Torrey Pines Post Acute And Rehabilitation
TORREY PINES POST ACUTE AND REHABILITATION in LAS VEGAS, NV — inspection on November 18, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
owner had with the discharging facility.
The owner indicated the independent facility did not admit residents who required assistance with ADLs or behavior monitoring. R2 displayed disruptive behaviors during the stay, was throwing stuff and hitting others so the owner had to call 911 and R2 was transferred to a hospital because the level of care R2 needed could not be provided by the independent living facility.
The owner stated R2's discharge by the facility to the home (independent living) was inappropriate. A facility policy titled Discharge Process undated, stated information provided to the receiving provider must include at a minimum all necessary information, and any other documentation to ensure a safe and effective transition of care.Complaint 2573776
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/18/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Torrey Pines Post Acute and Rehabilitation
1701 S.
Torrey Pines Drive Las Vegas, NV 89146
SUMMARY STATEMENT OF DEFICIENCIES
Provide medically-related social services to help each resident achieve the highest possible quality of life.
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and document review, the facility failed to ensure a resident with severe cognitive impairment received a competency assessment to determine decision-making capacity and the need for a guardian or representative for 1 of 5 sampled residents (Resident 2).
The deficient practice had the potential for a severely cognitive impaired resident to not understand or make an informed decision on the care and treatment being provided.Findings include:Resident 2 (R2) was admitted [DATE], readmitted [DATE], with diagnosis including schizoaffective disorder bipolar type, psychosis not due to a substance or known physiological condition, and manic episode.A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three (severe cognitive impairment).
Disorganized thinking behavior was present, fluctuated, changed in severity.R2's profile in the electronic medical record documented R2 was responsible party.A Psycho-Social Assessment Form dated 06/25/2025, Admission, documented possible discharge plan to another facility, anticipated long term care, responsible party self, no advanced directives, severely impaired decision making skills regarding tasks of daily life.
Additional comments included no relative resources available, no regional psychiatric facility placement available. R2's medical record lacked documented evidence of a Power of Attorney (POA) or guardianship documentation.A Social Services Note dated 06/24/2025, documented the regional psychiatric facility was not able to take R2 back. A suggestion was made to contact a service coordinator to look for an appropriate placement for R2. An Interdisciplinary Discharge summary dated [DATE], documented resident was discharged to a group home.A Resident Notice of Transfer or discharge date d 07/01/2025, documented resident would be discharged from the facility on 07/11/2025.
The reason for the transfer or discharge was marked: as per you/and your family request.
The signature line of the form read verbal consent from R2, dated 07/11/2025.On 11/18/2025 at 12:15 PM, the Social Service Assistant/Discharge Coordinator explained the discharge process included to ensure resident's needs would be met at the new facility.
The Social Service Assistant/Discharge Coordinator stated R2 was followed by a regional psychiatric facility which dropped R2 and was no longer involved or returning phone calls.
The Social Service Assistant/Discharge Coordinator acknowledged, due to R2's cognitive impairment R2 needed a legal representative and did not have one.
The Social Service Assistant/Discharge Coordinator stated R2 could not make their own decisions and acknowledged R2 was discharged to an independent living facility.
The Social Service Assistant/Discharge Coordinator acknowledged a competency assessment should have been completed for R2 to assess the need for a guardian and explained did not have knowledge of the process for guardianship, for residents with severe cognitive impairment.On 11/18/2025 at 12:20 PM, the Assistant Administrator explained a competency evaluation for a resident with a BIMS score of three and no familial support should have been completed for R2, and acknowledged the facility failed to do a competency evaluation for R2.On 11/18/2025 at 12:38 PM, a Physician Assistant (PA), recalled the R2 was admitted with psychosis, mainly had schizoaffective issues and was referred to a psychiatrist.
The PA reported R2 was stable some days, but it was back and forth.
R2's behavior was unpredictable.
The PA confirmed R2 could not make their own decisions and therefore needed a POA, guardianship or representative.A facility policy titled Assessing Resident's Mental Capacity undated, documented if a resident was identified having diagnosis of dementia or impaired cognition, the resident would be referred to the psychiatrist to determine if the resident had the capacity to make informed decisions regarding medical care, financial matters, and daily living activities. In the absence of surrogate or responsible party, the facility would follow state specific laws on guardianship and consent.Complaint
Facility ID:
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LAS VEGAS, NV, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from TORREY PINES POST ACUTE AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.