Inspection Reports for Brighton Place West Health Center LLC
331 SOUTHWEST OAKLEY AVENUE, TOPEKA, KS, 66606
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 24, 2017, found no deficiencies after a follow-up visit confirmed correction of prior issues. Earlier inspections identified deficiencies mainly related to resident bathing schedules, documentation of psychotropic medication dose reductions, and blood sugar monitoring. Complaint investigations substantiated concerns about inadequate personal hygiene care and medication management but did not result in enforcement actions or fines listed in the available reports. Prior reports also noted issues with elopement risk supervision, infection control, care planning, and staffing coverage, with corrective plans accepted each time. The overall trend shows improvement over time, with the facility addressing previously cited deficiencies and achieving substantial compliance in recent years.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
13.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
120% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
50 residents
Based on a August 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: Aug 28, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide necessary behavioral health care and services to residents, specifically related to Resident 1's mental health crisis and medication noncompliance.
Complaint Details
The investigation was complaint-related, focusing on Resident 1's refusal to take medications, escalating aggressive behaviors, and the facility's failure to involve the physician, guardian, emergency services, or law enforcement during a behavioral health crisis. The resident left AMA, was missing for seven days, and was later found dehydrated and sunburned. The complaint was substantiated with findings of immediate jeopardy.
Findings
The facility failed to provide adequate behavioral health care and services for Resident 1, who had schizophrenia and other mental health disorders, resulting in immediate jeopardy to resident health and safety. Resident 1 left the facility against medical advice without proper involvement of the physician, guardian, or law enforcement, leading to serious adverse outcomes including dehydration and exposure.
Deficiencies (1)
Failure to ensure each resident receives necessary behavioral health care and services, resulting in immediate jeopardy to resident health or safety.
Report Facts
Census: 50
Sample size: 3
Medication refusals: 5
Days Resident 1 was missing: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Involved in interactions with Resident 1 during behavioral crisis and departure AMA |
| Administrative Nurse E | Administrative Nurse | Involved in interactions with Resident 1 during behavioral crisis and departure AMA |
| Administrative Staff A | Administrative Staff | Provided statements regarding Resident 1's behavior, medication refusals, and discharge AMA |
Inspection Report
Routine
Census: 48
Deficiencies: 4
Date: Oct 17, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, medication management, food safety, and notification procedures during transfers or discharges.
Findings
The facility failed to deliver mail to residents on Saturdays, did not provide timely written notice to residents or their representatives and the Long-Term Care Ombudsman regarding facility-initiated transfers to the hospital, failed to ensure a resident remained free from significant medication errors resulting in psychosocial harm, and failed to maintain sanitary food preparation and storage conditions.
Deficiencies (4)
Failed to deliver mail to facility residents on Saturdays.
Failed to provide timely notification to residents, their representatives, and the Long-Term Care Ombudsman before transfer or discharge, including appeal rights, for three residents transferred to the hospital.
Failed to ensure Resident 21 remained free from significant medication errors, resulting in increased auditory and visual hallucinations and significant psychosocial distress.
Failed to prepare, store, distribute, and serve food under sanitary conditions, including undated food items and dirty kitchen equipment, placing residents at risk of foodborne illness.
Report Facts
Census: 48
Sample size: 13
Residents reviewed for discharge: 3
Residents reviewed for medication errors: 5
Weight of deli turkey meat container: 2.5
Days since shredded lettuce dated: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified lack of written notice to residents and representatives regarding transfers and medication order issues |
| Licensed Nurse G | Licensed Nurse | Discontinued both doses of Clozaril causing medication error |
| Licensed Nurse H | Licensed Nurse | Identified medication error with Clozaril discontinuation and contacted psychiatric provider |
| Social Services X | Social Services | Verified no discharge notices were sent to the state ombudsman office |
| Dietary Staff BB | Dietary Staff | Verified undated food and unsanitary kitchen conditions |
| Certified Medication Aide R | Certified Medication Aide | Unaware of responsibility to deliver mail on Saturdays and could not find mailbox key |
Inspection Report
Routine
Census: 48
Deficiencies: 4
Date: Oct 17, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, medication management, food safety, and notification procedures during transfers or discharges.
