Inspection Reports for
Brighton Place West Health Center LLC
331 SOUTHWEST OAKLEY AVENUE, TOPEKA, KS, 66606
Back to Facility ProfileDeficiencies (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
80
60
40
20
0
Occupancy
Latest occupancy rate
100% occupied
Based on a August 2025 inspection.
Occupancy rate 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 for a resident with cognitive impairment and psychiatric disorders.
Complaint Details
The complaint investigation found substantiated immediate jeopardy due to the facility's failure to manage a behavioral health crisis for Resident 1, including lack of physician and guardian involvement and failure to prevent the resident from leaving AMA despite having a legal guardian.
Findings
The facility failed to provide adequate behavioral health care and services for Resident 1, who exhibited medication refusal, escalating aggressive behaviors, and was allowed to leave the facility against medical advice without proper involvement of the physician, guardian, or law enforcement. This failure placed the resident in immediate jeopardy.
Deficiencies (1)
F 0740: The facility failed to ensure each resident received necessary behavioral health care and services, resulting in immediate jeopardy to resident health or safety.
Report Facts
Resident census: 50
Medication refusals: 5
Days resident was absent: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Involved in interactions with Resident 1 during behavioral escalation and AMA discharge |
| Administrative Nurse E | Administrative Nurse | Involved in interactions with Resident 1 during behavioral escalation and AMA discharge |
| Administrative Staff A | Administrative Staff | Provided statements regarding Resident 1's behavior, medication refusals, and discharge process |
Inspection Report
Routine
Census: 48
Deficiencies: 4
Date: Oct 17, 2024
Visit Reason
Routine inspection of Brighton Place West nursing home to assess compliance with regulatory standards including resident rights, medication management, food safety, and notification procedures.
Findings
The facility failed to deliver mail on Saturdays, provide timely written notice for facility-initiated transfers and discharge notifications to residents and the Long-Term Care Ombudsman, ensure residents were free from significant medication errors, and maintain sanitary food preparation and storage conditions.
Deficiencies (4)
F 0576: The facility failed to deliver mail to residents on Saturdays, violating residents' right to privacy in communication.
F 0623: The facility failed to provide timely written notice to residents and their representatives, and notify the Long-Term Care Ombudsman, before facility-initiated transfers or discharges for three residents.
F 0760: The facility failed to ensure Resident 21 remained free from significant medication errors, causing increased auditory and visual hallucinations and significant psychosocial distress.
F 0812: The facility failed to prepare, store, distribute, and serve food under sanitary conditions, placing residents at risk of foodborne illness.
Report Facts
Residents affected: 48
Sample residents reviewed: 13
Residents reviewed for discharge notice: 3
Residents reviewed for medication errors: 5
Deli turkey meat container weight: 2.5
Shredded lettuce age: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified lack of written notice for resident transfers and medication order issues |
| Social Services X | Social Services Staff | Verified no discharge notices sent to Ombudsman and unaware of notification requirements |
| Licensed Nurse G | Licensed Nurse | Discontinued medication orders incorrectly causing abrupt medication cessation |
| Licensed Nurse H | Licensed Nurse | Identified medication error and contacted psychiatric provider to correct orders |
| Dietary Staff BB | Dietary Staff | Verified unsanitary food storage and maintenance issues in kitchen |
| Certified Medication Aide R | Certified Medication Aide | Unable to locate mailbox key and unaware of mail delivery duties on Saturdays |
Inspection Report
Routine
Census: 48
Deficiencies: 4
Date: Oct 17, 2024
Visit Reason
Routine inspection of Brighton Place West nursing home to assess compliance with regulatory requirements including resident rights, medication management, food safety, and notification procedures.
Findings
The facility failed to deliver mail on Saturdays, did not provide timely written notice of facility-initiated transfers to residents and the Long-Term Care Ombudsman, had a significant medication error causing actual harm to a resident, and failed to maintain sanitary food preparation conditions.
Deficiencies (4)
F 0576: The facility failed to deliver mail to residents on Saturdays, violating residents' right to privacy in communication.
F 0623: The facility failed to provide timely written notice to residents and the Long-Term Care Ombudsman before facility-initiated transfers or discharges, impairing resident rights.
F 0760: The facility failed to ensure Resident 21 remained free from significant medication errors, resulting in increased hallucinations and significant psychosocial distress.
F 0812: The facility failed to prepare, store, distribute, and serve food under sanitary conditions, placing residents at risk of foodborne illness.
