Brighton Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) was developed and implemented for one of five sampled residents (Resident 4) when, Resident 4's care plan was not developed and initiated for two-person assistance with transfers. This failure had the potential to result in Resident 4's care needs to not be met and placed Resident 4 at risk for falls and injuries due to inadequate staff assistance.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet professional standards of practice for five of 53 of sampled residents (Residents 87, 101, 122, 123 and 124) when:1. Physician (MD) orders for insulin administration lacked parameters for MD notification for low or high blood glucose (a type of sugar in the blood that the body used for energy) levels for two of seven sampled residents (Resident 123 and 124). This failure had the potential to result in delayed MD notification and intervention for abnormal blood glucose levels. 2. Resident 124 experienced significant weight gain and had an SBAR completed on 4/3/26, which required initiation of 72-hour alert charting and ongoing monitoring for fluid overload. Alert charting was not initiated timely, was not completed consistently each shift and lacked communication of edema or related assessments. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that is palatable and attractive, for three of 49 sampled residents (Residents 33, 83, and 119) when residents complained the food lacked flavor, tasted bad or refused to eat their meal. These failure resulted in Resident 33 and 119 not eating all of their lunch and had the potential for unintended weight loss. During an observation and interview on 4/7/26 at 11:59 a.m. with Resident 119 in Resident 119's room, Resident 119 was sitting up in bed with a regular diet meal tray, on her bedside table, consisting of chopped chicken, potatoes, green beans, and a cup of hot chocolate. Resident 119 stated that she did not like the food. Resident 119 stated that the coffee did not taste good and that is why she requests hot chocolate. Resident 119 stated that the potatoes do not have a taste. [...]

Inspectors wroteBased on interview and record review, the facility failed to permit a resident to return to the facility following hospitalization for one of four sampled residents (Resident 142) when Resident 142 was not re-admitted back to the facility on [DATE]. This failure violated Resident 142's right to return to the facility and had the potential to result in delayed placement and care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for two of four sampled residents (Resident 133 and Resident 134) when:1. Resident 133's upper and lower extremities were coded inaccurately in the MDS assessment. This failure had the potential to result in Resident 133's care needs not met.2. Resident 134's diagnosis of anxiety was not coded in the MDS assessment. This failure had the potential for Resident 134's need not met and changes in behavior not monitored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a Preadmission screening and Resident Review (PASARR-a federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) level I screening for one of five sampled residents (Resident 100) when Resident 100's PASARR level I screening dated 6/3/24 did not indicate Resident 100's diagnosis of anxiety disorder (mental health condition characterized by excessive, uncontrollable, and persistent fear or worry that interferes with daily life) and no PASARR Level I screening was completed. This failure had the potential for Resident 100 to not receive the appropriate services related to her mental disorders.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for one of eight sampled residents (Resident 44), when the facility did not have a care plan to monitor for side effects of Plavix (antiplatelet - blood thinners that prevent blood cells called platelets from sticking together and forming dangerous clots in arteries). This failure placed Resident 44 at risk for not being monitored for side effects of antiplatelet medication such as bleeding, bruising, and passing out.

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely revise and implement a person-centered comprehensive care plan for one of five sampled residents (Resident 101) when Resident 101's care plan for oxygen (O2- a colorless, odorless and tasteless gas essential for life) was not updated and did not accurately reflect the physician's order for Resident 101's use of oxygen. This failure had the potential to result in Resident 101's care needs to not be met.

