Brighton Place San Diego

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a homelike environment for three of eight sampled residents (2, 4, 6). This failure had the potential to have negative psychosocial (intersection between an individual's psychological state (thoughts, feelings, and internal mental health) and their surrounding social environment (relationships, cultural norms, and societal factors)) effects on residents living in the affected rooms.

Inspectors wroteBased on observations, interviews, and record review the facility failed to report the alleged abuse of one (Resident 1) of seven sampled residents to the California Department of Public Health (CDPH) within two hours of the initial abuse allegation. This failure had the potential for further abuse to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the infection control program practices when: 1. The facility did not report COVID (infectious disease) outbreak to the California Department of Public Health Licensing and Certification (CDPH L&C, program which is responsible for regulatory oversight of licensed health care facilities and health care professionals to assess the safety, effectiveness, and quality of health care for all Californians).2. The resident's family member was not educated on infection control and the use of personal protective equipment (PPE, use of gown, gloves and mask to be worn or held by an individual for protection), for one of two residents (1) on contact precautions (used for infections, diseases, or germs that are spread by touching the patient or items in the room). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide residents and their families with a written Notice of Transfer/Discharge for three of three residents (Resident 1, 2, and 3), when reviewed for discharge. In addition, Resident 1 did not have a nurse's note, indicting when she left the facility for discharge, with whom she left, where she was going, and how she was being transported. These failures had the potential for residents to experience increased anxiety, when last minute discharges were conducted, with no ability to appeal the discharge, and the reader was uninformed of where the resident was transported to and when.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person -centered care plan related to discharge, during the stay for two of three residents (Resident 1 and Resident 3), reviewed for discharges. This failure had the potential for staff to be uninformed of the residents' wishes for discharge, resulting in an uncoordinated effort for a planned and organized discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan for discharge (leaving the facility) was developed for two of three sampled residents (Resident 2 and Resident 3). This failure increased the risk for Resident 2 and Resident 3 to have an unsafe discharge from the facility back to the community.

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of medical records within two business days of the request for one of two sampled residents (1). As a result, Resident 1's Responsible Party (RP 1) was not able to review the records in a timely manner.

Inspectors wroteBased on observation and interview, the facility failed to ensure that resident bathrooms were maintained in a sanitary manner for four of 16 sampled bathrooms (1 and 2). As a result, there was an increased risk of residents feeling uncomfortable using their bathroom.

Inspectors wroteBased on interview and record review, the facility failed to ensure that food temperatures were checked before serving to residents for two of 11 sampled days (10th, 11th). This failure placed residents at an increased risk of food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that dietary staff were trained to properly test the strength of kitchen sanitizer for two of two sampled dietary staff (Cook 1, Dietary Aide 2). As a result, there was an increased risk of food-borne illness.

Inspectors wroteBased on observation and interview, the facility failed to ensure: 1. Food was discarded before the expiration date 2. Food containers were labeled after opening 3. Dietary staff had their facial hair covered while in the kitchen for one of one kitchens. These failures placed residents at an increased risk of food-borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow their infection control policies and procedures to prevent the spread of infection and cross contamination when: 1. Resident 72's oxygen supplies were not stored properly. 2. The facility did not have an infection surveillance tracker to properly conduct a contact tracing for residents with respiratory illness. 3. The facility did not properly screen staff and visitors during an active coronavirus (COVID19- a virus that can cause severe respiratory illness) outbreak. This failure had the potential to increase the spread of infection for all residents, staff and visitors in the facility. The facility census was: 95.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 32 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) were not occupied by more than four residents This failure could potentially cause overcrowding and compromise the quality of care for the residents occupying the six-bed rooms.

