferred back to the facility on 12/4/17 with orders from the hospital. The orders included medications and treatments the physician wanted the resident to continue to receive at the facility. Included on the transfer medication orders was an order for, " Warfarin (Coumadin) - pharmacy to dose," indicating pharmacy would monitor results of blood tests to determine the resident's blood clotting time, and adjust the amount of Coumadin the resident should receive accordingly. Licensed Nurse 1 (LN 1) completed the Nursing Readmisson Data Collection when Resident A returned to the facility. According to the documentation, Resident A was alert to person, time and the situation. LN 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KENT11 Facility ID: CA080001515 If continuation sheet 3 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555746 (X3) DATE SURVEY COMPLETED 03/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE TORREY PINES POST-ACUTE 13101 Hartfield Ave San Diego, CA 92130 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE documented in the Narrative Summary, Resident A had a diagnosis of left lower leg arterial occlusion (blockage). LN 1 documented, "Verified all orders with (name of the resident's physician). Faxed med list to pharmacy." There was an unsigned handwritten note under the order for the Coumadin which read, "MD to dose Warfarin per RX" (according to the pharmacy, the physician was to prescribe the Coumadin dose). There was no documentation to show LN 1 told the resident's physician (MD 1) the pharmacy would not manage Resident A's Coumadin orders and MD 1 would be responsible for ordering the Coumadin. MD 1's orders included an order for nursing to monitor, "Scattered ecchymosis (bruising) to LLE (left lower leg), notify MD if s/s (signs and symptoms) of complications noted every shift." This order was written on the resident's Treatment Administration Record. Nursing did not develop a care plan on admission to address ongoing assessment of the resident's left leg, related to the diagnosis of left lower leg arterial occlusion or the bruising. Nursing did not develop a care plan for monitoring for the administration or side effects of Coumadin. MD 1 made a follow-up visit to the resident on 12/5/17. According to MD 1's documentation on the Continuing Care Nursing Home History and Physical, the resident was readmitted to the facility for rehabilitation. MD 1 documented under Assessment and Plan: "1. Femoral artery thrombosis, left. Now status post (after) intervention ... Continue anticoagulation with Coumadin." Review of the resident's Medication Administration Record (MAR) confirmed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KENT11 Facility ID: CA080001515 If continuation sheet 4 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555746 (X3) DATE SURVEY COMPLETED 03/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE TORREY PINES POST-ACUTE 13101 Hartfield Ave San Diego, CA 92130 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Coumadin was not added to the resident's scheduled medications for nursing to administer. Nursing initialed the Treatment Administration Record for Resident A to show they were monitoring the bruising on the resident's left lower leg; however, nursing did not document any further assessment of Resident 1's left leg until 12/10/17. At that time, LN 2 documented on the Daily Skilled Note, "LLE arterial occlusions with no complications noted." LN 2 checked the box on the note to indicate Resident A's left pedal pulses were palpable (a pulse on the top of the resident's left foot could be felt, indicating arterial blood was flowing to the resident's foot). On 12/11/17 at 12:09 P.M., LN 3 completed a Daily Skilled Note but failed to document an assessment of Resident A's pedal pulses or her left lower leg. On 12/12/17, according to the occupational therapist's Daily Treatment Encounter notes, Resident A complained of, "Pain in knee and foot. Pt. (resident) participated in manual massage for pain management in order for pt. to ambulate and participate in therapy." There was no documentation to show nursing assessed Resident A for the complaint of pain in her leg while she was in therapy. The next Daily Skilled Note was initiated, but not completed, on 12/12/17 at 2:41 P.M. The section for assessing pedal pulses and pain were both left blank. The next nursing documentation was dated 12/13/17 at 10:34 A.M., at which time, nursing completed a Change Of Condition assessment related to, "Left lower leg 8/10 pain (a pain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KENT11 Facility ID: CA080001515 If continuation sheet 5 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555746 (X3) DATE SURVEY COMPLETED 03/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE TORREY PINES POST-ACUTE 13101 Hartfield Ave San Diego, CA 92130 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE scale with 0 being no pain and 10 being the worst possible pain), cold to touch, scattered discoloration left leg." Per the same documentation, MD 1 saw the resident who was then transferred to the Emergency Department for evaluation. According to the hospital's Emergency Record, dated 12/13/17, Resident A had a cool, pulseless, mottled left lower extremity with delayed capillary refill (indicating impaired blood flow to the toes). Resident A complained of significant left leg pain and received IV morphine sulfate (narcotic pain medication administered directly into a vein), for pain relief. According to the hospital's Admission History and Physical notes, Resident A told the physician she had been experiencing left lower leg pain for 1 -2 days and had been unable to sleep the previous night due to pain. The hospital physician noted there was no record of the resident receiving anticoagulation since 12/4/17 when she was discharged to the facility. Resident A was admitted to the ICU (intensive care unit) for treatment. Unsuccessful attempts were made to reestablish blood flow to the affected