Brighton Place Spring Valley

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of financial abuse between a resident (Resident 1) and a Certified Nursing Assistant (CNA 1) to the California Department of Public Health (CDPH) within the 24 hour time requirement. This failure had the potential to delay investigation and affect the physical and psychosocial wellbeing of the resident.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of financial abuse for one of two residents reviewed for abuse (Resident 1). This failure had the potential to place residents at risk for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, comfortable, homelike environment for three of four sampled residents (Residents 1, 2, and 3) when a broken HVAC (Heating, Ventilation, and Air Conditioning) unit was not repaired in a timely manner, resulting in the inability for staff to control the temperature within a unit of the facility. As a result, Residents 1, 2, and 3 were uncomfortable and reported feeling too cold during the night.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 3) was provided with a safe and comfortable environment when Resident 3 was observed with a space heater in her bedroom. This deficient practice placed Resident 3 at risk for injury including burns and fire.

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. These failures had the potential for residents to experience increased anxiety, when last-minute discharges were conducted, with no ability to appeal the discharge.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement person-centered care plans related to resident discharges for two of three residents, (Resident 1 and Resident 3), when reviewed for dischargesThis 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 observation, interview, and record review, the facility failed to list and monitor specific behaviors for the use of a psychotropic medication (a drug that affects mental processes, mood, behavior, or perception), to determine the necessity of the medication for two of five residents (Resident 9 and Resident 48), reviewed for unnecessary medication. These failures had the potential for Resident 9 and Resident 48 to receive unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident room walls in a clean, homelike, and visually appealing manner for two of 24 residents (Resident 47 and Resident 54), reviewed for homelike environment. This failure had the potential for residents to feel not valued or appreciated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan related to hospice (end of life), care for one of one resident (Resident 47), reviewed for hospice care. This failure had the potential for Resident 47 to receive inconsistent care by staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change a peripheral intravenous catheter (PIV-a tube inserted into a vein used to draw blood and administer medications) per physician's order. This failure had the potential to place Resident 36 at further risk for infection. According to the admission Record, Resident 36 was admitted on [DATE] with diagnoses which included severe sepsis (an illness in which the body had an extreme response to an infection), urinary tract infection, and bacteremia (an infection in the bloodstream). On 5/5/25 at 10:29 A.M., an observation was conducted inside Resident 36's room. Resident 36 had a PIV catheter inserted into his left arm. The PIV was covered with a transparent dressing and was dated 4/29/25. On 5/6/25 at 10:10 A.M., a concurrent observation and record review was conducted with Licensed Nurse (LN) 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document a rationale for the use of oxygen for one of three residents (Resident 39) reviewed for oxygen therapy. This failure had the potential to place Resident 39 at risk for unnecessary treatments and services. Resident 39 was readmitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, a lung condition caused by damage to the lungs), per the facility's admission Record. An observation and interview with Resident 39 was conducted on 5/5/25 at 11:24 A.M. Resident 39 was in bed, with a clear plastic oxygen tube under his nose. Resident 39 stated he used the oxygen most of the time because he had COPD. Resident 39 stated he went out of the building three times a week for a medical appointment, and he did not use the oxygen tube for those trips. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement Registered Dietitian (RD 1) recommendations for one of three residents reviewed for nutrition (Resident 43). This failure had the potential for Resident 43 to not receive foods and supplements he preferred with his meals and snacks.

Inspectors wroteBased on interview and record review, the facility failed to offer one of five residents (Resident 5) influenza (flu-annual season October through March) and pneumococcal (protects against serious lung infection referred to as pneumonia) vaccines as recommended by the Centers for Disease Control (CDC-a Federal agency responsible for preventing and controlling diseases), when reviewed for Immunization. This failure put Resident 5, and all other residents at risk of contracting and/or transmitting influenza and pneumococcal.

Inspectors wroteBased on interview and record review, the facility failed to offer one of five residents (Resident 5) a COVID-19 (a highly contagious virus caused by the SARS-CoV-2) vaccine recommended by the Centers for Disease Control (CDC-a Federal agency responsible for preventing and controlling diseases), when reviewed for Immunizations. This failure put Resident 5, and all other residents at risk of contracting and/or transmitting the COVID-19 virus.

Inspectors wroteBased on interview and record review, the facility failed to ensure the inhaler (handheld devices that deliver medicine through the mouth into the lungs) medication ordered by the physician was available for administration for one of three sampled residents (Resident 1). This failure had the potential for adverse health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to apply a splint to Resident 1 ' s right hand as ordered by a physician. This failure had the potential to worsen Resident 1 ' s wrist drop (a medical condition that prevents the wrist and fingers from extending fully).