Inspectors wroteBased on interviews, and record reviews, the facility failed to send a copy of the notice to transfer/discharge form to the Ombudsman office for two of six reviewed residents (Resident 6 and 72) that required immediate transfer to an acute care hospital for urgent needs. These failures resulted in a lack of resident discharge notification to the State Long Term Care (LTC) Ombudsman to advocate and assist the residents (Resident 6 and 72) with appeal rights as needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete a comprehensive elopement assessment for one of six sampled residents (Resident 198). As a result, Resident 198 eloped from the facility. Findings A review of Resident 198's admission Record dated 12/27/24, indicated that Resident 198 had a diagnosis of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During an observation on 1/12/25 at 10:50 A.M. Resident 198 was observed ambulating without assistance or assistive devices in the main hallway of the building. Resident 198 was accompanied by a facility staff member. During an observation on 1/13/25 at 8:50 A.M. The location of Resident 198's elopement was identified and found to provide access to Highway on and off ramps. During an interview on 1/13/25 at 8:50 A.M. with the Administrator (ADM). [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to accurately code the Minimum Data Set (MDS-a federally mandated resident assessment tool) according to the Resident Assessment Instrument (RAI-instructions for MDS) manual and the facility's MDS policies and procedures for three of 29 sampled residents (Resident 72, 29, and 23) when: 1. Resident 72's fall incident was not accurately coded. 2. Resident 29's fall incident was not accurately coded. 3. Resident 23's pneumonia diagnosis was coded as active without supporting documentation. As a result, the facility sent Residents (Resident 72, 29, and 23) MDS's to the federal database with inaccurate health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening Resident Review (PASRR, a federal requirement to help ensure that individuals were not inappropriately placed in nursing homes) was accurate for one of six sampled residents (Resident 69). This failure had the potential for Resident 69's mental health needs to be unmet.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement or develop a person centered care plan for two of 29 sampled residents (Resident 84, 9, 198) when: 1. Resident 84's nutritional care plan did not address nutritional preferences and dislikes. 2. Resident 9's care plan did not include a Hospice care plan. 3. Resident 198's care plan did not indicate a person-centered approach to prevent future wandering/elopement while at the facility. As a result, Resident 84's and Resident 9's plan of care was not personalized that promotes or maintains their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions for skin breakdown and/or pressure injury (bed sores) for one of five sampled residents (47) was maintained. Resident 47 had a low air loss mattress (LAL mattress: An air mattress to prevent pressure injury) for prevention of skin breakdown that were not set to the residents' current weight. This failure had the potential for Resident 47 to develop a pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents' (Resident 84) planned meal tray card (guidance to staff on what to serve for a meal to a resident) and menu was nutritionally substituted according to preferences to promote nutritional adequacy to current health status. This failure had the potential to result in a poor nutritional intake and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form to meet the needs of one of six sampled residents (Resident 27). This failure had the potential to cause unintended weight loss and medical complications. Findings Per Resident 27's admission record, Resident 27 was admitted on [DATE] with diagnoses including Cerebral Infarction (blood loss to the brain) and End Stage Renal Disease (ESRD-irreversible kidney failure). A record review of Resident 27's minimum data set (MDS - a federally mandated resident assessment tool) dated 12/12/24 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 12 points out of 15 possible points which indicated Resident 27 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their smoking policy for two of 17 residents (Residents 18 and 40) reviewed for smoking and tobacco use. This deficient practice had the potential for accidents and injuries.

Inspectors wroteBased on interview, and record review, the facility staff failed to monitor and document urine output (UO) per the facility's policy, for one of three sampled residents (Resident 2) with a urinary catheter (a tube inserted into the bladder to aid in urine flow). This failure had the potential for Resident 2 to have urinary retention and developed urinary tract infection (UTI).

Inspectors wroteBased on interview, and record review, the facility failed to ensure proper medication administration for one of three sampled residents (Resident 1), when an anti-rejection medication (are medicines that keep organ transplants from being attacked by the immune system) was not administered per the physician's order. As a result, there was an increased risk for Resident 1's transplanted organ to be rejected by her body.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (1) who had a colostomy (a surgical procedure that creates an opening in the large intestine, or colon, through the abdominal wall for the stool to pass into a bag) received the necessary care and treatment when the facility did not develop a baseline care plan (sufficient information to provide care properly), get a physician order, and treatments provided to Resident 1 was documented in the resident's treatment administration record (TAR). These failures had the potential for Resident 1 not to receive colostomy care timely as prescribed by the physician and not receive consistent care from the licensed nurses during colostomy bag changes.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement measures to keep a resident from elopement (leaving the facility without permission) and provide monitoring for one sampled resident (Resident 1). In addition, the Licensed Nurse (LN) 2 failed to clarify an out on pass (therapeutic leave) order for Resident 1 on 5/28/24. As a result, Resident 1 eloped on 6/1/24 and returned to the facility on 6/2/24. This failure had the potential to compromise Resident 1's health, safety and well- being.