Findings
The facility failed to deliver mail on Saturdays, did not provide timely written notice of facility-initiated transfers to residents or their representatives, failed to notify the Long-Term Care Ombudsman of discharges, had a significant medication error causing psychosocial harm to a resident, and failed to maintain sanitary food preparation and storage conditions.
Deficiencies (4)
Failed to deliver mail to residents on Saturdays, violating residents' right to privacy in communication.
Failed to provide timely written notice to residents or their representatives and notify the Long-Term Care Ombudsman before transfer or discharge for three residents.
Failed to ensure a resident remained free from significant medication errors, resulting in increased hallucinations and psychosocial distress.
Failed to prepare, store, distribute, and serve food under sanitary conditions, including undated food items and dirty kitchen equipment.
Report Facts
Residents in census: 48
Sample residents reviewed: 13
Residents reviewed for discharge: 3
Residents reviewed for medication errors: 5
Weight of deli turkey meat container: 2.5
Days shredded lettuce was dated: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified lack of written notice for transfers and medication order issues |
| Licensed Nurse G | Licensed Nurse | Discontinued both doses of Clozaril causing medication error |
| Licensed Nurse H | Licensed Nurse | Identified medication error and contacted psychiatric provider |
| Social Service X | Social Services | Verified no discharge notices sent to ombudsman and lack of awareness of notification requirements |
| Dietary Staff BB | Dietary Staff | Verified undated food and unsanitary kitchen conditions |
| Certified Medication Aide R | Certified Medication Aide | Unaware of mail delivery responsibilities on Saturdays |
Inspection Report
Routine
Census: 49
Deficiencies: 11
Date: May 15, 2023
Visit Reason
The inspection was a routine regulatory survey of Brighton Place West nursing home to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including resident dignity, mail delivery, notification of Medicare coverage, transfer/discharge notices, activity provision and certification, treatment and care according to orders, accident hazard prevention, staffing adequacy, medication regimen review, unnecessary drug use, and vaccination documentation.
Deficiencies (11)
Failed to ensure residents R33 and R41 were treated in a dignified manner, discussing incontinence in front of others.
Failed to provide a system to ensure mail was consistently delivered on Saturdays.
Failed to issue CMS Skilled Nursing Facility Advance Beneficiary Notification and Notification of Medicare Non-Coverage forms to residents R32 and R99.
Failed to provide timely written notification of transfer/discharge to resident R32 or their representative.
Failed to provide activities consistently on Saturdays and failed to have a certified activity professional.
Failed to implement physician order for daily weights to monitor congestive heart failure for resident R29.
Failed to ensure chemicals were stored in a safe, secure manner, leaving laundry room door propped open.
Failed to ensure sufficient licensed nurse coverage and adequate weekend staffing.
Failed to ensure the Consultant Pharmacist identified and reported irregularities for monitoring hypertensive medication for residents R33 and R29.
Failed to follow physician order for monitoring hypertensive medication for resident R33 and failed to administer as needed antihypertensive medication as ordered for resident R29.
Failed to obtain pneumococcal vaccination consents, declinations, or administration information for residents R10, R29, R9, and R27.
Report Facts
Residents affected: 49
Sample size: 13
Medication review period: 81
Medication review period: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide M | Certified Nurse Aide | Named in dignity and daily weight monitoring findings |
| Administrative Nurse D | Administrative Nurse | Named in dignity, mail delivery, transfer notification, staffing, medication administration findings |
| Licensed Nurse G | Licensed Nurse | Named in mail delivery, activities, daily weight monitoring, medication administration findings |
| Administrative Staff B | Administrative Staff | Named in mail delivery, Medicare notification, activities, staffing findings |
| Activity Coordinator Z | Activity Coordinator | Named in activities and certification findings |
| Administrative Staff A | Administrative Staff | Named in activities and staffing findings |
| Administrative Nurse E | Administrative Nurse | Named in medication regimen review findings |
| Consultant Pharmacist GG | Consultant Pharmacist | Named in medication regimen review findings |
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 3
Date: Dec 1, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for the nursing home facility.