Report Facts
Residents in facility: 48
Residents in sample: 13
Residents reviewed for discharge: 3
Residents reviewed for medication errors: 5
Deli turkey meat container weight: 2.5
Days shredded lettuce stored: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified lack of written notice for resident transfers and medication order issues |
| Licensed Nurse G | Licensed Nurse | Discontinued medication orders incorrectly causing medication error for Resident 21 |
| Licensed Nurse H | Licensed Nurse | Identified medication error and contacted psychiatric provider to correct Resident 21's medication |
| Social Service X | Social Services | Verified lack of discharge notices sent to Ombudsman and responsibility for bed hold policy notification |
| Certified Medication Aide R | Certified Medication Aide | Unable to find mailbox key and unaware of mail delivery duties on Saturdays |
| Dietary Staff BB | Dietary Staff | Verified unsanitary food storage and kitchen conditions |
Inspection Report
Routine
Census: 49
Deficiencies: 12
Date: May 15, 2023
Visit Reason
Routine inspection of Brighton Place West nursing home to assess compliance with regulatory requirements including resident dignity, communication, medication administration, staffing, and vaccination policies.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inconsistent mail delivery, failure to provide required Medicare notices, inadequate notification of resident transfers, inconsistent activities especially on weekends, lack of certified activity professional, failure to follow physician orders for daily weights and medication monitoring, unsafe chemical storage, insufficient licensed nurse coverage and weekend staffing, failure to ensure pharmacist medication regimen review identified irregularities, failure to administer as needed antihypertensive medication, and failure to document pneumococcal vaccinations or refusals.
Deficiencies (12)
F0550: The facility failed to ensure residents R33 and R41 were treated in a dignified manner, placing them at risk for decreased psychosocial well-being.
F0576: The facility failed to provide a system to ensure mail was consistently delivered on Saturdays, placing 49 residents at risk for decreased psychosocial wellbeing.
F0582: The facility failed to issue required Medicare notification forms SNF ABN 10055 and NOMNC 10123 to residents R32 and R99, risking decreased autonomy and impaired right to appeal.
F0623: The facility failed to provide timely written notification of transfer to resident R32 or their representative, risking miscommunication and missed healthcare opportunities.
F0679: The facility failed to provide activities consistently on Saturdays, placing residents at risk for decreased psychosocial wellbeing.
F0680: The facility failed to provide a certified activity professional, placing residents at risk for decreased psychosocial wellbeing.
F0684: The facility failed to implement a physician order for daily weights to monitor congestive heart failure for resident R29, risking delayed treatment and untreated illness.
F0689: The facility failed to ensure chemicals were stored securely, placing three cognitively impaired residents at risk for preventable accidents and injuries.
F0725: The facility failed to ensure sufficient licensed nurse coverage and adequate weekend staffing, placing residents at risk for decline and inadequate care.
F0756: The facility failed to ensure the consultant pharmacist identified and reported irregularities in monitoring hypertensive medication for residents R33 and R29, risking unnecessary medication administration.
F0757: The facility failed to ensure residents R33 and R29's drug regimens were free from unnecessary drugs due to failure to monitor and administer antihypertensive medications as ordered.
F0883: The facility failed to obtain pneumococcal vaccination consents, declinations, or administration information for residents R10, R29, R9, and R27, placing them at increased risk for pneumonia and complications.
Report Facts
Residents affected: 49
Sample residents reviewed: 13
Medication review period: 81
Medication review period: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff B | Administrative Staff | Reported lack of knowledge about required Medicare forms and activities coordinator certification |
| Licensed Nurse G | Licensed Nurse | Reported on mail delivery issues, activities missed on Saturdays, medication administration, and transfer notification practices |
| Certified Nurse Aide M | Certified Nurse Aide | Provided information on dignity practices and daily weight procedures |
| Administrative Nurse D | Administrative Nurse | Reported on dignity practices, transfer notification, chemical storage, and medication administration expectations |
| Administrative Nurse E | Administrative Nurse | Described medication review and order update process |
| Consultant Pharmacist GG | Consultant Pharmacist | Reviewed clinical records monthly and provided medication recommendations |
| Activity Coordinator Z | Activity Coordinator | Not certified and on vacation during inspection |
Inspection Report
Routine
Census: 43
Deficiencies: 3
Date: Dec 1, 2021
Visit Reason
Routine inspection to assess compliance with regulatory requirements related to resident environment, medication management, infection control, and other care standards at Brighton Place West nursing home.
