Other·February 1, 2019

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 survey for the investigation of two complaints. Compalint number: CA00570024. Category: Admission, Transfer, & Discharge Rights. See F626. Complaint number: CA00580514. Category: Resident Rights. See F585. Representing the California Department of Public Health: Health Facilities Evaluator Nurse 36709. Inspection was limited to the specific complaint or facility reported incident investigated and does not represent the findings of a full inspection of the facility. Glossary: CNA - Certified Nursing Assistant LN - Licensed Nurse Adm Coord- Admissions Coordinator ADON- Assistant Director of Nursing DON - Director of Nursing RP- Responsible Party

F585 SS=D Grievances CFR(s): 483.10(j)(1)-(4)

F585 §483.10(j) Grievances. §483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or 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: QAEQ11 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 06/20/2018 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 entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. §483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. §483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident. §483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QAEQ11 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 06/20/2018 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 (ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; (iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; (iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law; (v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns (s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; (vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QAEQ11 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 06/20/2018 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 (vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to ensure lost hearing aids were promptly replaced for one of three sampled residents (24). This failure had the potential to affect the quality of life and care of Resident 24. Findings: Resident 24 was admitted to the facility on 10/28/17 with diagnoses, which included urinary tract infection and history of a fall, per the History and Physical, dated 10/30/17. This document indicated Resident 24 was hard of hearing, with mild cognitive impairment, and a family member was the DPOA (durable power of attorney- responsible party). An interview was conducted with Resident 24's RP on 4/12/18 at 12:58 P.M. Resident 24's RP stated the resident was admitted to the facility with two hearing aids. The RP stated before Resident 24 went to bed, the caregivers would remove his hearing aids and give them to the LNs to be secured in a locked cart. The RP stated prior to Resident 24's discharge from the facility on 11/14/17, the hearing aids went missing. The RP stated he completed a facility form and was told by the administrator the hearing aids would be replaced. The RP stated in 1/18 he attempted to follow up and was told the administrator was no longer at the facility. The RP stated he kept working with the business office, and left repeated messages for the interim administrator, but had not received any calls back. The RP stated the hearing aids FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QAEQ11 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 06/20/2018 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 had still not been replaced. An interview was conducted with Resident 20 on 4/13/18 at 3:24 P.M. Resident 20 stated she had one hearing aid for her left ear. Resident 20 stated she preferred to keep her hearing aid at her bedside at night, and had declined to have the LNs keep her hearing aid at night. An interview was conducted with CNA 3 on 4/13/18 at 3:31 P.M. CNA 3 stated before bedtime she would assist residents in removing their hearing aids and either stored them in the bedside table or gave them to the LNs for storage, depending on the resident's preference. An interview was conducted with LN 2 on 4/13/18 at 3:35 P.M. LN 2 stated usually residents did not like to sleep with their hearing aids, so they were locked up in the medication cart. LN 2 stated most residents had a container where their hearing aids were stored. LN 2 opened the medication cart and a drawer that was double locked next to the narcotic medications was shown to be where the hearing aids were locked up at night. LN 2 stated, "They (the hearing aids) are locked up in the cart and endorsed to the next shift so the residents can get them back in the morning." An interview was conducted with the ADON on 4/13/18 at 3:41 P.M. The ADON stated all belongings were inventoried on admission and hearing aids would be included in the inventory. The ADON stated if a resident was confused or had cognitive impairment, their hearing aids were locked in the medication cart by the LNs at night. The ADON further stated, if hearing aids were lost, a grievance form was completed, an investigation was done, and if the hearing aids were on the inventory sheet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QAEQ11 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 06/20/2018 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 and were not found, they would be replaced. A review of Resident 24's inventory sheet, dated 10/16/17, indicated the resident had one right and one left hearing aid on admission. The inventory sheet was not signed upon discharge. A review of the facility's Complaint/Grievance form was reviewed. The first section titled Complaint/Grievance, indicated Resident 24's RP complained the resident's hearing aids were missing. This section of the form was not signed or dated. The second section titled Documentation of Investigation, indicated the hearing aids were not found, and since the resident had them locked up by the LNs the facility would replace the hearing aids. A note in this section dated 11/10/17 indicated the administrator spoke with the RP. Another note in this section, dated 11/28/17, indicated the RP was working on getting the hearing aids replaced. This section on the form was signed and dated 11/30/17. The third section on the form titled Resolution, indicated the facility would reimburse the cost of the lost hearing aids, the complaint was resolved, and the RP received written communication. This section of the form was unsigned and undated. A review of email communication between the facility and the hearing aid vendor, dated 12/1 to 12/8/17, indicated the payment process might take a few weeks. Further email communications, dated 1/2, 1/22, 2/28, and 3/30/18, indicated the payment had not been made and Resident 24 had not been fitted for his hearing aids. An interview was conducted with DON 2 on 4/13/18 at 5 P.M. DON 2 stated since the resident secured his hearing aids with the LNs, the facility was responsible for replacing them. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QAEQ11 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 06/20/2018 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 DON acknowledged the hearing aids for Resident 24 should have been replaced months ago and was probably the result of miscommunication with the interim administrator. The DON stated she would ensure the hearing aids were replaced as soon as possible. A review of the facility's policy titled Missing Items, dated 4/11, indicated, "...Policy Detail: ...4. The outcome of the investigation will be reported to the resident and responsible party... 6. Progress on missing items reported will continue at each scheduled morning stand up meeting until resolution..."