Findings
The facility failed to provide a homelike environment, ensure pharmacist recommendations were followed for medication monitoring, and maintain proper infection control practices related to laundry handling and water temperature documentation. These deficiencies placed residents at risk for impaired health, unnecessary medication side effects, and infection.
Deficiencies (3)
Failed to provide a homelike environment, including cluttered hallways and use of overhead intercom paging.
Failed to ensure Consultant Pharmacist recommendations were acknowledged and followed for residents R20 and R10, risking unnecessary medication use and side effects.
Failed to ensure laundry staff covered clothing racks when transporting clean linen/clothing and failed to measure and record water temperatures for washing machines, risking infection.
Report Facts
Residents in census: 43
Sample size: 14
Residents reviewed for unnecessary medication: 5
Medication monitoring months missed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| M | Certified Nurse's Aide (CNA) | Interviewed regarding work order process and intercom system use |
| G | Licensed Nurse (LN) | Interviewed regarding medication parameters and intercom system |
| D | Administrative Nurse | Interviewed regarding work order repairs and pharmacy review reports |
| V | Maintenance Director | Interviewed regarding floor repairs and water temperature logs |
| GG | Consultant Pharmacist (CP) | Interviewed regarding pharmacy recommendations and medication monitoring |
| U | Housekeeping/Laundry Staff | Interviewed regarding laundry rack covering procedures |
| W | Housekeeping Manager | Interviewed regarding laundry rack covering and water temperature logs |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jul 24, 2017
Visit Reason
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.
Findings
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.
Deficiencies (3)
Deficiency related to regulation 483.10(f)(1)-(3)
Deficiency related to regulation 483.24(a)(2)
Deficiency related to regulation 483.45(d)(e)(1)-(2)
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jul 24, 2017
Visit Reason
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.
Findings
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.
Deficiencies (3)
Resident 37, 48, and 22’s bathing schedule has been updated with a minimum of two showers per week per their choice; dependent residents could be affected; nursing staff educated on bathing ADL documentation; monitoring of bathing documentation planned.
Resident 37, 48, and 22’s bathing schedule updated; dependent residents could be affected; nursing staff educated on bathing ADL documentation; monitoring of bathing documentation planned.
Physicians for residents #14, #40, #45, and #33 updated regarding Gradual Dose Reduction or Risk vs. Benefit; blood sugar parameters audited and added to Treatment Administration Record; nursing and medical staff educated; pharmacist to audit charts monthly.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 30, 2017
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiencies found were 'E' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date of substantial compliance: Jul 24, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and communicated findings |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 3
Date: Jun 30, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #112841 and #113505 to assess compliance with resident rights and care standards.
Complaint Details
The visit was triggered by complaint investigations #112841 and #113505.
Findings
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.
Deficiencies (3)
Facility failed to provide scheduled showers as needed and preferred for 3 of 3 sampled residents (#37, #48, #22), risking inadequate personal hygiene and skin issues.
Facility failed to provide scheduled showers to maintain good grooming and personal hygiene for 4 of 4 sampled residents (#22, #34, #37, #48).
Facility failed to ensure 4 of 5 sampled residents (#14, #40, #33, #45) had gradual dose reductions attempted or risk versus benefit statements for continued use of psychotropic medications and failed to provide blood glucose parameters for Resident #33.