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, adverse medication effects, and infection.
Deficiencies (3)
F 0584: The facility failed to provide a homelike environment, with soiled linen carts and equipment left in hallways and use of overhead intercom paging that increased risk of institutionalized experience for residents.
F 0756: The facility failed to ensure the Consultant Pharmacist's recommendations were acknowledged and followed for residents R20 and R10, risking unnecessary medication use and adverse side effects.
F 0880: The facility failed to ensure laundry staff covered clothing racks during transport and failed to maintain water temperature logs for washing machines, increasing risk of infection.
Report Facts
Resident census: 43
Sample residents reviewed: 14
Residents reviewed for medication: 5
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 about medication parameters and intercom system use |
| D | Administrative Nurse | Interviewed about work orders and pharmacy review process |
| V | Maintenance Director | Interviewed about floor repair and water temperature logs |
| GG | Consultant Pharmacist (CP) | Interviewed about pharmacy recommendations and medication monitoring |
| U | Housekeeping/Laundry Staff | Interviewed about laundry rack covering procedures |
| W | Housekeeping Manager | Interviewed about laundry infection control policies |
Inspection Report
Follow-Up
Deficiencies: 0
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 related to regulations 483.10(f)(1)-(3), 483.24(a)(2), and 483.45(d)(e)(1)-(2) were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jul 24, 2017
Visit Reason
This document is a Plan of Correction prepared in response to previous state and federal regulatory deficiencies identified at Brighton Place West.
Findings
The plan addresses deficiencies related to resident bathing schedules, nursing documentation, and medication management including Gradual Dose Reduction and blood sugar parameter monitoring.
Deficiencies (3)
F242-D Resident 37, 48, and 22’s bathing schedule has been updated to a minimum of two showers per week per their choice. Nursing staff have been educated on bathing ADL documentation and monitoring will be ongoing.
F312-E Resident 37, 48, and 22’s bathing schedule has been updated with a minimum of two showers per week per their choice. Nursing staff have been educated on bathing ADL documentation and monitoring will continue.
F329-E Physicians for residents #14, #40, #45, and #33 have been updated on Gradual Dose Reduction and Risk vs. Benefit. Blood sugar parameters for resident #33 were added to the Treatment Administration Record and nursing staff educated accordingly.
Report Facts
Plan of Correction completion date: Jul 24, 2017
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 30, 2017
Visit Reason
A Health survey was conducted to determine if the facility complies 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, pattern, 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 based on credible allegation of compliance and evidence of correction.
Deficiencies (1)
The facility had 'E' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
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.
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.
Deficiencies (3)
F242: The facility failed to provide scheduled showers as needed and preferred for residents #37, #48, and #22, risking inadequate personal hygiene and skin issues.
F312: The facility failed to provide scheduled showers to maintain good grooming and personal hygiene for residents #22, #34, #37, and #48.
F329: The facility failed to ensure gradual dose reductions or obtain risk versus benefit statements for psychotropic medications for residents #14, #40, #33, and #45, and failed to provide blood glucose parameters for resident #33.
Report Facts
Resident census: 49
Days without shower: 57
Days without shower: 19
Days without shower: 18
Psychotropic medication duration: 17
Blood glucose readings: 63
Blood glucose readings: 405
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 compliance 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 enforcement remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited with deficiencies at an 'F' level indicating no harm but potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in enforcement communication. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Nov 18, 2015
Visit Reason
This document is a Plan of Correction prepared by Brighton Place West in response to previous state and federal regulatory deficiencies. It outlines corrective actions to address cited deficiencies and ensure compliance with Medicare and Medicaid requirements.
Findings
The plan addresses multiple deficiencies including posting of complaint hotline information, maintaining safe temperature levels, completing resident assessments, ensuring registered nurse staffing, posting nurse staffing data, infection control, and nurse aide performance reviews. The facility commits to monitoring and re-education to maintain compliance.
Deficiencies (8)
F156C: The facility will post the state complaint hotline information visibly and inform residents of their grievance rights upon admission. Staff have been educated on the posting location and purpose.
F257E: The facility will maintain ambient air temperature between 71 and 81 degrees Fahrenheit. Maintenance staff will monitor temperature daily and add thermometers to resident areas.
F272E: The facility completed diet and comprehensive assessments for specified residents and will follow Resident Assessment Instrument guidelines with ongoing audits.
