Health inspection·December 10, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings:1. During a record review on 12/10/25 the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included fibromyalgia (a condition that causes widespread body pain, fatigue, and sleep issues), need for assistance with personal care.During a record review, the MDS (Minimum Data Set-a federally mandated assessment tool) indicated Resident 1 had a BIMS (Brief Interview for Mental Status) of 12, which indicated moderate cognitive impairment.During a concurrent observation and interview with Resident 1 on 12/10/25 at 7:22 A.M., Resident 1 was observed in bed, with multiple white and brown blankets covering her. There was an air vent observed on the ceiling, directly above the foot of Resident 1's bed. Resident 1 stated, The last few nights its been very cold. I've got a lot of blankets on me right now. At night, its so cold, even with the covers my body is like ice. Resident 1 stated the vent blew air towards her, which made her feel colder. Resident 1 stated she slept with her head under the covers because it was so cold.2. During a record review on 12/10/25 the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses which included need for assistance with personal care, chronic obstructive pulmonary disease (a lung disease which makes breathing difficult) and bradycardia (a slow heart rate).During a record review, the MDS (Minimum Data Set-a federally mandated assessment tool) indicated Resident 1 had a BIMS (Brief Interview for Mental Status) of 12, which indicated moderate cognitive impairment.During a concurrent observation and interview with Resident 2 on 12/10/25 at 7:49 A.M., Resident 2 was observed laying in bed with a brown blanket on her. Resident 2 stated, Its too cold here, not just at night, but all day.It seems like its really cold between 4 and 6 in the morning. Resident 2 stated the thermostat could not be adjusted to a warmer temperature, but she was unsure why. Resident 2 stated staff brought her a space heater to use, but the resident next door was using it.3. During a record review on 12/10/25 the admission Record indicated Resident 3 was admitted on [DATE] with diagnoses which included difficulty in walking, need for assistance with personal care, and unspecified fall.During a record review, the MDS (Minimum Data Set-a federally mandated assessment tool) indicated Resident 1 had a BIMS (Brief Interview for Mental Status) of 12, which indicated moderate cognitive impairment.During a concurrent observation and interview with Resident 3 on 12/10/25 at 7:53 A.M., Resident 3 was observed laying in bed. There was a space heater observed across the room, on the floor. The space heater was turned on. Resident 3 stated staff provided the space heater to her I have them turn it on from 6 to 9:30 in the morning. Otherwise its too cold at night. Page 1 of 3 055685 055685 12/10/2025 Brighton Place Spring Valley 9009 Campo Road Spring Valley, CA 91977

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 3 stated she would not be able to sleep without the space heater, because she would feel too cold at night.During a concurrent observation and interview with the Maintenance Supervisor (MS) on 12/10/25 at 8:37 A.M., the MS stated, the thermostat stopped working a few weeks ago. The MS stated the broken HVAC unit controlled the temperature for rooms 1 through 5. The MS stated the facility was waiting for approval from the facility's corporate department to fix the broken HVAC unit.During an interview with the Director of Nursing (DON) on 12/10/25 at 9:02 A.M., the DON stated it was important for residents to experience a comfortable environment, which included temperature.During a record review on 12/10/25 the facility policy titled Resident Rooms and Environment, revised January 2012, indicated, The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences.Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following.F. Comfortable temperatures. 055685 Page 2 of 3 055685 12/10/2025 Brighton Place Spring Valley 9009 Campo Road Spring Valley, CA 91977

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings:1. During a record review on 12/10/25 the admission Record indicated Resident 3 was admitted on [DATE] with diagnoses which included difficulty in walking, need for assistance with personal care, and unspecified fall.During a record review, the MDS (Minimum Data Set-a federally mandated assessment tool) indicated Resident 1 had a BIMS (Brief Interview for Mental Status) of 12, which indicated moderate cognitive impairment.During a concurrent observation and interview with Resident 3 on 12/10/25 at 7:53 A.M., Resident 3 was observed laying in bed. There was a space heater observed across the room, on the floor. The space heater was turned on. Resident 3 stated staff provided the space heater to her I have them turn it on from 6 to 9:30 in the morning. Otherwise its too cold at night. Resident 3 stated she would not be able to sleep without the space heater, because she would feel too cold at night.During a concurrent observation and interview with the Maintenance Supervisor (MS) on 12/10/25 at 8:37 A.M., the MS stated, We're not allowed to have those [space heaters] in residents' rooms. They could get burned. the MS statedDuring an interview with the Director of Nursing (DON) ON 12/10/25 AT 9:02 A.M., the DON stated, We can't give space heaters to the residents. They're a fire hazard.During a record review on 12/10/25, the facility's policy titled Electrical Appliances, revised January 2012, indicated, Only authorized electrical appliances are permitted in resident living areas. The policy did not provide guidance on the use of space heaters in resident rooms. 055685 Page 3 of 3