F626 SS=D Permitting Residents to Return to Facility CFR(s): 483.15(e)(1)(2)

F626 §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QAEQ11 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 06/20/2018 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 §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure Resident 45 was allowed to return to the facility after a hospitalization. This failure had the potential to create unnecessary stress and affects the continuity of care for Resident 45. Findings: Resident 45 was admitted to the facility on 10/26/17 with diagnoses which included tracheostomy (a surgical opening through the neck into the windpipe, to provide an airway for breathing) status per the facility's Admission Record. On 2/2/18 at 4:55 P.M., four empty beds were observed in the west hallway upon entrance to the facility. An interview with LN 1 was conducted on 2/2/18 at 5:03 P.M. LN 1 stated the facility did not have respiratory therapists or ventilators, so did not usually have residents with tracheostomies. A review of Resident 45's Progress Notes, dated 10/26/17 at 6 P.M., indicated the resident was admitted to the facility with a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QAEQ11 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 06/20/2018 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 tracheostomy. An interview was conducted with the acting DON 1 on 2/7/18 at 9:57 A.M. DON 1 stated she had been at the facility for approximately the past six weeks, until the facility had a new DON. DON 1 stated the facility was able to provide basic tracheostomy (trach) care for Resident 45, until the resident developed thick green sputum (a mixture of saliva and mucus). DON 1 stated, at that point Resident 45's physician orders changed so that the facility was unable to meet the resident's care needs. During an interview with DON 1 on 2/7/18 at 10:05 A.M., DON 1 stated she had overheard one of the nurses state Resident 45's responsible party (RP) had requested a bed hold, and wanted the resident to return to the facility. DON 1 stated she did not remember if the facility had heard from the hospital regarding Resident 45's discharge. DON 1 further stated when the hospital contacted the facility to discharge the resident, she would have reviewed the paperwork and consulted with the ADON and other resource consultants to make a decision regarding Resident 45's readmission. An interview was conducted with the ADON on 2/7/18 at 10:13 A.M. The ADON stated she was aware Resident 45's RP wanted the resident to return to the facility. The ADON stated when the referral from the hospital came in, the admissions coordinator (adm coord) would bring it to the DON for review. A review of the hospital's Case Management Summary Report, indicated the following: 1/13/18 at 6:05 P.M., "...Plan for today is arrange snf (skilled nursing facility) or subacute... [name of facility] did not accept patient back because they are unable to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QAEQ11 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 06/20/2018 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 manage his care..." 1/16/18 at 6:29 P.M., "...Doctors wants to cap trach in hope to close the trach. Also (RP) hopes to return to (facility) if trach is capped... Awaiting response from (facility) if they will accept capped trach...: 1/17/18 at 3:42 P.M., "...(Facility) continues to refuse pt... Did receive auth (authorization) for sub-acute..." 1/18/18 at 9:56 A.M., "Pt decannulated (trach removed) this am by Dr. (doctor)... update to both ...subacute and (facility). Discharge plan later today or tomorrow." 1/19/18 at 9:44 A.M., "Spoke to Dr. (at subacute facility)... can no longer accept this pt d/t (due to) decannulation... to check on SNF division availability. Left 2 VMs (voice messages) with (facility) to see if they can take pt back as pt formerly admitted..." 1/19/18 3:45 P.M., "...Pt and (RP) do not want to give more SNF names as (facility) is their 1st choice- AND pt had given $6,000 via check to hold bed..." An interview was conducted with the adm coord on 4/13/18 at 2:55 P.M. The adm coord stated there was a list of criteria for admission that she referred to when she received a referral from a hospital, and in addition the referral was reviewed by the DON or ADON for final clinical approval. The adm coord stated Resident 45's RP did put payment down for a bed hold, but the facility was not able to readmit the resident because they were not able to meet his needs. The adm coord stated communication with the hospital was documented through an online program. A review of communication to the facility from the hospital, dated 1/16/18 at 2:26 P.M., indicated, "We are planning on capping the trach in hopes that he will be able to have the trach closed. Will you accept with a capped FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QAEQ11 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 06/20/2018 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 trach?.." A review of communication to the facility from the hospital, dated 1/18/18 at 4:26 P.M., indicated, "Pt (patient) was admitted to your facility prior to this admission. Pt is decannulated (trach removed). No more trach. Please review referral. Pt to discharge tomorrow..." A review of communication to the facility from the hospital, dated 1/19/18 at 8:25 A.M., indicated, "Please let me know if you're able to take this pt again. He is decannulated; no trach. Discharge plan for today..." A review of communication from the facility to the hospital, dated 1/19/18 at 10:59 A.M., indicated, "I'm sorry, but per my nursing team and DON, we cannot meet (Resident 45's) needs." On 4/13/18 at 4:16 P.M. an interview was conducted with acting DON 2, who stated she was a regional nursing consultant, and acting DON until the facility's new DON started next week. DON 2 stated her understanding was that Resident 45's physician had stated the resident required a subacute level of care the facility could not provide. DON 2 stated Resident 45's readmission was discussed at a regional level and the team made the decision not to readmit the resident due to clinical reasons. A review of the facility's Admission Agreement, dated 5/11, indicated, "...Bed Holds and Readmission: ...If you are away from our Facility for more than seven days due to hospitalization or other medical treatment, we will readmit you to the first available bed in a semi-private room if you need the care provided by our Facility and wish to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QAEQ11 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 06/20/2018 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 readmitted..." A review of the facility's policy titled Readmission Process, dated 4/11, indicated, "...Readmission: 1. The original admission Agreement may be used ONLY if both of the following criteria are met: a. No more than thirty (30) days have past since the last discharge; and b. There have been no significant changes in the resident-specific information, as obtained from the original Admission..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QAEQ11 Facility ID: CA080001515 If continuation sheet 12 of 12