F323J: No plan of correction needed for this deficiency.
F354F: The facility will provide registered nurse coverage for at least 8 consecutive hours daily, 7 days a week, with monitoring of staffing levels.
F356C: The facility will post nurse staffing data daily in a clear format accessible to residents and visitors, maintaining records for 18 months.
F441F: The facility will maintain an infection control program with re-education of nursing and housekeeping staff and conduct random audits to ensure compliance.
F497C: The facility will complete performance reviews of every nurse aide at least annually, with audits to verify compliance.
Report Facts
Plan of Correction completion date: Nov 18, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rodney Close | Administrator | Submitted the Plan of Correction to KDADS |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 6, 2015
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, 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)
The survey identified 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the plan of correction acceptance letter. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 8
Date: Nov 6, 2015
Visit Reason
The inspection was a Health Resurvey and Extended Health Resurvey combined with a Complaint investigation.
Complaint Details
The complaint investigation revealed failures in posting complaint hotline information, supervision leading to resident elopement and injury, and infection control practices.
Findings
The facility failed to post state complaint hotline information, maintain comfortable room temperatures, complete timely comprehensive assessments, provide adequate supervision to prevent resident elopement, maintain required RN coverage, post nurse staffing data properly, implement infection control practices, and perform nurse aide performance reviews.
Deficiencies (8)
F156: The facility failed to post contact information for the state's complaint hotline and inform residents of their right to file grievances with State agencies.
F257: The facility failed to maintain comfortable and safe temperature levels in resident rooms and common areas for multiple days during the survey.
F272: The facility failed to complete comprehensive triggered Care Area Assessments timely for multiple residents, and failed to complete a comprehensive diet assessment for one resident.
F323: The facility failed to provide adequate supervision for a resident at risk for elopement who left the facility unattended, resulting in injury.
F354: The facility failed to provide 8 hours of continuous RN coverage on 7 days in October 2015.
F356: The facility failed to post complete and accurate daily nurse staffing information in a prominent place and maintain records for at least 18 months.
F441: The facility failed to follow infection control practices including changing gloves between tasks and proper cleaning techniques to prevent infection spread.
F497: The facility failed to perform nurse aide performance reviews at least every 12 months.
Report Facts
Resident census: 48
Days without RN coverage: 7
Resident sample size: 13
Fall risk score: 17
Fall risk score: 18
Elopement risk score: 16
Elopement risk score: 15
Minutes resident was away: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Provided statements regarding complaint hotline posting, RN coverage, nurse staffing forms, and nurse aide performance reviews | |
| Administrative nursing staff D | Provided statements regarding RN coverage, MDS and CAA completion, and nurse staffing forms | |
| Licensed staff H | Observed elopement event, infection control practices, and provided statements about door alarms | |
| Administrative consultant staff B | Acknowledged incomplete nurse staffing forms and lack of nurse aide performance reviews | |
| Direct care staff Q | Provided statements about elopement risk and door alarm procedures | |
| Direct care staff M | Provided statements about resident supervision and door alarm procedures | |
| Housekeeping staff V | Observed cleaning practices and provided statements about cleaning product use | |
| Housekeeping staff T | Provided statements about cleaning procedures and glove use |
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 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, and not immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility was cited for 'F' level deficiencies that were widespread with no harm but potential for more than minimal harm, not constituting immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Oct 7, 2015
Provider agreement termination date: Jan 7, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the Life Safety Code survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process related to cited deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 2
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 at Brighton Place West.
Findings
The facility provided a secure environment for Resident #1 by revising the care plan, updating the Elopement Book, locking the patio gate with a combination code, and educating staff on Elopement Drill procedures.
Deficiencies (2)
F0000: The plan of correction operates as Brighton Place West's written credible allegation of compliance with Federal Medicare and Medicaid requirements.
F323-D: A secure environment was provided for Resident #1 by revising the care plan, updating the Elopement Book, locking the patio gate with a combination code, and educating staff on Elopement Drill.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 27, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had 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) was corrected as of the revisit date. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected as of 10/27/2014.
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Oct 8, 2014
Visit Reason
The inspection was conducted as a complaint investigation related to two complaint investigations (#79083 and #79506) concerning the facility's failure to provide a secure environment to prevent resident elopement.
Complaint Details
The visit was triggered by complaint investigations #79083 and #79506. The complaint was substantiated as the facility failed to prevent elopement of a resident with cognitive and psychiatric impairments.