Inspectors wroteBased on observation, interview, and record review, the facility to provide the necessary services to maintain good grooming and personal hygiene for one of five sampled residents (Resident 13) when Resident 13 was not provided showers on his scheduled days in accordance with his needs and plan of care. This failure resulted in Resident 13 to miss his showers and had the potential to result in skin breakdown and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed rails were properly maintained in safe working condition for one of five sampled residents (Resident 68) when Resident 68's bedrail was not functional and not securely locked. This failure placed Resident 68 at risk for injury such as falls, skin tears and possible entrapment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse staffing information was accurately posted when: 1. The actual number of hours worked per shift by Registered Nurses (RNs), Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs) was not accurately reflected.2. The actual number of Licensed Staff (RN's, LVNs, and CNAs) was not specifically reflected in the staffing sheets. This failure resulted in an inaccurate posting of daily nurse staffing information and had the potential to result in residents, visitors and the public from determining the number and type of nursing staff providing direct care in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 84 and Resident 133) drug regimen was free from unnecessary drugs when:1. Resident 84 received Namenda (medication used to improve memory, attention, reason, and language abilities) for memory loss without a written informed consent and monitoring of side effects and behaviors. This failure resulted in Resident 84 receiving medication and not properly informed of the possible side effects which had the potential for Resident 84 to have experienced side effects of medication and changes of behavior without proper monitoring.2. Resident 133 received acetaminophen (medication used to treat pain) tablet as needed for pain and oxycodone HCL (hydrochloride) (opioid prescription medication used to treat pain) tablet as needed for pain daily without pain parameters. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the needs of residents in accordance with established national guidelines for three of 49 sampled residents (Residents 41, 53 and 95) when Residents 41, 53 and 95 were not served cornbread with lunch on 4/8/26 and the menu indicated cornbread to be served. These failures resulted in Residents 41, 53 and 95 not receiving all the nutrition and calories for lunch and the potential for unintended weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food preferences were followed for one of eight sampled residents (Resident 33) when he was served cabbage and the resident's care plan stated resident disliked cabbage. This failure violated Resident 33's food preference and had the potential to result in weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed store and prepare food in accordance with professional standard for food service safety for 49 residents who were served food from the ice machine and kitchen when there was no air gap (a safety feature that uses open air to physically separate a clean water line from a dirty drain line) at the ice machine drain and no air gap at the drain of food preparation sink. These failures had the potential to result in contamination of ice and food and could lead to illnesses.

Inspectors wroteBased on observation, interview and record review the facility failed to have an effective pest control program to ensure the facility was free of pests for 51 residents that ate food prepared in the kitchen when two flies were in the kitchen on 4/7/26 and one fly was in the kitchen on 4/8/26. These failures had the potential for cross-contamination (the transfer of harmful germs from one surface to another) from the flies to resident food which could result in illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for the residents, staff, and visitors when the fire protection system (a combination of equipment and technologies designed to detect, alert, control, and extinguish fires automatically or manually, aiming to save lives, minimize property damage, and ensure safe evacuation) stopped functioning from 12/31/25 to 1/2/26, and the facility failed to notify the California Department of Public Health (CDPH, a government agency for the State of California in charge of protecting the public's health and helps shape positive health outcomes for individuals, families and communities) and the California Department of Healthcare Access and Information (HCAI, a government agency for the State of California in charge of safety regulations for health care facilities, provide financial assistance to [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent falls for one of three sampled residents (Resident 1) when Resident 1 was assessed to be at risk for falls on 1/22/25, had impulsive behavior and staff were aware of Resident 1 not using the call light to request assistance to walk in his room and effective individualized interventions to prevent falls were not implemented. Resident 1 experienced an unwitnessed fall on 3/15/25, fall on 3/16/25 and a fall on 3/17/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan was developed and implemented to meet the identified needs for one of three sampled residents (Resident 1) when Resident 1 was assessed as being a high fall risk with poor safety awareness and a known behavior of not calling staff for assistance and the facility did not develop and implement effective care plan interventions including assistance and supervision to prevent falls. This failure resulted in Resident 1 ' s unwitnessed falls on 3/15/25 and 3/16/25 sustaining a fracture of the left greater trochanter (a type of hip fracture [broken bone] where the femur [upper thigh bone] meets the pelvis) causing pain and decreased mobility which required transportation to the emergency department (ED) for assessment and treatment of his injury. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the physician-prescribed therapeutic diet (a diet order as part of treatment for a disease or clinical condition to decrease or increase specific nutrients in the diet) for one of four sampled residents (Resident 1) when, during lunch on 11/1/24, Resident 1, who has physician prescribed No Added Salt (NAS) diet Mechanical Soft texture, was served a piece of uncut country-fried steak. This failure had the potential to result in a choking episode and further compromise the nutritional and medical status of Resident 1.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff reported an allegation of abuse for 1 (Resident #55) of 1 resident reviewed for abuse.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure the medication error rate was not greater than 5 percent (%). The facility had 2 medication errors out of 27 total opportunities, resulting in a medication error rate of 7.41%, affecting 2 (Resident #78 and Resident #43) of 5 residents observed during medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rooms measured at least 80 square (sq.) feet (ft.) per resident in 26 (Rooms 100, 102, 104, 106, 108, 110, 112, 200, 204, 206, 208, 210, 212, 214, 300, 301, 302, 303, 304, 305, 404, 406, 408, 410, 412, and 414) of 40 resident rooms in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the Long Term Care Ombudsman office (LTC-Ombudsman, a resident advocacy agency) of transfer to the hospital for one of three sampled residents (Resident 1) when the facility failed to send a copy of Resident 1's transfer and discharge notification to the local LTC-Ombudsman office. This failure resulted in the LTC-Ombudsman not aware of Resident 1's discharge circumstances should appeals be filed by the resident or his representative.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive, person centered care plan for one of three sampled residents (Residents 1) when Resident care plan intervention to have auto locks to wheelchair (device used to automatically lock the wheels whenever the person stands or sits) was not implemented to prevent falls. This failure placed Resident 1 at risk for falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure support personnel were competent to effectively carry out the function for food and nutrition services when two of two sampled Maintenance Assistants (MA 1 and MA 2) did not clean and sanitize the facility ice machine in accordance to the manufacturer's recommendations. (Cross reference F908.) This failure had the potential for the ice machine to not function properly, cause contamination of the ice, and lead to resident illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the nutritional needs of residents were being met in accordance with established dietary national guidelines when the Registered Dietitian Nutritionist (RDN) did not sign to demonstrate approval of the facility's food menus. This failure placed the residents at risk for not receiving adequate nutrition which could further compromise their medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety when multiple food items available for resident consumption were stored without being covered and without open dates inside Freezer 1, walk in refrigerator, kitchen dry food storage areas and inside refrigerators in nursing station 1 and 3. These findings had the potential to cause gastric upset from the consumption of improper stored food.

