Bayshire Torrey Pines: Stage III Pressure Ulcer Care Delayed - CA
Resident 1 was readmitted to Bayshire Torrey Pines Post-Acute on February 1 with a history of cerebral infarction and moderate cognitive deficits. The admission assessment documented an open area on the tailbone measuring 1.5 by 1.5 centimeters, but no care plan was created until February 4.
LN 1, a licensed nurse interviewed by federal inspectors, explained the facility's problematic practice: "Admission nurses do not stage pressure ulcers and wait until the wound Medical Doctor stages for them but are not always available during admissions to stage pressure ulcers."
The delay violated federal requirements. LN 1 acknowledged that pressure ulcer care "should have been included in Resident 1's 48-hour baseline care plan if Resident 1 did have an actual pressure ulcer to prevent any worsening or delay in pressure ulcer care."
During those first three days, the resident received only basic maintenance treatment. The admission doctor ordered barrier cream applied twice daily to protect the skin, treating the wound as a minor skin issue rather than addressing it as the stage III pressure ulcer it would later be diagnosed as.
On February 4, when the wound specialist finally assessed the resident, the diagnosis became official: stage III sacrum pressure injury present on admission, now measuring 0.6 centimeters in length, 1.2 centimeters in width, and 0.6 centimeters deep. The doctor immediately ordered intensive treatment including wound cleanser, dead tissue removal with Santyl ointment, and monitoring for signs of infection.
The MDS nurse, who conducts federally mandated resident assessments, told inspectors the admission documentation was clear enough: "The admission assessment states open area to coccyx with measurements. I believe that's a pressure ulcer."
She explained that nurses "are told to not stage it until the RN wound nurse is able to stage it if there is really a pressure ulcer." But she acknowledged the three-day delay was problematic: "The pressure ulcer care plan was not in place within the 48-hour time frame and should be in place to indicate an actual pressure ulcer to help determine if the pressure ulcer got worse and to provide the proper treatment to promote healing."
Director of Nursing agreed the delay was unacceptable during her interview with inspectors. She stated it was "important to include an actual pressure ulcer on the admission assessment and the baseline care plan to prevent the pressure ulcer from worsening and delaying treatment."
The DON said her expectations were clear: admission nurses should document pressure ulcers immediately, noting at minimum whether skin was red and whether it blanched or stayed red when pressure was applied. "The admission RNs should not wait for the wound RN to stage the pressure ulcer or wait until the wound RN initiated the actual pressure ulcer care plan within 48 hours to prevent worsening complications and delaying treatments."
The facility's own policy, dating to 2001, requires assessing residents for pressure injury risk factors within eight hours of admission and using protective dressings for at-risk individuals. Resident 1's pressure ulcer risk assessment scored 17 out of 18, indicating moderate risk for developing additional wounds.
Stage III pressure ulcers extend through the full thickness of skin and into underlying tissue. They require immediate, specialized treatment to prevent infection and further tissue death. The three-day delay meant the stroke patient with cognitive deficits went without proper wound monitoring during the critical early period when intervention is most effective.
Federal inspectors cited the facility for failing to provide necessary care and services to prevent pressure ulcers from developing or worsening. The violation was classified as causing minimal harm with the potential for actual harm, affecting few residents.
The case illustrates a dangerous practice where admission nurses defer medical judgment to specialists who may not be immediately available, leaving vulnerable residents without timely treatment for serious wounds that are clearly visible upon arrival.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bayshire Torrey Pines Post-acute from 2025-02-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
BAYSHIRE TORREY PINES POST-ACUTE in SAN DIEGO, CA was cited for violations during a health inspection on February 21, 2025.
Resident 1 was readmitted to Bayshire Torrey Pines Post-Acute on February 1 with a history of cerebral infarction and moderate cognitive deficits.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.