Torrey Pines Post Acute: No Correction Plan Filed - NV
Resident 2 scored three out of 15 on a cognitive assessment at Torrey Pines Post Acute and Rehabilitation, indicating severe impairment. The resident had been diagnosed with schizoaffective disorder bipolar type and psychosis, with disorganized thinking that fluctuated in severity.
Despite these conditions, facility records listed the resident as their own "responsible party" with no power of attorney or guardianship documentation on file.
The resident's psycho-social assessment from June documented "severely impaired decision making skills regarding tasks of daily life" and noted "no relative resources available." Staff also wrote that no regional psychiatric facility placement was available.
A month later, the facility discharged the resident to a group home. The discharge notice marked the reason as "per you/and your family request" and showed only "verbal consent from R2" as authorization.
The Social Service Assistant who coordinated the discharge told inspectors the resident "could not make their own decisions" due to cognitive impairment. The assistant acknowledged the resident "needed a legal representative and did not have one" but was still "discharged to an independent living facility."
When asked about competency assessments, the discharge coordinator admitted not having "knowledge of the process for guardianship, for residents with severe cognitive impairment."
The facility's Assistant Administrator confirmed to inspectors that "a competency evaluation for a resident with a BIMS score of three and no familial support should have been completed" and acknowledged the facility "failed to do a competency evaluation."
A physician assistant who treated the resident described the patient's condition as unpredictable. The resident "was stable some days, but it was back and forth," the PA said. "R2's behavior was unpredictable."
The physician assistant confirmed the resident "could not make their own decisions and therefore needed a POA, guardianship or representative."
The resident had been followed by a regional psychiatric facility that "dropped R2 and was no longer involved or returning phone calls," according to the discharge coordinator. Staff suggested contacting a service coordinator to find appropriate placement, but the resident was ultimately sent to independent living anyway.
Federal regulations require nursing homes to provide social services that help residents achieve the highest quality of life. The facility's own policy stated that residents with dementia or impaired cognition should be referred to a psychiatrist to determine capacity for making informed decisions about medical care, financial matters, and daily activities.
The policy also required following state laws on guardianship and consent when no surrogate or responsible party exists.
The resident's medical record showed admission and readmission dates but lacked any documentation of efforts to establish legal representation or assess decision-making capacity despite clear evidence of severe impairment.
Staff acknowledged the regional psychiatric facility had stopped returning calls, leaving the cognitively impaired resident without professional mental health support during the transition to independent living.
The inspection found the facility failed to ensure the severely cognitively impaired resident received proper assessment and protection before discharge, potentially leaving someone unable to understand or make informed decisions about their care without appropriate legal safeguards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Torrey Pines Post Acute and Rehabilitation from 2025-11-18 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 13, 2026 · Our methodology
TORREY PINES POST ACUTE AND REHABILITATION in LAS VEGAS, NV was cited for violations during a health inspection on November 18, 2025.
Resident 2 scored three out of 15 on a cognitive assessment at Torrey Pines Post Acute and Rehabilitation, indicating severe impairment.
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.
Frequently Asked Questions
- What happened at TORREY PINES POST ACUTE AND REHABILITATION?
- Resident 2 scored three out of 15 on a cognitive assessment at Torrey Pines Post Acute and Rehabilitation, indicating severe impairment.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in LAS VEGAS, NV, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from TORREY PINES POST ACUTE AND REHABILITATION or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 295045.
- Has this facility had violations before?
- To check TORREY PINES POST ACUTE AND REHABILITATION's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.