limb. According to documentation on the Palliative Care Progress Note, (care that is aimed at relieving the symptoms of severe illness), dated 12/18/17, Resident A's chief complaint at that time was, "Severe left lower extremity pain" requiring, "escalating doses of oral morphine which have not been effective." Resident A also received hydromorphone (narcotic pain medication), "which slightly helped the pain, but did not fully alleviate (resolve) it." Resident A told the physician, "She would rather be sleeping all the time and in no pain/suffering rather than continuing to be awake and alert having such severe pain." Per the same note, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KENT11 Facility ID: CA080001515 If continuation sheet 6 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555746 (X3) DATE SURVEY COMPLETED 03/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE TORREY PINES POST-ACUTE 13101 Hartfield Ave San Diego, CA 92130 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident A declined amputation of the limb, choosing to focus on comfort. Resident A remained in the hospital until 12/19/17 when she died at 7:02 A.M. The cause of death listed on the Death Summary, dated 12/19/17, was left lower extremity limb ischemia. MD 1 was interviewed on 12/15/17 at 3:45 P.M. and again on 1/18/18 at 1:20 P.M. MD 1 stated when Resident A was readmitted to the facility on 12/4/17, he thought pharmacy was ordering the lab tests and Resident A's Coumadin dosing, based on the test results. MD 1 said when he visited the resident the morning after she was admitted, the Coumadin order was not in the computer-based system but it was not unusual for the orders to be entered later in the day. MD 1 stated he expected nursing to call him if the pharmacy was not doing the Coumadin dosing. CNA 1 was interviewed on 1/19/18 at 1:41 P.M. CNA 1 said he was working on 12/9/17 when the resident complained of, "leg pain specifically." CNA 1 said he put the resident back to bed, elevated her leg on a pillow and reported the resident's complaint to LN 4. CNA 1 said LN 4's response was, "I already gave her medication." There was no documentation on the MAR to show Resident 1 received any pain medication on 12/9/17. There was no documentation in the nursing notes to show LN 4 assessed the resident for the cause of her pain. CNA 2 was interviewed on 1/18/18 at 1:41 P.M. CNA 2 stated Resident A twice complained to him of pain and asked to see the nurse on 12/12/17. CNA 2 said he told LN 4 who said, "I already gave her everything, she has to wait." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KENT11 Facility ID: CA080001515 If continuation sheet 7 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555746 (X3) DATE SURVEY COMPLETED 03/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE TORREY PINES POST-ACUTE 13101 Hartfield Ave San Diego, CA 92130 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The Occupational Therapist (OT 1) was interviewed on 2/13/18 at 12:35 P.M. OT 1 said Resident A was very motivated with her therapy because she wanted to go home. OT 1 said during therapy on 12/12/17, Resident A complained of a tingling pain in her left foot. The OT said she removed the resident's socks and rubbed the resident's big toe and ankle, which seemed to relieve her pain. OT 1 said during therapy in the morning, she did not notice any change in temperature of the resident's leg. According to OT 1, later in the day at about 3 P.M., she answered Resident A's call light and found the resident, "vigorously rubbing" her left leg. Per OT 1, Resident A complained of, "excruciating" pain at 9/10 and when the OT felt the resident's foot it, "Felt like I was touching an ice cube" (indicating possible severe restriction of arterial blood flow). OT 1 said she also noticed a bruise on the resident's inner ankle. According to OT 1, the resident said she wanted to talk to her physician (MD 1), but he was gone for the day. OT 1 said she reported her observations to the licensed nurse LN 4 who, "Brushed it off and said the resident had poor circulation." OT 1 said, "She didn't seem to be too bothered about it." OT 1 said she did not report her concerns to anyone else and went home. According to documentation on the MAR, LN 4 administered 650 milligrams of Tylenol to Resident 1 for, "c/o (complaint of) achy pain generalized pain" on 12/12/17 at 6:55 P.M., approximately four hours after OT 1 said she reported to her Resident A was complaining of "excruciating" pain in her leg. LN 4 failed to document any assessment of the resident's left leg after the OT's report to her earlier in the evening. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KENT11 Facility ID: CA080001515 If continuation sheet 8 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555746 (X3) DATE SURVEY COMPLETED 03/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE TORREY PINES POST-ACUTE 13101 Hartfield Ave San Diego, CA 92130 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE At 3:15 A.M. on 12/13/17, LN 5 documented on Resident A's MAR, she gave the resident 650 milligrams of Tylenol for, "c/o left leg achy 4/10 pain." LN 5 failed to document an assessment of the resident's leg to determine the cause of the resident's pain. OT 1 was interviewed on 2/13/18 at 12:35 P.M. OT 1 said she went to Resident A's room at 8 A.M. on 12/13/17. The OT said at that time, Resident A's leg was mottled and, "Her leg didn't look good." OT 1 said she then reported her concerns to LN 6 who went in to see the resident. OT 1 said since the incident she had been told she should have completed a Stop and Watch Early Warning Tool on 12/12/17, (a form available to staff to report any identified change to nursing, which would prompt nursing to assess the change in the resident's condition), but at the time, she did not know about the form, so she failed to complete one. LN 6 was interviewed on 1/2/18 at 3 P.M., and again on 2/13/18 at 1:15 P.M. LN 6 said on 12/13/18, she went in to see Resident A in