Report Facts
Residents not showered: 3
Residents reviewed for ADL care: 4
Residents reviewed for unnecessary drugs: 5
Days without shower: 57
Days without shower: 22
Blood glucose readings: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nursing Staff A | Verified lack of gradual dose reduction and risk versus benefit documentation for psychotropic medications; stated staff should record shower refusals and monitor shower frequency. | |
| Medication Aide B | Administered medications to Resident #14 and reported resident behavior and medication adherence. | |
| Medication Aide G | Administered medications to Resident #40 and used phone application to provide medication information. | |
| Direct Care Staff F | Reported residents' shower preferences and assistance needs; unaware who monitored shower frequency. | |
| Direct Care Staff H | Reported residents' shower preferences and assistance needs; unaware who monitored shower frequency. | |
| Licensed Nursing Staff C | Reported on Resident #40's behavior and medication effectiveness. | |
| Social Worker E | Reported on Resident #40's behavior and interactions. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Nov 10, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiencies found at 'F' level with no harm but potential for more than minimal harm not constituting immediate jeopardy.
Report Facts
Effective date for denial of payments: Feb 10, 2017
Provider agreement termination date: May 10, 2017
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process regarding cited deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Nov 18, 2015
Visit Reason
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.
Findings
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.
Deficiencies (8)
Failure to post contact information for the state's complaint hotline and inform residents of grievance rights.
Failure to maintain a comfortable and safe temperature level within the range of 71 to 81 degrees Fahrenheit.
Incomplete diet and comprehensive assessments for several residents.
No plan of correction needed for deficiency F323.
Failure to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.
Failure to post nurse staffing data daily in a clear and readable format accessible to residents and visitors.
Failure to maintain an infection control program to prevent disease and infection transmission.
Failure to complete a performance review of every nurse aide at least once every 12 months.
Report Facts
Temperature range: 71
Temperature range: 81
Nurse staffing hours: 8
Nurse aide performance review frequency: 12
Record retention period: 18
Temperature monitoring frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rodney Close | Administrator | Submitted the Plan of Correction |
| Irina Strakhova | Added and modified the Plan of Correction | |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Nov 6, 2015
Visit Reason
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.
Findings
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.
Deficiencies (1)
'F' level deficiencies, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the report and referenced in relation to enforcement and compliance decision. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 8
Date: Nov 6, 2015
Visit Reason
The inspection was a Health Resurvey, Extended Health Resurvey, and Complaint investigation triggered by complaint #KS00091622.
Complaint Details
Complaint investigation #KS00091622 included findings of failure to post complaint hotline information and failure to supervise an elopement risk resident resulting in injury.
Findings
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.
Deficiencies (8)
Failure to post contact information for the state's complaint hotline and inform residents of their right to file grievances.
Failure to maintain comfortable and safe temperature levels in resident rooms and common areas.
Failure to complete comprehensive assessments and triggered Care Area Assessments (CAA) timely for multiple residents.
Failure to provide adequate supervision for an elopement risk resident who left the facility unattended and sustained injuries.
Failure to provide 8 hours of continuous RN coverage 7 days a week.
Failure to post and maintain daily nurse staffing information in a clear, complete, and accessible manner.
Failure to follow infection control practices including improper glove use and inadequate cleaning and disinfecting of resident rooms.
Failure to perform nurse aide performance reviews at least once every 12 months.
Report Facts
Resident census: 48
RN coverage days missed: 7
Fall risk assessment score: 17
Fall risk assessment score: 18
Elopement risk assessment score: 16
Elopement risk assessment score: 15
Nurse aide count: 12
Nurse aide in-service hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Acknowledged failure to post complaint hotline and RN coverage deficiencies. | |
| Administrative nursing staff D | Responsible for MDS and CAAs completion; acknowledged failure to complete CAAs timely and RN coverage deficiencies. | |
| Licensed staff H | Observed failing to change gloves between procedures and involved in elopement incident. | |
| Consultant staff B | Acknowledged failure to complete nurse aide performance reviews and incomplete nurse staffing postings. | |
| Direct care staff P | Reported resident elopement and injury. | |
| Direct care staff Q | Described elopement risk resident supervision procedures. | |
| Direct care staff M | Described elopement risk resident supervision procedures. | |
| Housekeeping staff V | Observed failing to remove gloves when cleaning toilet. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 7, 2015
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiencies found were 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Enforcement effective date: Oct 7, 2015
Provider agreement termination date: Jan 7, 2016
Plan of Correction submission timeframe: 10
Informal Dispute Resolution request timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 27, 2014
Visit Reason
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.
