Inspection Reports for Brighton Place West Health Center LLC

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The revisit confirmed that all cited deficiencies identified by their regulation numbers 483.10(f)(1)-(3), 483.24(a)(2), and 483.45(d)(e)(1)-(2) were corrected as of the revisit date.

This document is a Plan of Correction prepared and executed in response to previously identified deficiencies from a regulatory inspection to ensure compliance with federal Medicare and Medicaid requirements.

The plan addresses deficiencies related to bathing schedules for residents, education of nursing staff on bathing documentation, monitoring of bathing documentation, updates to physicians regarding psychotropic medication dose reductions, and audits of diabetic residents' blood sugar parameters.

A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies to be 'E' level deficiencies, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective July 24, 2017.

The inspection was conducted as a Health Resurvey and Complaint Investigations #112841 and #113505 to assess compliance with resident rights and care standards.

The facility failed to provide scheduled showers as preferred for multiple residents, placing them at risk for inadequate personal hygiene and skin issues. Additionally, the facility failed to ensure gradual dose reductions or risk versus benefit documentation for psychotropic medications for several residents, and lacked blood glucose parameters for one resident, placing residents at risk for unnecessary medication use and adverse health consequences.

The visit was triggered by complaint investigations #112841 and #113505.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required, and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.

This document is a Plan of Correction prepared and executed in response to previously identified deficiencies in the facility's compliance with federal Medicare and Medicaid requirements.

The plan outlines corrective measures for multiple deficiencies including posting complaint hotline information, maintaining safe temperature levels, completing resident assessments, ensuring RN staffing coverage, posting nurse staffing data, maintaining infection control programs, and conducting nurse aide performance reviews.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective November 18, 2015.

The inspection was a Health Resurvey, Extended Health Resurvey, and Complaint investigation triggered by complaint #KS00091622.

The facility was found deficient in multiple areas including failure to post state complaint hotline information, failure to maintain comfortable room temperatures, untimely completion of comprehensive assessments, inadequate supervision of an elopement risk resident resulting in injury, failure to provide 8 hours of RN coverage on some days, incomplete nurse staffing postings, failure to prevent infection transmission due to improper glove use and cleaning practices, and failure to perform nurse aide performance reviews.

Complaint investigation #KS00091622 included findings of failure to post complaint hotline information and failure to supervise an elopement risk resident resulting in injury.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy.

This is a post-certification revisit conducted to verify that previously identified deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report confirms that the deficiency identified under regulation 483.25(h) with ID prefix F0323 was corrected as of 10/27/2014.

This document is a Plan of Correction prepared and executed in response to previous state and federal regulatory deficiencies identified at Brighton Place West.

The plan addresses deficiencies related to securing the environment for Resident #1, including revising the resident's care plan, updating the Elopement Book, locking the patio gate with a combination code, and educating staff on Elopement Drill procedures.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The inspection was conducted as a result of complaint investigations #79083 and #79506 regarding the facility's failure to provide a secure environment to prevent elopement of a resident.

The facility failed to provide a secure environment to prevent elopement for one resident with cognitive impairments, hallucinations, and delusions. The resident eloped twice, walking to a hospital, and the facility did not consistently perform 15-minute checks or maintain a photo binder as required by policy.

The visit was complaint-related, investigating allegations that the facility failed to prevent elopement of a resident. The resident eloped twice, walking significant distances to a hospital. The facility did not consistently document 15-minute checks between elopements and hospital admission, and lacked a photo binder for residents at risk of elopement as required by policy.

This post-certification revisit was conducted to verify that previously identified deficiencies from the prior survey were corrected.

All previously cited deficiencies listed on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.

This document is a Plan of Correction prepared and executed in response to previous state and federal regulatory deficiencies identified at Brighton Place West.

The plan addresses multiple deficiencies including care plan updates, neurological assessments after falls, monitoring of bowel movements and glucose, medication management, infection control, and safe food handling practices. The facility has implemented staff in-services and monitoring procedures to ensure compliance and improve resident care.

A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility complies with Federal participation requirements for nursing homes in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be level "F", widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective August 12, 2014.

The inspection was a Health Resurvey and complaint investigation related to regulatory compliance and resident care.

The facility had multiple deficiencies including failure to complete significant change assessments, develop individualized care plans, perform neurological checks after falls, monitor drug regimens effectively, maintain sanitary food preparation, and uphold infection control standards.

The inspection included complaint investigations KS00072686 and KS00072684.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payment for new admissions and termination of provider agreement were outlined if substantial compliance is not achieved.

