Resident 84, who has Stage 4 chronic kidney disease and moderate cognitive deficits, received meal trays with oranges and potatoes despite both items appearing on his documented dislikes list. His meal tray card clearly stated "Dislikes: Oranges, Potatoes."
On January 12, inspectors observed the resident's lunch tray containing green peas, mashed potatoes, chicken and oranges. The resident explained he couldn't eat the oranges because "it is not good for my kidneys and it's on my dislikes list." He also said he disliked the green peas and potatoes.
The resident, who described himself as "at the border of not having to need dialysis," told inspectors the facility consistently served him inappropriate meals. Excess potassium can build up in people with kidney disease because damaged kidneys cannot properly remove the mineral from the body, potentially causing harmful health effects.
Two days later, inspectors found the same resident with pork and toast for breakfast. "Pork is on my dislikes list," he said, pointing to his meal tray. "They should already know." He warned that if the facility continued ignoring his meal preferences, "I could lose weight in an unhealthy way."
Dietary Supervisor 1 acknowledged the problems during interviews with inspectors. She knew the resident preferred a renal diet and had completed his dietary evaluation in October 2024, which documented his dislikes including orange juice, oranges, tomatoes, fresh potatoes, spinach, peas, beef and pork.
"For a renal diet, Resident 84 should not be served orange juice, fresh oranges, tomatoes, fresh potatoes and spinach," the dietary supervisor told inspectors. She said kitchen and nursing staff should have checked his meal tray card and substituted nutritionally equivalent alternatives.
The facility's own policy required providing residents meals consistent with their preferences and physician orders as indicated on tray cards, with suitable substitutes when preferred items weren't available.
Licensed Nurse 2 confirmed that oranges are "usually not acceptable" for renal patients because they spike blood sugar and are "rich in potassium and are not good for the kidneys." She said the resident's preferences should have been honored with nutritionally adequate substitutions.
Director of Nursing acknowledged his expectations were for dietary staff to honor meal preferences and provide nutritional alternatives. "If we don't offer nutritional alternatives for Resident 84 that complications such as weight loss can happen," he told inspectors.
The dietary failures extended beyond preferences to basic food safety requirements. In another case, Resident 27, who has limited hand use and cannot cut food with utensils, received a quarter-inch slice of meat despite his meal ticket specifying "chopped meat." The resident told inspectors he would be unable to eat the meat in its current form.
"A resident could choke if they didn't have the correct diet," Certified Nursing Assistant 25 explained to inspectors.
Licensed Vocational Nurse 2 described the facility's double-check system where two nurses verify meal orders against meal tickets before serving residents. "If it doesn't match then we send it back to the kitchen," she said, adding that wrong meals could cause choking or allergic reactions.
The Director of Nursing admitted the failure when shown a picture of Resident 27's incorrectly prepared meal. "That tag says chopped meat and it is not, that's on me I checked that. If they had dysphagia, it could cause choking. It's not acceptable."
Food safety violations extended throughout the kitchen. Inspectors found expired dill pickle relish in the walk-in refrigerator, along with opened bags of shredded cheese and lettuce that weren't labeled with use-by dates. A container of unlabeled applesauce sat without identification.
"The expired relish should have been thrown out," Dietary Supervisor 1 told inspectors. She also confirmed that all opened food should have been properly labeled with opening dates.
A dietary aide preparing breakfast trays worked with his beard uncovered, violating the facility's infection control policy requiring hair restraints for all facial hair while in kitchen areas.
The facility struggled with broader infection control failures during an active COVID-19 outbreak. Two residents tested positive for the virus between January 6 and January 13, but the facility didn't begin screening staff until January 14 — two days after the second case emerged.
The infection preventionist told inspectors that screening should have started January 12 when the second resident was hospitalized with COVID symptoms. "It was important to do screening for staff and residents to control the spread of infection," she said.
Contact tracing never occurred after the first positive case, despite facility policies requiring it. The facility also lacked any infection surveillance tracking for 2024 or January 2025.
Visitor screening proved equally inconsistent. The visitor log showed multiple incomplete entries where visitors failed to indicate whether they had COVID symptoms, and some entries weren't dated. The administrator acknowledged the screening was "inconsistent" during the outbreak period.
Additional violations included improper storage of oxygen equipment. Resident 72's oxygen tubing lay unlabeled on the floor with the concentrator placed on his roommate's side of the room, creating confusion and cross-contamination risks.
"It was an infection control issue because the oxygen tubing was on the floor and not labeled and we would not know if he used it or not," Licensed Nurse 5 explained. The Director of Nursing noted that if the confused roommate used the equipment, it could cause "improper use of oxygen" and infection control risks.
The facility also housed six residents each in two rooms despite regulations limiting occupancy to four residents per room. The administrator confirmed the facility lacked current waivers for the oversized rooms, with the last waiver dating to 2012.
Smoking assessments for two residents fell months behind schedule. Resident 18's last assessment occurred in April 2024, missing two quarterly reviews, while Resident 40's assessment was three months overdue. The MDS nurse acknowledged the importance of current assessments to evaluate smoking safety and update care plans.
Brighton Place San Diego's 95 residents faced these multiple care and safety failures during the January inspection, with problems spanning from basic nutrition needs to infection control during a disease outbreak.
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.