the morning. According to LN 6, Resident A was very upset and, "Mad at me because she had been waiting to see the doctor and she had complained of leg pain to the nurse the previous day." LN 6 said she assessed Resident A's leg which was cold to the touch and added she could not detect a pedal pulse. At that time, LN 6 said she reported her assessment findings to her supervisor, LN 3. LN 6 also said she would have expected nursing to have developed a care plan for Resident A on admission to address potential problems that could arise from the development of a second blood clot in the resident's leg. LN 6 said interventions on the plan should include, palpating for a pedal pulse, assessing for pain and temperature of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KENT11 Facility ID: CA080001515 If continuation sheet 9 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555746 (X3) DATE SURVEY COMPLETED 03/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE TORREY PINES POST-ACUTE 13101 Hartfield Ave San Diego, CA 92130 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the limb, administering Coumadin as prescribed to prevent further clots, and notifying the physician of any changes. LN 6 said nursing should have been assessing the resident every shift. LN 3 was interviewed on 2/13/18 at 1:25 P.M. LN 3 said she was the supervisor on duty on 12/13/18 when LN 6 reported her concerns about Resident A's leg. LN 3 said she assessed Resident A's leg and noted it was cold with no detectable pulse in her foot. LN 3 said Resident A was very upset, had pain rated at 8 out of 10 and wanted to see her physician. LN 3 said she notified the resident's physician who gave orders for the resident to be transferred to the hospital. LN 3 said the night shift nursing staff were responsible for double checking the orders of new residents admitted that day. LN 3 said it would appear the night shift staff did not verify Resident A's Coumadin was ordered nor did they develop a care plan to address the resident's arterial blood clot. The Assistant Director of Nursing (ADON) was interviewed on 2/13/18 at 1:45 P.M. According to the ADON, the nurses used a Clinical Admission Checklist to assist them in completing all the requirements for new admissions. Prompts on the checklist included for nursing to verify physician's orders and compare them with orders from the discharging hospital, and to initiate care plans. The DON stated the night shift staff were supposed to verify all the areas were completed for each new resident. The following morning, the IDT (an interdisciplinary team with representation from various departments providing care to the residents)) would review the checklist at the morning meeting. The ADON said the admitting nurse, the night shift nurse and the IDT all failed to follow up on the resident's Coumadin orders from the hospital and failed to ensure a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KENT11 Facility ID: CA080001515 If continuation sheet 10 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555746 (X3) DATE SURVEY COMPLETED 03/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE TORREY PINES POST-ACUTE 13101 Hartfield Ave San Diego, CA 92130 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care plan was developed for the potential for further blood clots in Resident A's leg. The ADON said nursing should have been completing a Daily Skilled Note for Resident A every shift for three days and then daily afterwards, which would have included pedal pulse and pain assessments. Only one of the three Daily Skilled Notes initiated for Resident A, from her admission on 12/4/17 to her discharge on 12/13/17, was completed and in the resident's record. LN 1, LN 2, LN 4 and LN 5 no longer worked at the facility and were unavailable for interview. According to the facility's policy entitled, Admission Data Collection and Orders last revised on 09/17, "2. The charge nurse who admits the resident is responsible for completing the Nursing Admission Data Collection, verifying orders are present on admission ..." and "6a) Orders should be reviewed with the physician and verified." The facility's policy entitled Change of Condition for Skilled Nursing, last revised 04/2017 was reviewed. According to the policy, "All associates shall communicate about a resident's status change to appropriate licensed personnel upon observation ....the associates will complete the Stop and Watch documentation and notify the charge nurse." Upon receiving a Stop and Watch documentation, ...."the licensed nurse will: perform a comprehensive evaluation or assessment" ..... and, " .....Call the appropriate Health Care Provider ... ....." According to the same policy, a resident change of condition may include, "Complaint of new or unrelieved pain." Resident A was readmitted to the facility for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KENT11 Facility ID: CA080001515 If continuation sheet 11 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555746 (X3) DATE SURVEY COMPLETED 03/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE TORREY PINES POST-ACUTE 13101 Hartfield Ave San Diego, CA 92130 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE rehabilitation on 12/4/17 after hospitalization and treatment for a blood clot in her left leg. The resident had a diagnosis of atrial fibrillation, which increased her risk for developing blood clots. The hospital physician discharged the resident with orders for Coumadin to prevent further clots. The facility failed to implement the plan of care and obtain orders from the resident's physician for the Coumadin and the resident went 9 days without the anticoagulation medicine. Nursing also failed to develop a care plan to monitor for potential blood clots in the resident's leg, and failed to assess and notify the physician when the resident complained of excruciating pain in her leg. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KENT11 Facility ID: CA080001515 If continuation sheet 12 of 12