Brighton Place San Diego: Discharge Planning Failures - CA
State inspectors visited Brighton Place San Diego on August 13, 2025, following a complaint about a discharge. What they found extended beyond a single case.
The first resident, identified in inspection records only as Resident 1, had been admitted to the facility with Alzheimer's disease. Social service notes from January 12, 2025 recorded that she was going to be transferred to another facility for supervised care in a secured unit, the kind of environment designed specifically for people with dementia who cannot safely leave on their own. A discharge planning review the following day confirmed the transfer was being treated as a lateral move for continuity of care. The name of the receiving facility was not documented. Neither was a discharge care plan. There was no record that one had ever been created.
The second resident, Resident 3, had been admitted with encephalopathy, a condition affecting brain function. Social service notes from July 11, 2025 recorded that he was discharged that same day to a board and care home for a lower level of care. Again, a discharge planning review existed. Again, no discharge care plan had been developed or implemented.
Inspectors interviewed two licensed nurses about what they found.
Licensed Nurse 2, who reviewed both residents' clinical records with inspectors on August 13, said she could not locate a discharge care plan for either resident. She said the absence of those plans could have harmed both residents' actual discharges because everything was left to last-minute planning. Without a care plan, she said, there was no collaborated goal and no organization of staff to honor what the residents wanted.
Licensed Nurse 1 had put it plainly in a separate interview: discharge care plans should be developed at admission, so all staff know from the beginning what the resident's wishes are and can work toward them together. She described the plans as essential to reducing anxiety for residents and families during what is already a difficult transition.
The Director of Nursing agreed. She told inspectors that discharge care plans should be developed and implemented at the time of admission, that they exist specifically for staff communication, and that without them, staff are not working toward any common goal. She acknowledged that both Resident 1 and Resident 3 faced potential harm because of the missing plans.
The facility's own policy, dated August 2023, commits to person-centered, comprehensive, interdisciplinary care designed to meet each resident's health, safety, psychosocial, behavioral, and environmental needs. What the inspection found was a gap between that commitment and what actually happened for at least two people on their way out the door.
Inspectors rated the harm level as minimal, a designation that reflects the regulatory floor, not necessarily the experience of a woman with progressive memory loss being moved to a locked dementia unit while staff had no formal record of what she needed or wanted from that move, or of a man with a brain disease discharged the same day his social worker noted his departure, with no plan ever written down.
The inspection covered three residents reviewed for discharges. Two of them had no discharge care plans.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brighton Place San Diego from 2025-08-13 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
BRIGHTON PLACE SAN DIEGO in SAN DIEGO, CA was cited for violations during a health inspection on August 13, 2025.
State inspectors visited Brighton Place San Diego on August 13, 2025, following a complaint about a discharge.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.