This post-certification revisit was conducted to verify correction of previously cited deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The revisit report shows that the deficiency identified under regulation 483.25(h) was corrected as of 10/24/2013. No other deficiencies or uncorrected issues are noted.

This document is a Plan of Correction prepared in response to a previous complaint-related inspection at Brighton Place West, addressing alleged deficiencies related to resident safety and compliance with Federal Medicare and Medicaid requirements.

The plan acknowledges deficiencies related to resident elopement risk assessment, particularly for cognitively impaired residents, and outlines corrective actions including assessment upon admission and ongoing monitoring by the Director of Nursing or designee.

This Plan of Correction is related to a complaint investigation at Brighton Place West, addressing deficiencies cited in complaint ID 100313.

The inspection was conducted as a complaint investigation (#68491 and #69280) regarding the facility's failure to provide adequate supervision for a cognitively impaired resident who eloped from the facility.

The facility failed to ensure adequate supervision for a cognitively impaired, independently mobile resident who left the facility unsupervised for approximately 4 hours and 25 minutes, exposing the resident to warm temperatures without the facility's knowledge. The resident was on 15-minute checks, but staff did not recognize the elopement risk at admission.

The complaint investigation found that the facility did not provide adequate supervision for resident #1, who was cognitively impaired and independently mobile, resulting in the resident leaving the facility unsupervised for over 4 hours. The resident was identified as an elopement risk after the incident, and the facility failed to implement appropriate safeguards at admission.

This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report shows that all previously cited deficiencies identified by their regulation numbers (483.15(h)(2), 483.20(d), 483.20(k)(1), 483.25(l), and 483.65) were corrected as of the revisit date.

This document is a Plan of Correction submitted by Brighton Place West in response to previously cited deficiencies from a regulatory inspection.

The Plan of Correction addresses multiple deficiencies including environmental cleanliness, individualized care plans, medication management with black box warnings, and proper glucose monitoring procedures. Corrective actions and ongoing monitoring plans are described for each deficiency.

The inspection was a Non-Compliance Revisit to verify correction of previously cited deficiencies related to housekeeping, care planning, medication management, and infection control.

The facility failed to maintain a sanitary environment, develop comprehensive individualized care plans for residents, monitor medication effectiveness and black box warnings, and properly disinfect shared blood glucose monitors and maintain infection control standards during accu-checks.

This is a post-certification revisit conducted to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.

All previously reported deficiencies identified by regulation numbers were corrected as of the revisit date, June 11, 2013.

The inspection was conducted as a Health Resurvey and Extended Health Resurvey to assess compliance with federal regulations for nursing facilities.

The facility was found deficient in multiple areas including failure to conduct pre-employment reference checks for new hires, inadequate housekeeping and maintenance leading to unsanitary conditions, incomplete comprehensive assessments and care plans for residents, failure to maintain accurate and accessible clinical records, failure to monitor and maintain safe water temperatures, inadequate monitoring of drug regimens including antipsychotic and antihypertensive medications, failure to provide required nurse aide in-service training, and failure to properly store nebulizer masks and sanitize shared equipment.

This document is a Plan of Correction prepared by Brighton Place West in response to previously identified deficiencies from a regulatory inspection.

The plan addresses multiple deficiencies including verification of employee references, environmental cleanliness, medication documentation, care plan individualization, water temperature safety, and staff training. Corrective actions and ongoing monitoring procedures are outlined for each deficiency.

This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report confirms that deficiencies previously cited under regulations 483.12(a)(4)-(6), 483.12(b)(1)&(2), and 483.60(a),(b) have been corrected as of 06/22/2012.

This document is a Plan of Correction submitted by Brighton Place West in response to deficiencies cited in a complaint investigation (Brighton Place West Complaint 061412).

The plan addresses deficiencies related to resident discharge procedures, notification of legal representatives regarding bed hold notices, and proper disposition of medications upon discharge. The facility outlines corrective actions including staff in-service training, monitoring, and reporting to the Quality Improvement committee.

This Plan of Correction is related to a complaint investigation identified as Brighton Place West Complaint 061412.

The inspection was conducted as a result of investigations of complaints #57320, #57600, and #56875 regarding facility compliance with transfer/discharge notice requirements, bed-hold policy notification, and pharmaceutical service procedures.

The facility failed to notify a legal representative prior to discharge for one resident, failed to provide timely bed-hold notices for two residents, and failed to obtain physician orders regarding disposition of medications for one resident. Documentation and communication deficiencies were noted related to resident transfers and medication handling.

The deficiencies are a result of investigations of complaints #57320, #57600, and #56875. The facility failed to notify a legal representative of a discharge, failed to provide timely bed-hold notices, and failed to obtain physician orders for medication disposition.