Other·July 17, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of a complaint. Complaint number: CA 00635280 Category: Resident/Patient/Client abuse Sub-category: Employee to Resident Representing the California Department of Public Health: 35611, Health Facilities Evaluator Nurse The inspection was limited to the specific complaint investigated and does not represent a full inspection of the facility. One deficiency was written as a result of complaint number CA 00635280.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ZCM11 Facility ID: CA080000051 If continuation sheet 1 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055795 (X3) DATE SURVEY COMPLETED 07/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRIGHTON PLACE SAN DIEGO 1350 Euclid Ave San Diego, CA 92105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report an allegation of employee to resident physical abuse to the Department of Public Health for 1 of 1 sampled resident (1). This failure had the potential to result in a delay of investigation and decreased physical and psycho-social well-being of the resident. Finding: On 4/29/19 at 8:21 A.M., a hospice (supportive staff who care for terminally ill patients) agency reported to the Department, Resident 1's daughter alleged her mother was beaten by a facility female certified nursing assistant (CNA). In addition, the resident alleged a male CNA tried to lay on top of her. An unannounced visit was made to the facility on 4/30/19 at 9:40 A.M., to investigate the allegation. Resident 1 was readmitted to the facility on 4/11/19 under hospice care for end stage heart disease, per physician's admission order. On 4/30/19 at 10:30 A.M., an interview with the Admin/AC was conducted. The Admin/AC FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ZCM11 Facility ID: CA080000051 If continuation sheet 2 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055795 (X3) DATE SURVEY COMPLETED 07/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRIGHTON PLACE SAN DIEGO 1350 Euclid Ave San Diego, CA 92105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated Resident 1's family reported the allegation of abuse to the hospice nurse on 4/26 19. On the same date before midnight, the hospice nurse notified the facility charge nurse (CN). The Admin/AC further stated he received a text message from CN about the allegation on 4/27/19. The Admin/AC stated it was third person information and, "Because it was reported to hospice staff, not to us, that's why I told them (hospice nurse) to report it to you guys (the Department)." The Admin/AC stated he did not report to the Department because he did not have first-hand information from the daughter. On 4/30/19 at 11:20 A.M., a concurrent interview and review of facility policy and procedure was conducted with the director of nursing (DON). The DON stated hospice was an outside agency who visited Resident 1 in the facility. The DON reviewed the facility policy titled, Abuse- Reporting & (and) Investigations. The DON further stated the facility policy was to notify the Department for any allegation of abuse made by an outside agency. This was not done for Resident 1. A review of the facility's policy titled, AbuseReporting & (and) Investigations, dated 3/18, was conducted. This policy indicated, "... The facility will report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies... III. Notification of Outside Agencies of Allegations of Abuse... B. Administrator or designed representative will also notify... CDPH (California Department of Public Health) by telephone and in writing (SOC 341) within two (2) hours of initial report..." This policy was not followed when the facility did not report an allegation of employee to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ZCM11 Facility ID: CA080000051 If continuation sheet 3 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055795 (X3) DATE SURVEY COMPLETED 07/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRIGHTON PLACE SAN DIEGO 1350 Euclid Ave San Diego, CA 92105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident physical abuse made by the outside agency to the facility for Resident 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5ZCM11 Facility ID: CA080000051 If continuation sheet 4 of 4