Brighton Place San Diego

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

their families by the Social Service Director (SSD). LN 1 stated Notices of Transfers/Discharges were important, so the residents knew what was coming and that staff were making preparations for the discharge. LN 1 stated if the Notice was not provided, it could increase anxiety for the resident before discharge, because they did not have time to prepare and ask questions. LN 1 stated without a Notice of Discharge being provided, it also eliminated the resident's right to appeal the discharge, because they were never informed they had that right. An interview and record review was conducted with LN 2 on 8/13/25 at 11:05 A.M. LN 2 stated written Notice of Transfer/Discharge were given to the residents and families within 30 days prior to discharge. LN 2 stated the Notice of Transfer/discharge was important, so residents and families were aware the discharge was pending and they could appeal, provide input, and make choices about where they were being discharged to. LN 2 stated Notice of Transfer/Discharge also decreased anxiety, so planning and preparation for discharge could be provided. LN 2 reviewed Resident 1, 2, and 3's clinical record and could not find any documentation a written Notice of Transfer/Discharge was ever provided. LN 2 stated the SSD was responsible for providing the Notice of Transfer/Discharge to the residents and their families.The SSD was unavailable on 8/13/25 for an interview.An interview and record

review was conducted with the Director of Nursing (DON) on 8/13/ 25 at 11:20 A.M. The DON reviewed Resident 1's nurses note and stated there was no discharge documentation related to when the residents left the facility or where she was transported to. The DON stated a nurse's note was required for every discharge of when, where, how and with who. The DON stated this was a nursing standard or practice and was not followed when Resident 1 was discharged . The DON stated since the LN did not document the necessary information, the reader had no idea of what happened to the resident and there was no continuum of care. The DON continued, stating Notice of Transfer/Discharge were required for every discharge to inform the residents and their family of what was coming, to decrease anxiety and fear. The DON stated the Notice of Transfer/Discharge also provided instructions to the residents and family on how to appeal the discharge. The DON stated since the Notice was not provided as required, there was the potential that the residents were not adequately prepared for the discharge, and they were unaware of the appeal process.According to the facility's policy, titled Notice of Transfer/Discharge, dated October 2017, .1.

When a transfer or discharge is initiated.the facility will provide the resident, responsible party, and the Ombudsman with a Notice of Transfer and Discharge 30 days prior to the transfer or discharge. IV. The facility's notice of Proposed Transfer and Discharge includes an explanation of the right to appeal the transfer.According to the facility's policy, titled Discharge and Transfer of Residents, dated February 2018, .IV. Prior to discharge, Social Services Staff or Nursing will provide the resident/resident representative with

the Notice of Proposed Transfer and Discharge document.VIIII. Discharge Documentation: .nursing staff must document the following information in the resident's medical record: A written statement for the reason of discharge; The date, time, and condition of the resident upon discharge; .

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brighton Place San Diego

1350 N. Euclid Avenue San Diego, CA 92105

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings:An unannounced visit was made to the facility on 8/13/25, in response to a complaint involving a discharge.1. Resident 1 was admitted to the facility on [DATE REDACTED], with diagnoses which included Alzheimer's disease (progressive memory loss), per the facility's admission Record.On 8/13/25, Resident 1's clinical record was reviewed.According to the facility's Social Service notes, dated 1/12/25 at 5:31 P.M., Resident 1 was going to be discharged to (name of facility), for supervised care in a secured unit (when residents are unable to leave the unit because of cognitive impairment, such as dementia, who require supervision and a safe environment).According to the facility's Discharge Planning Review, dated 1/13/25, Resident 1 was being discharged as a lateral transfer to another facility for continuum of care. The name of the facility she was being transferred to was not documented.There was no documented evidence that a discharge care plan had been developed or implemented.2. Resident 3 was admitted to the facility on [DATE REDACTED], with diagnoses which included encephalopathy (a progressive disease in which the brain functioning is affected), per the facility's admission Record.On 8/13/25, Resident 3's clinical record was reviewed.According to the facility's Social Service notes, dated 7/11/25 at 3:20 P.M., Resident 3 was discharged to Board and Care (name of facility).According to the facility's Discharge Planning Review, dated 7/11/25, Resident 3 was being discharged for a lower level of care.There was no documented evidence that a discharge care plan had been developed or implemented. An interview was conducted with Licensed Nurse 1 (LN 1) on 8/1/25 at 11 A.M. LN 1 stated discharge care plans should be developed upon admission, so all staff were aware of the residents' discharge wishes. LN 1 stated the discharge care plans were also important, because staff should be working towards a common goal of getting the residents ready for discharge, to decrease anxiety for the them and their families. An interview and record review was conducted with LN 2 on 8/13/25 at 11:05 A.M. LN 2 stated discharge care plans were important, so staff were aware of the residents' goals for discharging. LN 2 stated if a discharge care plan was not created, then there was no collaborated goal and organization of staff honoring the resident's wishes to discharge. LN 2 reviewed Resident 1 and Resident 3's clinical records and stated she could not locate a discharge care plan for either resident, which could have harmed their actual discharge, due to last minute planning.An interview was conducted with the Director of Nursing DON. The DON stated individual discharge care plans should be developed and implemented at the time of admission. The DON stated discharge care plans were important for staff communication, to know what the residents' plans were for an organized, goal-oriented, discharge. The DON stated by Resident 1 and Resident 3, not having a discharge care plan, there was potential the for harm because staff were not working towards the resident's goal of discharging. According to the facility's policy, titled Comprehensive Person-Centered Care Planning, August 2023, The facility will provide person-centered, comprehensive, and interdisciplinary care that reflets best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain

the highest physical, mental, and psychosocial well-being.

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