Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BAYSHIRE TORREY PINES POST-ACUTE
SAN DIEGO, CA · 45 certified beds · Last Life Safety survey December 12, 2024
CMS Certification Number 555746 · first certified October 1999
Also on this campus
The same campus holds a state-licensed assisted living facility, with its own state record on the Assisted Living Index: Bayshire Torrey Pines (13101 Hartfield Ave). Matched by the telephone number the two records share. The records are separate and are never added together.
Ownership
Operated by BAYSHIRE SENIOR COMMUNITIES · For profit - Limited Liability company
- Ownership changed June 30, 2023 (change of ownership)from S-H OPCO CARMEL VALLEY LLC
Position within CA
27 citations — more than 77% of the 1,165 certified nursing homes in CA. Compared within CA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 10 citations; the earlier surveys in the window averaged 8.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (December 2025 to June 2026). Most CA facilities have been surveyed by May 2027. This facility’s last Life Safety survey was December 2024. Facilities in CA are typically surveyed 12–18 months after the last one (median 14), measured over 1,766 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 27 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 27 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in CA, and nationally. Surveyors differ markedly between states, so the CA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 27 |
| Median facility in CA | 19 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 8, 2023 | 13 |
| January 11, 2024 | 4 |
| December 12, 2024 | 10 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-12-12 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2024-12-12 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2024-12-12 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2024-12-12 |
| K-0161 | Use approved construction type or materials. | 2 | 2024-12-12 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-12-12 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2024-12-12 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2023-03-08 |
What the citations cover
- Smoke Deficiencies 13
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Emergency Preparedness Deficiencies 3
- Egress Deficiencies 2
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 13 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Emergency Preparedness Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Construction Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 12, 2024 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (January 13, 2025) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (January 13, 2025) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (January 13, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (January 13, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (January 13, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 13, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (January 13, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 13, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (January 13, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 13, 2025) |
January 11, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (February 2, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (February 2, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 2, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 2, 2024) |
March 8, 2023 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (April 4, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (April 4, 2023) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (April 4, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 4, 2023) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (April 4, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 4, 2023) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (April 4, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (April 4, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 4, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (April 4, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 4, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (April 4, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (April 4, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.