Findings
The report confirms that the deficiency identified under regulation 483.25(h) with ID prefix F0323 was corrected as of 10/27/2014.
Deficiencies (1)
Deficiency under regulation 483.25(h) previously cited and corrected.
Report Facts
Deficiency correction date: Oct 27, 2014
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 27, 2014
Visit Reason
This document is a Plan of Correction prepared and executed in response to previous state and federal regulatory deficiencies identified at Brighton Place West.
Findings
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.
Deficiencies (1)
Failure to provide a secure environment for Resident #1, including inadequate elopement risk management.
Report Facts
Plan of Correction completion date: Oct 27, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| SACARABROOKS | Administrator | Submitted the Plan of Correction |
| IRINASTRAKHOVA | Added and modified the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 8, 2014
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiency rated as 'D' level indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Signed letter regarding survey findings and plan of correction acceptance. |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Oct 8, 2014
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to provide a secure environment to prevent elopement for one resident with noted hallucinations and delusions, and identified at risk for elopement.
Report Facts
Resident census: 46
Antipsychotic doses: 7
Antianxiety doses: 7
Distance of first elopement: 2.7
Distance of second elopement: 1.1
Inspection Report
Follow-Up
Deficiencies: 8
Date: Aug 12, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the prior survey were corrected.
Findings
All previously cited deficiencies listed on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Deficiencies (8)
Deficiency related to regulation 483.20(b)(2)(ii)
Deficiency related to regulations 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Deficiency related to regulations 483.60(b), (d), (e)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Aug 12, 2014
Visit Reason
This document is a Plan of Correction prepared and executed in response to previous state and federal regulatory deficiencies identified at Brighton Place West.
Findings
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.
Deficiencies (8)
Resident #34's MDS reflects current overall status, care plan updated to reflect rapid fluctuations and functioning in ADLs related to mental health and diabetes.
The facility has developed a comprehensive and individual care plan for residents #41 and #35.
Residents will have neurological assessments done with any fall or incident involving the head area.
Monitoring of bowel movements, glucose monitoring, and behaviors for residents #6, #25, #28, #34, and #38 with parameters placed on Physician's Order Sheet and Glucose Monitoring Sheet.
Facility will thaw food by refrigeration, part of cooking process, under potable water or microwave for safe food handling.
Parameter for blood sugars for resident #6 updated on Glucose Monitoring Sheet and Physician's Order Sheet; correct documentation of bowel monitoring, glucose monitoring, behavior monitoring, and antibiotic follow-up.
All medication carts, treatment carts, and medication room are free of expired medications and treatment products.
Facility has established an Infection Control Program with staff following proper infection control procedures.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | Listed as contact person for Plan of Correction assistance |
Inspection Report
Enforcement
Deficiencies: 1
Date: Jul 18, 2014
Visit Reason
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.
Findings
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.
Deficiencies (1)
Level "F" deficiencies, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey and certification. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 7
Date: Jul 18, 2014
Visit Reason
The inspection was a Health Resurvey and complaint investigation related to regulatory compliance and resident care.
Complaint Details
The inspection included complaint investigations KS00072686 and KS00072684.
Findings
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.
Deficiencies (7)
Failure to complete a significant change assessment for a resident with moderate cognitive impairment showing changes in ADLs and continence.
Failure to develop individualized comprehensive care plans for residents with specific needs including coping skills, nutrition, and bathing preferences.