Findings
The facility failed to provide adequate supervision and a secure environment to prevent elopement for one resident with cognitive impairments and psychosis. The resident eloped twice by leaving through an unsecured courtyard gate, and the facility did not consistently document 15-minute checks or maintain a photo binder as required by policy.
Deficiencies (1)
F 323: The facility failed to provide a secure environment to prevent elopement for one resident with cognitive impairment and psychosis who eloped twice through an unsecured courtyard gate. Staff did not consistently document 15-minute checks between the first elopement and hospital admission, and the facility lacked a photo binder of residents at risk for elopement as required by policy.
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
Plan of Correction
Deficiencies: 9
Date: Aug 12, 2014
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 facility identified multiple deficiencies related to resident care plans, neurological assessments after falls, monitoring of bowel movements and glucose, medication management, food thawing procedures, and infection control practices. Corrective actions and staff training were implemented to address these issues.
Deficiencies (9)
F0000: The plan of correction operates as a credible allegation of compliance with Federal Medicare and Medicaid requirements.
F274-D: Resident #34's MDS was updated to reflect rapid fluctuations in mental health and diabetes-related ADL functioning, with ongoing audits planned.
F279-D: Comprehensive individualized care plans were developed for residents #41 and #35, with audits to ensure updates per physician orders.
F309-D: Neurological assessments are performed after any fall or head injury, with staff trained on related policies and monitoring of compliance.
F329-E: Monitoring of bowel movements, glucose, and behaviors was enhanced for specified residents, with staff training and audits implemented.
F371-F: Food thawing procedures were corrected to ensure safe handling by refrigeration, potable water, or microwave methods, with staff training and audits.
F428-E: Blood sugar parameters and documentation for multiple residents were updated and monitored, with pharmacy consultant audits.
F431-D: Medication and treatment carts and rooms were cleared of expired products, with random checks by DON and pharmacist consultant.
F441-F: An Infection Control Program was established with staff trained on cleaning procedures and monitoring by infection control nurse.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 12, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-07-18.
Findings
All previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 8
Date: Jul 18, 2014
Visit Reason
Health Resurvey and complaint investigations KS00072686 and KS00072684 were conducted to assess compliance with regulatory requirements.
Complaint Details
The inspection was triggered by complaints KS00072686 and KS00072684, focusing on care planning, medication monitoring, infection control, and food safety.
Findings
The facility failed to complete significant change assessments, develop individualized care plans, perform neurological checks after a fall, monitor medication effectiveness and side effects, maintain sanitary food preparation, discard expired medications timely, and maintain an effective infection control program.
Deficiencies (8)
F274: The facility failed to complete a significant change assessment for a resident with moderate cognitive impairment who showed changes in ADLs and continency.
F279: The facility failed to develop individualized comprehensive care plans for residents with mental health, nutritional, and bathing needs.
F309: The facility failed to perform neurological checks for a resident who fell and hit his/her head.
F329: The facility failed to consistently monitor bowel movements, behaviors, side effects, blood sugar levels, and antibiotic effectiveness for residents on psychotropic and other medications.
F371: The facility failed to store, prepare, distribute, and serve food under sanitary conditions, including improper thawing of chicken.
F428: The consultant pharmacist failed to identify and report inconsistent bowel, behavior, and side effect monitoring and lack of blood sugar parameters for residents on psychotropic medications.
F431: The facility failed to ensure medication carts, treatment carts, and medication room were free of expired medications and treatment products.
F441: The facility failed to maintain an infection control program and failed to follow proper infection control procedures for cleaning resident rooms, including inadequate cleaning of call lights and light switches and improper glove use.
Report Facts
Resident census: 48
Deficiency severity SS=D: Deficiencies with severity level D
Deficiency severity SS=E: Deficiencies with severity level E
Deficiency severity SS=F: Deficiencies with severity level F
Expired medication date: 2014
Expired medication open date: 2014
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 18, 2014
Visit Reason
A Health survey was conducted 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, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Deficiencies (1)
The facility had level "F" deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the letter regarding acceptance of plan of correction and enforcement decision. |
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 widespread 'F' level deficiencies 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)
The facility was found to have widespread 'F' level deficiencies in Life Safety Code compliance with no immediate jeopardy but potential for more than minimal harm.