Inspectors wroteBased on interview, and record review, the facility failed to maintain the ice machine in accordance with manufacturer's instructions for use when the ice machine was not cleaned and sanitized per manufacturer's guideline. (Cross reference F802.) This failure had the potential for the ice machine to not function properly, cause contamination of the ice, and lead to resident illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed professional standards of practice for two of two sampled residents (Resident 22 and Resident 45) who used indwelling urinary catheters (a flexible tube inserted into the bladder to drain urine) when Resident 22's and Resident 45's urinary catheter tubing was not secured to prevent discomfort and accidental dislodgment of the catheter. This failure had the potential to cause discomfort, injury to the urethra (duct that leads from the bladder and transports urine out of the body) and accidental dislodgment of the indwelling catheter.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish an environment free from accidents and hazards for two of 27 sampled residents (Resident 13, 96) when: 1. Resident 13 and Resident 96 smoked in an area without smoking fire safety accommodations to ensure the residents remained safe while they smoked. This failure potentially placed Resident 13 and 96 at risk for smoking related injuries. 2. Resident 59 was not accommodated with staff assistance when ambulating to the restroom as indicated in her plan of care. This failure had the potential for Resident 59 to fall and sustain injuries from fall.

Inspectors wroteBased on interview and record review the facility failed to maintain medical records that were complete and accurately documented for three of 27 sampled residents (Resident 110, Resident 43, and Resident 45) when: 1. The physician's visit and assessment of Resident 110 was not documented on the progress note for [DATE]; and the Physician Orders for Life-Sustaining Treatment (POLST-a summary of medical orders to be followed during a medical emergency and end of life wishes) dated [DATE], was not revised by the physician to reflect end of life wishes. This failure had the potential for end of life wishes not to be respected in the event of an emergency. 2. [...]

Inspectors wroteBased on observation and interview and record review, the facility failed to ensure the minimum square footage was maintained for 25 of 47 resident rooms (100, 102, 104, 106, 108, 110, 112, 114, 116, 118, 120, 122, 200, 204, 206, 208, 210, 212, 214, 216, 304, 306, 308, 310, and 314), and three of 25 sampled resident rooms (104, 216, and 304) did not provide residents and staff with enough space to accommodate resident needs when: 1. Staff had limited space and difficulty providing resident care in room [ROOM NUMBER]. 2. Resident 96 was not able to exit or enter his room when care was being given to his roommates in room [ROOM NUMBER]. 3. Resident 59 was not able to easily and safely ambulate herself to and from the restroom or store her wheelchair in room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations to meet the needs and preferences for one of 23 sampled residents (Resident 59) when Resident 59 did not have the bedroom set up in a manner that provided sufficient space to easily and safely navigate to and from her restroom and to keep her wheelchair within easy reach. This failure had the potential to result in injury to Resident 59.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program to prevent the transmission of infections for one of six sampled residents (Resident 11) when an oxygen humidifier (a device that introduced moisture to a gas) and a nasal cannula (NC) tubing were not replaced after five days and continued to be used for 13 days. This failure placed Resident 11 at risk for developing respiratory infections.