Failure to perform neurological checks for a resident who fell and hit his/her head.
Failure to consistently monitor bowel movements, behaviors, and side effects of medications for residents on psychotropic drugs, and failure to monitor blood sugar levels with parameters.
Failure to store, prepare, distribute, and serve food under sanitary conditions, including thawing food at room temperature.
Failure to ensure medication carts, treatment carts, and medication room were free of expired medications and treatment products.
Failure to maintain an infection control program and failure to follow proper infection control procedures for cleaning resident rooms, including inadequate cleaning of call lights and light switches and failure to change gloves after cleaning toilets.
Report Facts
Deficiencies cited: 7
Resident sample size: 11
Days with missing bowel movement documentation: 6
Days with missing bowel movement documentation: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Nursing Staff | Named in relation to failure to complete significant change assessments, care plan development, neurological checks, and medication monitoring. |
| Staff D | Administrative Nursing Staff | Named in relation to care plan development, infection control, medication monitoring, and oversight of expired medications. |
| Staff E | Administrative Nursing Staff | Named in relation to care plan development and medication monitoring. |
| Staff R | Direct Care Staff | Named in relation to care plan individualization and bowel movement documentation. |
| Staff Q | Direct Care Staff | Named in relation to bowel movement documentation. |
| Staff Y | Housekeeping Staff | Named in relation to failure to follow infection control cleaning procedures. |
| Staff KK | Consultant Pharmacist | Named in relation to failure to identify and report medication monitoring deficiencies. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jan 9, 2014
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiencies found to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Denial of payment effective date: Apr 9, 2014
Termination effective date: Jul 9, 2014
Plan of correction submission timeframe: 10
Fair hearing request timeframe: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sacara Brooks | Administrator | Facility administrator named in the report. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator. |
| Joe Ewert | Commissioner of Survey, Certification and Credentialing Commission | Copied on the report. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 24, 2013
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiency under regulation 483.25(h) previously cited
Report Facts
Deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 24, 2013
Visit Reason
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.
Complaint Details
This Plan of Correction is related to a complaint investigation at Brighton Place West, addressing deficiencies cited in complaint ID 100313.
Findings
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.
Deficiencies (1)
Resident is no longer residing in facility. Residents who are cognitively impaired could be affected by this deficient practice related to elopement risk assessment.
Report Facts
Plan of Correction completion date: Oct 24, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| SACARABROOKS | Administrator | Submitted the Plan of Correction |
| IRINASTRAKHOVA | Added the Plan of Correction | |
| MARY JANE KENNEDY | Modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Oct 3, 2013
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure adequate supervision to prevent elopement of a cognitively impaired resident.
Report Facts
Census: 49
Fall risk assessment score: 10
Duration of elopement: 265
Heat index: 95.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff D | Reported admission date and 15-minute checks start time for resident #1. | |
| Administrative staff A | Reported door alarm system and resident's child as DPOA. | |
| Direct care staff Q | Reported last seen time of resident during 15-minute checks. | |
| Direct care staff P | Reported inability to locate resident during 15-minute checks. | |
| Licensed nursing staff H | Reported last seen time and resident's refusal of assessments. | |
| Housekeeping/maintenance staff JJ | Reported door alarm functioning. | |
| Activity/social services staff KK | Reported staff search efforts for missing resident. |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jun 28, 2013
Visit Reason
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.
Findings
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.
Deficiencies (4)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulations 483.20(d) and 483.20(k)(1)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jun 28, 2013
Visit Reason
This document is a Plan of Correction submitted by Brighton Place West in response to previously cited deficiencies from a regulatory inspection.
Findings
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.
Deficiencies (4)
Flooring and bathroom areas require deep cleaning and maintenance.
Care plans for residents #27 and #23 lack individualized care and preferences.
Black Box Warnings for resident #30 were not placed on the care plan; medication reviews needed for residents #24 and #1.