Inspectors wroteBased on interview and record review, the Facility failed to report allegations of abuse by staff members against one resident, Resident 1. Resident 1 reported feeling violated while in the Facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the water management program included a risk assessment to identify legionella and other waterborne pathogens that could grow in the facility water system. This deficient practice had the potential to affect all residents who currently resided in the facility. The facility also failed to ensure staff wore sterile gloves when they set up equipment to perform an indwelling catheter insertion for 1 (Resident #60) of 2 sampled residents reviewed for urinary catheters.

Inspectors wroteBased on interview, record review, facility policy review, and the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) manual, the facility failed to ensure the annual Minimum Data Set (MDS) assessment was accurate for the preadmission screening and resident review (PASARR) Level II for 1 (Resident #15) of 4 residents reviewed for PASARR.

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to implement the comprehensive care plan for 1 (Resident #17) of 2 residents reviewed for accidents. Resident #17's care plan included interventions for smoking and elopement that were not implemented.

Inspectors wroteBased on observation, interview, record review, document review, and facility policy review, the facility failed to 1 (Resident #17) of 2 sampled residents reviewed for accidents, did not leave the facility without staff knowledge, and did not smoke in a non-designated smoking area.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure an as needed psychotropic medication had a stop date and was limited to 14 days for 2 (Resident #16 and Resident #42) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure expired medications were discarded in 1 of 1 medication storage room and medications were properly stored for 3 (Residents #7, #12, and #116) of 18 sampled residents.

Inspectors wroteBased on interview, facility policy review, and review of employee records, the facility failed to maintain an effective training program for 2 (Licensed Vocational Nurse [LVN] #3 and LVN #7) of 5 staff members reviewed for training and competencies.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that five of five sampled residents call cords were within their reach. Additionally, one resident, Resident 1, did not have an accessible type of call system that was appropriate for his functional level. Additionally, Residents two through five call cords were not placed within their reach. This failure had the potential to prevent residents from obtaining needed assistance from staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper respiratory care and treatment for 2 of 3 sampled residents (1 and 2) was provided consistent with professional standards of practice when: (1) the licensed nurses applied a bi-pap (a machine that delivers different levels of oxygen to help breathe) to Resident 1 without a proper setting order from the physician, and (2) Resident 2 received an oxygen treatment without documented evidence of a change of condition, and the physician was notified. These deficient practices had the potential for the residents to have complications related to improper treatment while receiving oxygen therapy.

Inspectors wroteBased on interview and record review, the facility failed to proved adequate supervision for one Resident (1). This failure led to the elopement (leaving the facility unaccompanied and/or unplanned ) of Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call lights were within reach of four of 61 residents. (5, 158, 25, 30) As a result, there was a potential the residents' needs were not met in a timely manner.

Inspectors wroteBased on interview and record review, a CNA failed to treat one of 61 residents (Resident 12) with dignity when he ignored her requests for assistance, and made a gesture and sound indicating she had a foul odor. As a result, Resident 12 stated, I felt humiliated.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to obtain reference checks for one of one employees reviewed (CNA 1) during an investigation of a facility reported incident. This failure had the potential to place residents at risk for abuse or neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff performed a complete wound assessment for one of 61 residents screened (22). As a result, Resident 22's wound deteriorated.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the LNs followed the facility policy for TF (a tube used to deliver nutrition to an individual who was unable to swallow food safely) for one of one resident reviewed for TF (Resident 17) when: 1. The LN administered a TF left over from the previous day, and 2. The LNs did not accurately document the TF administration on the MAR. As a result, there was a potential Resident 17 received contaminated TF, and an inaccurate volume of the physician-ordered TF.

Inspectors wroteBased on interview and record review, the facility failed to ensure the staff conducted pre and post pain assessment on three of four residents assessed for pain. (52, 9, 45) As a result, there was a potential the residents' pain was not relieved.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy for two of two residents (9, 45) reviewed for controlled drugs (drugs at high risk for abuse). As a result, the facility was at risk for controlled drug loss and theft.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 27 medications were administered per the physicians' order. The facility's medication error rate was 11.11%. As a result, the facility could not ensure medications were correctly administered to all residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement the facility's infection control prevention plan when two staff members did not use the required personal protective equipment (PPE - N95 respirator, face shield, gown and gloves) when entering multiple resident rooms in the yellow zone (unit where residents were being monitored for COVID). As a result, there was the potential to spread infection(s) to other residents and staff members.