HANFORD, CA - Federal inspectors cited Brighton Post Acute for failing to prevent a devastating series of falls that left a high-risk resident with a fractured hip, requiring emergency hospital treatment.
The 361 E. Grangeville Blvd facility faced violations after a resident experienced three falls within 72 hours in March 2025, despite being assessed as high-risk for falls and requiring supervision for basic mobility tasks.
Three Falls in Three Days
The incident sequence began March 15 when the resident rushed to a shared bathroom without his walker. Another resident pushed the bathroom door open from inside, striking the first resident in the head and causing him to fall. The impact left him with facial injuries and an abrasion on his left hip.
"It hurt really bad," the resident told inspectors, describing the pain from landing on his left hip.
The facility performed a portable X-ray that showed no fractures, but the resident fell again the next day, March 16, while attempting to retrieve clothing from his closet. He reported blacking out briefly before regaining consciousness on the floor between beds.
This second fall prompted emergency transport to the hospital, where a CT scan revealed an acute comminuted fracture of the greater trochanter of the left femur - a serious hip fracture where the bone breaks into multiple pieces.
The resident returned to the facility March 17 with orders to remain non-weight bearing on his left leg. Despite these restrictions and staff reminders, he fell a third time that same day while attempting to walk to his doorway.
Medical Significance of Hip Fractures
Hip fractures in elderly residents represent serious medical emergencies that can permanently impact mobility and independence. The greater trochanter fracture involves the upper portion of the thighbone where it connects to the pelvis, an area critical for hip stability and walking.
Comminuted fractures, where bones break into three or more pieces, are particularly concerning as they indicate significant impact force and may require surgical repair. These injuries often lead to chronic pain, reduced mobility, and increased dependency on assistive devices.
Inadequate Fall Prevention Measures
The resident's medical assessments indicated he required supervision or touching assistance for basic activities including toilet transfers and walking short distances. His cognitive assessment showed moderate impairment, and he scored 10 on the fall risk assessment, placing him in the high-risk category.
Despite these documented risk factors, the facility's care plan interventions remained generic rather than addressing his specific needs. Multiple staff members reported that the resident consistently refused to use his call light or walker, preferring to navigate independently by grabbing furniture and walls.
"I just want to prove to myself that I can still do it," the resident told staff when questioned about his continued attempts to walk alone.
The Licensed Vocational Nurse assigned to the resident confirmed that standard interventions like encouraging call light use and providing education were ineffective. "The care plans did not address Resident 1's specific needs, such as his noncompliance with the call light," the nurse stated during the inspection.
Systemic Care Planning Failures
Federal inspectors found that Brighton Post Acute's care plans failed to address the root causes of the resident's fall risk: impulsive behavior, poor safety awareness, and noncompliance with assistive devices. The facility's Assistant Director of Nursing acknowledged that care plans should be individualized for each resident's specific needs but admitted the interventions "were not specific and individualized to him and could apply to any resident."
The MDS Coordinator confirmed that effective interventions like frequent supervision schedules, gait belt requirements, and structured toileting assistance were not implemented despite the resident's documented need for constant supervision during mobility tasks.
Regulatory Standards for Fall Prevention
Federal regulations require nursing homes to implement resident-specific fall prevention plans that address underlying risk factors, not just symptoms. When initial interventions prove ineffective, facilities must implement additional or different approaches until falls are reduced or eliminated.
The facility's own policies required staff to identify interventions related to specific risks and implement resident-centered prevention plans. If falls recur despite initial interventions, the policy mandated additional measures based on reassessment of root causes.
Facility Response and Citations
The Centers for Medicare & Medicaid Services issued two violations: F656 for failing to develop individualized care plans and F689 for inadequate supervision to prevent accidents. The F689 violation was classified as "actual harm" due to the resident's fractured hip requiring emergency treatment.
Brighton Post Acute is disputing the citations, though the inspection documented clear failures in implementing appropriate safety measures for a high-risk resident with known compliance issues.
The facility's Director of Nursing expressed concern about the three falls occurring within three days but told inspectors, "we could not do anything to prevent his falling." This statement contradicted the facility's own policies requiring escalated interventions when standard measures prove ineffective.
For complete details of the violations and facility response plans, refer to the full CMS inspection report available through the federal nursing home database.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brighton Post Acute from 2025-04-01 including all violations, facility responses, and corrective action plans.
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