Charge Nurses required competency check and demonstration on accucheck and infection control standards.
Report Facts
Deficiency completion date: Jun 28, 2013
Plan of Correction presentation date: Jul 3, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| SACARABROOKS | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 46
Deficiencies: 4
Date: Jun 11, 2013
Visit Reason
The inspection was a Non-Compliance Revisit to verify correction of previously cited deficiencies related to housekeeping, care planning, medication management, and infection control.
Findings
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.
Deficiencies (4)
Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior on 2 of 2 halls.
Failed to develop comprehensive and individualized care plans for residents, including hospice services and shaving care plans.
Failed to ensure residents' drug regimens were free from unnecessary drugs, including failure to identify black box warnings and monitor medication effectiveness.
Failed to establish and maintain an infection control program, including failure to disinfect shared blood glucose monitors per manufacturer's instructions, failure to perform hand hygiene, and failure to maintain a clean field during accu-checks.
Report Facts
Census: 46
Deficiencies cited: 4
Medication doses: 500
Medication doses: 800
Contact time: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse H | Named in infection control and accu-check procedure deficiencies | |
| licensed nurse I | Named in medication monitoring and infection control interviews | |
| administrative nursing staff D | Named in interviews regarding care plan expectations and infection control | |
| housekeeping staff X | Named in housekeeping deficiencies | |
| maintenance staff Y | Named in housekeeping deficiencies | |
| direct care staff O | Named in care plan and shaving care deficiencies | |
| direct care staff P | Named in care plan and shaving care deficiencies |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 11, 2013
Visit Reason
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.
Findings
All previously reported deficiencies identified by regulation numbers were corrected as of the revisit date, June 11, 2013.
Report Facts
Deficiencies corrected: 10
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 13
Date: Apr 12, 2013
Visit Reason
The inspection was conducted as a Health Resurvey and Extended Health Resurvey to assess compliance with federal regulations for nursing facilities.
Findings
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.
Deficiencies (13)
Failed to provide evidence of reference verification prior to hire for 5 of 5 new employees.
Failed to provide a comfortable and clean environment for residents on 3 of 3 hallways.
Failed to comprehensively assess for the use of psychotropic drugs for 2 residents.
Failed to provide an accurate assessment for one resident regarding antidepressant medication use.
Failed to develop comprehensive and individualized care plans for 5 residents.
Failed to revise/update the care plan for one resident after a fall.
Failed to maintain Minimum Data Set assessments for the previous 15 months accessible to all professional staff for 2 residents.
Failed to monitor and maintain water temperatures below 120 degrees Fahrenheit, placing residents in immediate jeopardy.
Failed to provide parameters for blood pressure monitoring and failed to monitor blood pressure and behavioral medication effectiveness for several residents.
Failed to complete 12 hours of nurse aide in-service training annually.
Failed to maintain complete and organized clinical records readily accessible for resident care for 5 residents.
Failed to train 3 employees on emergency procedures when hired.
Failed to sanitize a community counter after a resident performed a blood sugar test and failed to properly store nebulizer masks for 2 residents.
Report Facts
Census: 49
New employees hired: 8
Sampled new employees: 5
Residents sampled: 16
Inservice training hours: 10
Water temperature: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Reported responsibility for obtaining pre-employment screening verification and care plan development | |
| Administrative staff B | Reported responsibility for obtaining reference checks and confirmed lack of evidence of emergency procedure training for staff | |
| Administrative nursing staff D | Provided multiple interviews regarding care plan expectations, water temperature monitoring, and record accessibility | |
| Administrative nursing staff E | Provided interviews regarding care plan updates and behavioral medication monitoring | |
| Licensed nursing staff K | Licensed Nurse | Mentioned in relation to care plan development and blood pressure monitoring |
| Licensed nursing staff L | Discussed blood pressure monitoring and care plan updates | |
| Direct care staff O | Mentioned in relation to shaving care and lack of emergency procedure training | |
| Direct care staff P | Mentioned in relation to lack of emergency procedure training | |
| Direct care staff Q | Described monitoring bowel movements for a resident | |
| Direct care staff R | Described shaving assistance for a resident | |
| Dietary staff DD | Provided information about water temperature monitoring and maintenance | |
| Pharmacy consultant II | Failed to identify and report lack of monitoring for blood pressure and behavioral medications |
Inspection Report
Plan of Correction
Deficiencies: 14
Date: Apr 8, 2013
Visit Reason
This document is a Plan of Correction prepared by Brighton Place West in response to previously identified deficiencies from a regulatory inspection.
