Resident 84 had stage 4 chronic kidney disease, meaning his kidneys were moderately or severely damaged and not properly filtering waste from his blood. On January 12, inspectors found him with a lunch tray containing green peas, mashed potatoes, chicken and oranges. His meal tray card clearly listed "Dislikes: Oranges, Potatoes."
"I did not like green peas, potatoes and could not eat the oranges because it is not good for my kidneys and it's on my dislikes list," Resident 84 told inspectors.
The next morning, he received pork and toast for breakfast. Pork was also on his dislikes list.
"They should already know," he said, pointing to his meal tray. "If the facility continued to not honor his meal preferences he could lose weight in an unhealthy way."
Dietary Supervisor 1 knew exactly what was wrong. She had completed Resident 84's dietary evaluation in October, documenting his dislikes as orange juice, oranges, tomatoes, fresh potatoes, spinach, peas, beef and pork. For someone with kidney disease, she explained, oranges, tomatoes, fresh potatoes and spinach were medically inappropriate, not just preferences.
"The kitchen and nursing staff should have looked at Resident 84's meal tray card to see Resident 84's preference list and not serve Resident 84 what was on the dislikes and prepared a menu that substituted his dislikes that was nutritionally equivalent," she told inspectors.
But the system had broken down completely. Licensed Nurse 2 explained that while medical orders specified diet types, they didn't include preferences. Only the meal tray cards showed what residents actually wanted or needed to avoid.
"For renal/kidney orders oranges are usually not acceptable because it spikes renal, spikes the blood sugar and it's rich in potassium and are not good for the kidneys," LN 2 said.
The problem ran deeper than missed meal cards. Resident 84's care plan, which should guide all staff in his daily care, contained no mention of his food preferences despite his serious kidney condition.
"Resident 84's nutritional care plan was not person-centered and should include Resident 84's food preference since looking at the meal tray card was missed," LN 2 said.
Director of Nursing agreed the care plan had failed. "Resident 84's nutritional care plan was not person-centered and should be person centered to reflect his preferences," she told inspectors. "It was important for Resident 84's care plan to be person centered because this guides the care we should be providing for Resident 84 to promote his physical, mental and psychosocial well-being."
The facility's care planning failures extended beyond nutrition. Resident 9 had been admitted to hospice care on January 4 for end-stage heart failure, the most severe form when the heart becomes too weak to pump blood effectively. Yet eleven days later, inspectors discovered no hospice care plan existed.
"There is no care plan for Resident 9 to be on hospice," the Director of Nursing admitted. "Resident 9 would not have a comprehensive resident centered care plan since hospice is missing."
Another resident with Alzheimer's disease had escaped the facility on January 2, climbing over a fence and heading toward a nearby church before staff caught him. Resident 198 had a wandering care plan, but it wasn't individualized enough, the DON said.
Hospital records from December showed multiple references to Resident 198's elopement risk and wandering behavior. A psychiatric consultation noted "attempts to wander off by herself" and that she "needs redirection as she wanders off." Yet the facility's Elopement Risk binder, last updated in June, didn't include her name.
Beyond care planning, basic food safety protocols were breaking down. Kitchen staff failed to record food temperatures before serving meals on January 10 and 11. Cook 1 said he "may have forgotten to fill it out." The gaps violated the facility's own policy requiring temperature logs "at the beginning of the tray line."
Staff training had also failed. Dietary Aide 2, hired in October, didn't know how to test kitchen sanitizer strength after 90 days on the job. When asked to demonstrate, he said he "did not test the sanitizer in the red buckets and he did not know how to do so."
Cook 1 knew the sanitizer test strips should be held in liquid for 10 seconds, but repeatedly demonstrated the process incorrectly, holding strips for only four seconds. The test strip container clearly read "IMMERSE FOR 10 SECONDS."
The Administrator confirmed that Dietary Aide 2 had not completed his initial competencies checklist. His employee file contained no evidence of orientation or training specific to kitchen work, despite being employed for three months.
Equipment maintenance also posed risks. Resident 47, who weighed 233 pounds, had a doctor's order for a low air loss mattress set to his weight to prevent pressure sores. Inspectors found the mattress pump set for a 400-pound resident and on static mode with no alternating pressure.
"If the LAL mattress pump was not on the correct setting, it may cause the resident to develop a pressure injury because the mattress would be too firm," Certified Nurse Assistant 31 explained.
The Director of Nursing acknowledged that "if the resident was on a firm mattress consistently, then the resident would not get the full benefit of being on a LAL mattress which would be to prevent pressure injury."
The facility's own policies required care plan updates for "onset of new problems" and "change of condition," but staff repeatedly failed to follow through. Resident 84 continued receiving foods that could harm his kidneys. Resident 9 received no hospice-specific care despite his terminal diagnosis. Resident 198 remained unlisted as an elopement risk despite climbing fences.
For Resident 84, the daily meal failures represented more than dietary disappointment. With stage 4 kidney disease, excess potassium from oranges could build up in his blood, creating harmful health effects his damaged kidneys couldn't filter out. Each ignored preference card brought him closer to the "unhealthy" weight loss he feared.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brighton Place San Diego from 2025-01-15 including all violations, facility responses, and corrective action plans.