Inspectors wroteBased on observation, interview and record review the facility failed to conduct reference checks prior to hiring a certified nursing assistant (CNA)1. This failure had the potential to increase the risk of abuse for facility residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently provide dialysis (treatment to remove waste from the body) access care, including removal of dressing and assessment of the site for one of three sampled residents (Resident 1). In addition, the dialysis communication form was not completed consistently for three of three sampled residents (Resident 1, Resident 2, and Resident 3), reviewed for dialysis. As a result, there was the potential for complications after dialysis.

Inspectors wroteBased on observation, interview and record review the facility failed to be provided prescribed medication to two of three residents reviewed (Resident 1, 2). This failure had the potential to cause a decrease in health status of Resident 1 and 2.

Inspectors wroteBased on observations, interviews, record review, review of a technical brief from the manufacturer of the facility's blood glucose monitoring system, review of the Environmental Protection Agency's (EPA) list of approved disinfectants, and facility policy review, the facility failed to ensure staff cleaned and disinfected a multi-resident glucometer in accordance with manufacturer's instructions between use for 2 (Resident #48 and Resident #83) of 4 total residents observed for fingerstick blood sugars. In addition, the facility failed to implement their Water Management policy to prevent the potential growth and spread of Legionella (a bacteria known to cause Legionnaires' disease) and other water-borne pathogens. This had the potential to affect all 89 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and facility document review, the facility failed to ensure rooms were not occupied by more than four residents. Specifically, room [ROOM NUMBER] was occupied by six residents, and room [ROOM NUMBER] was occupied by five residents, with an additional bed available for a total occupancy of six residents when the room was at full capacity. This deficiency affected 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) of 32 rooms in the facility.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to notify the physician that 1 (Resident # 84) of 5 sampled residents reviewed for unnecessary medications was consistently refusing medications.

Inspectors wroteBased on record review, interviews, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments reflected current tobacco use for 1 (Resident #50) of 2 sampled residents reviewed for smoking.

Inspectors wroteBased on interviews, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, the facility failed to submit a status change to a Pre-admission Screening and Resident Review (PASRR) Level I Screening Document following a new mental illness diagnosis for 1 (Resident #48) of 2 sampled residents reviewed for PASRR requirements. Specifically, Resident #48 had a negative PASRR Level 1 Screening upon admission to the facility but was later diagnosed with a new mental illness diagnosis, and the facility failed to submit a status change to the resident's PASRR Level I Screening.

Inspectors wroteBased on interviews, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) Level I Screening Document reflected the presence of a diagnosed mental illness at the time of admission for 1 (Resident #48) of 2 sampled residents reviewed for PASRR requirements. Specifically, Resident #48 had a diagnosis of major depressive disorder at the time of admission to the facility, but their PASRR Level I Screening reflected they had no diagnosed mental illnesses, resulting in a negative PASRR Level 1 Screening.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to provide nail care and remove facial hair for 2 (Resident #33 and Resident #84) of 4 sampled residents reviewed for assistance with activities of daily living (ADLs).

Inspectors wroteBased on record review and interviews, the facility failed to ensure the electronic medical record (EMR) for 1 (Resident #26) of 4 sampled residents reviewed for advance directives accurately reflected the resident's desired code status (describes the type of resuscitation procedures, if any, a person would like their healthcare team to provide in the event their heart stopped beating, or they stopped breathing). Specifically, Resident #26's EMR reflected the resident was to receive cardiopulmonary resuscitation (CPR) instead of do not resuscitate (DNR) as desired by Resident #26 and as indicated by their Physician Orders for Life Sustaining Treatment (POLST).

Inspectors wroteBased on record review and interviews, the facility failed to ensure medication delivered by the pharmacy for 1 (Resident #245) of 22 sampled residents was appropriately received by facility staff in a manner to ensure the medication was placed in the resident's medication storage area and readily available for administration.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure 1 (Resident #48) of 5 sampled residents reviewed for unnecessary medications and 6 residents observed during medication administration was free from significant medication errors. Specifically, facility staff failed to hold (not give) Resident #48's medications when their systolic blood pressure was outside of parameters ordered by the physician.

