Brighton Post Acute

In the surveyor’s words

From the most serious findings on record at Brighton Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 1, 2025

  Based 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. […]

• Actual harm, isolatedF684May 19, 2023

  Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan when: 1. Resident 1 experienced a choking episode and Licensed Vocational Nurse (LVN) 2 left Resident 1's room to call Emergency Services (EMS)/911 and did not recognize the need to immediately provide emergent care, such as oral suction (removal of mucus, phlegm (thick secretion in the airway), saliva from the oral cavity (mouth) or application of oxygen, consistent with nursing professional standards of practice. […]

• No harm, potential for more than minimal, widespreadF921Jan 2, 2026

  Based 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… […]

• No harm, potential for more than minimal, patternF658Apr 10, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF804Apr 10, 2026

  Based 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. […]