Findings
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.
Deficiencies (14)
Failure to properly obtain and document employee references prior to employment.
Environmental issues including urine odors in bathrooms, unlabeled towel bars and care equipment, damaged walls, and carpet cleaning.
Care Area Assessments (CAA) for residents #24 and #46 lacked identification of causal factors for psychotropic medication use.
Minimum Data Set (MDS) for resident #10 did not reflect the number of days the resident received an antidepressant.
Care plans for residents #1, #32, #23, #27, and #20 were not individualized to specific needs and preferences.
Care plan for resident #24 was not updated/revised following a fall on 4-6-13.
MDS documents were not organized and accessible to nurses and doctors after hours.
Water temperatures in 4 resident rooms were excessive, requiring immediate shut off and ongoing monitoring.
Physician-signed blood pressure parameters were not obtained for resident #24 and others receiving hypertensive medications.
Pharmacy consultant monitoring of medication administration records (MARS) and behavior monitoring forms was lacking.
Nebulizers were not properly stored in plastic bags for residents #35 and #24.
In-Service Training Calendar for 2013 was not posted with time and date for each month.
Clinical records for residents #1, #23, #46, #24, and #10 were not completed, organized, and readily accessible.
Two employees had not attended all staff in-service on disaster preparedness and emergency procedures.
Report Facts
Number of affected resident rooms with excessive water temperatures: 4
Date of fall incident for resident #24: Apr 6, 2013
Date of in-service training attended by two employees: Apr 5, 2013
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jun 22, 2012
Visit Reason
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.
Findings
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.
Deficiencies (3)
Deficiency related to regulation 483.12(a)(4)-(6)
Deficiency related to regulation 483.12(b)(1)&(2)
Deficiency related to regulation 483.60(a),(b)
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jun 22, 2012
Visit Reason
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).
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Brighton Place West Complaint 061412.
Findings
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.
Deficiencies (3)
Resident no longer resides in the facility; residents with legal representation could be affected by deficient discharge notification practices.
Resident legal representation provided bed hold notice; deficiencies in notification procedures for planned or unplanned leave of absence.
Deficient practice in obtaining orders for disposition of medications upon resident discharge.
Report Facts
Complete Date: Jul 4, 2012
Complete Date: Jun 22, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| SACARABROOKS | Administrator | Submitted Plan of Correction to KDADS |
| IRINA STRAKHOVA | Added Plan of Correction | |
| MARY JANE KENNEDY | Modified Plan of Correction |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 3
Date: Jun 14, 2012
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to notify a legal representative of a discharge prior to discharge for one resident with moderately impaired cognition.
Failed to provide written notice of the facility's bed-hold policy within 24 hours of transfer for two residents.
Failed to obtain a physician's order regarding disposition of medications for one resident discharged involuntarily and transferred to jail.
Report Facts
Census: 48
Sample size: 5
Residents with bed-hold notice deficiency: 2
Residents with discharge notice deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing administrative staff A | Administrative Nursing Staff | Interviewed regarding discharge notification, bed-hold notices, and medication disposition |
| Social service staff E | Social Service Staff | Interviewed regarding bed-hold notice procedures and documentation |
| Interested party B | Interviewed regarding resident discharge and readmission |
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