Inspectors wroteBased on interview and record review, the facility failed to provide a prescribed medication, Xifaxan (a medication prescribed to treat symptoms of liver failure) to one of three residents reviewed (Resident 1). This failure had the potential to cause a decrease in health status for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for four of six residents reviewed (Residents 3, 90, 241 and 30), when: 1. Insulin was administered two hours after breakfast for Resident 3; and 2. Resident 90's 72 hour neurological checks were not completed, following an unwitnessed fall; and, 3. Resident 241's medication administration via G-tube (a gastric tube inserted through the belly directly to the stomach for administration of liquid nourishment, fluids and medications) were crushed and administered together, along with liquid medications and the LN did not flush between medication administrations; and, 4. Resident 30's crushed mediations were not flushed between G-tube administrations as ordered. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor fluid intake for three of three residents (Residents 10, 47, 82), reviewed for fluid restrictions, (a limited amount of liquids each day), due to dialysis (a treatment for kidney failure, which removed toxins and excess fluid by filtering the blood) treatments. This failure had the potential for Residents 10, 47, and 82, to develop fluid overload or dehydration.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the medication error rate was less than five percent. Eleven medication errors out of 42 opportunities were identified during medication administration, when nursing: 1. Administered five crushed medications via G-tube (a gastric tube inserted through the belly directly to the stomach for administration of liquid nourishment, fluids and medications) at the same time. In addition, to administering a combination of four separate liquid medications via G-tube at the same time to Resident 241. 2. Administered two crushed medications via G-tube at the same time to Resident 30. This failure resulted in the medication error rate of 26.1%.

Inspectors wroteBased on interview and record review, the facility failed to consistently provide snacks for two of two unsampled residents (CN 3, and CN 4). In addition, the facility did not provide a variety of fresh fruits such as bananas for two of five unsampled residents (CN 2, CN 5). As a result, there was potential for residents to experience hunger for long periods of time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were stored and prepared in the kitchen in accordance with the professional standard for food service safety when: (1) The sanitation bucket's chemical concentration was out-of-range; and (2) Opened food items in the dry storage were not labeled or stored in a sanitary manner; and (3) The utensils stored in the drawer had dried food particles; and (4) A scooper was left inside the container bin with potato flakes; and (5) Inside the walk-in refrigerator had the following: [...]

Inspectors wroteBased on Interview and record review, the facility failed to reimburse the RP for dental implants that went missing for one of one resident, (Resident 240), reviewed for dignity. This failure had the potential to cause the resident unnecessary emotional embarrassment.

Inspectors wroteBased on interview and record review, the facility failed to provide bi-weekly (two times a week) showers for one of three residents, (Resident 10) reviewed for Activities of Daily Living (ADL). This failure had the potential for Resident 10 to develop skin issues and to experience a decline in self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clarify parameters of oxygen use within a physician's order for one of two residents (Resident 10), reviewed for oxygen use. This failure had the potential for Resident 10 to develop oxygen toxicity (too much supplemental oxygen, which could damage the lungs).

Inspectors wroteThe facility failed to ensure multi use (used for more than 1 resident) house supply of topical medications had labels of when they were opened for one of one treatment cart reviewed. This failure had the potential for administration of expired medications to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an expired medication was discarded from the medication storage room, for one of one medication room reviewed for Medication Storage. This failure had the potential for administration of expired medications to be administered to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their policy and procedure related to food brought into the facility from the outside and stored in the facility's resident-only designated refrigerator, when items inside the refrigerator were not labeled with resident's name, date and expiration. In addition, there was no assigned staff with the responsibility for maintaining the contents and cleanliness of the residents' refrigerator. As a result, the residents' refrigerator was not kept in a sanitary manner which had the potential to cause foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure LN 15 performed hand hygiene between glove changes for 1 unsampled resident (54). In addition, a urinal with yellow liquid was left on the table while Resident (3) was eating. As a result, there was a potential for the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident rooms accommodated no more than four residents per room. This had the potential to impact resident care and quality of life.