Report Facts
Effective date for denial of payment: Apr 9, 2014
Effective date for termination of provider agreement: 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. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator for Kansas Department for Aging & Disability Services. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| 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 visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.25(h) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.25(h): Previously cited deficiency was corrected by the revisit date of 10/24/2013.
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.
Findings
The plan addresses deficiencies related to resident elopement risk assessment and monitoring. It states that the resident involved is no longer residing in the facility and outlines corrective actions including admission assessments and random audits.
Deficiencies (1)
F323-D: Resident is no longer residing in facility. Residents who are cognitively impaired could be affected by this deficient practice. Residents will be assessed for elopement risk upon admission and monitored by random audits.
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 | |
| MARYJANEKENNEDY | 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 related to allegations of inadequate supervision and safety for a cognitively impaired resident who eloped from the facility.
Complaint Details
The complaint investigation #68491 and #69280 substantiated that the facility failed to provide adequate supervision for resident #1, who eloped from the facility. The resident was cognitively impaired, had a history of suicidal ideations, and was identified as an elopement risk. Staff performed 15-minute checks but lost sight of the resident, who left the facility for over 4 hours.
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 facility knowledge. The resident was identified as an elopement risk but was not adequately monitored despite 15-minute checks.
Deficiencies (1)
483.25(h) The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision to prevent elopement of a cognitively impaired resident. The resident left the facility unsupervised for over 4 hours despite being identified as an elopement risk and under 15-minute checks.
Report Facts
Resident 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 and 15-minute checks for resident #1 | |
| Administrative staff A | Reported door alarm system and resident's DPOA status | |
| Direct care staff Q | Reported performing 15-minute checks and last seeing resident at 11:20 A.M. | |
| Direct care staff P | Reported inability to find resident at 11:30 A.M. | |
| Licensed nursing staff H | Reported last sighting of resident and resident's refusal of assessments | |
| Housekeeping/maintenance staff JJ | Reported door alarm functioning | |
| Activity/social services staff KK | Reported staff search efforts for resident |
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 identified deficiencies from a regulatory inspection.
Findings
The plan addresses multiple deficiencies including environmental cleanliness, individualized care planning, medication management with black box warnings, and proper glucose monitoring procedures. Corrective actions and monitoring plans are outlined for each deficiency.
Deficiencies (4)
F253-E: Flooring and bathrooms require deep cleaning and repairs including carpet replacement and tile fixing. Ongoing cleaning schedules and monitoring will be implemented.
F279-D: Care plans for residents #27 and #23 were revised to reflect individualized care and preferences. Monitoring and audits will ensure care plan individualization.
F329-D: Black box warnings have been added to care plans for resident #30. Psychiatrists will review medications for residents #24 and #1 to ensure proper treatment of chronic mental illness.
F441-E: Charge nurses completed competency checks on accucheck procedures and infection control. Random audits will maintain proper glucose monitoring practices.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 28, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously reported deficiencies identified by regulation numbers 483.15(h)(2), 483.20(d), 483.20(k)(1), 483.25(l), and 483.65 were corrected by the revisit date of 06/28/2013.
Inspection Report
Re-Inspection
Census: 46
Deficiencies: 4
Date: Jun 11, 2013
Visit Reason
The visit was a non-compliance revisit to verify correction of previously cited deficiencies related to housekeeping, care planning, drug regimen, 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)
483.15(h)(2) Housekeeping and maintenance services were inadequate, with stained carpets, chipped tiles, rust, and unclean bathroom fixtures observed on multiple days.
483.20(d), 483.20(k)(1) The facility failed to develop comprehensive and individualized care plans for residents, including hospice services and personal care preferences such as shaving frequency.
483.25(l) The facility failed to identify appropriate black box warnings for medications and did not adequately monitor medication effectiveness for residents receiving psychotropic drugs.
483.65 Infection control was deficient as staff failed to disinfect shared blood glucose monitors per manufacturer instructions, did not perform hand hygiene, and did not maintain a clean field during accu-check procedures.
Report Facts
Resident census: 46
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse H | Named in infection control and medication administration findings | |
| Licensed nurse I | Named in medication monitoring and infection control findings | |
| Administrative nursing staff D | Named in care planning and medication monitoring findings | |
| Housekeeping staff X | Named in housekeeping deficiency | |
| Maintenance staff Y | Named in housekeeping deficiency | |
| Direct care staff O | Named in care planning deficiency related to shaving | |
| Licensed nursing staff H | Named in care planning and medication monitoring | |
| Licensed nursing staff I | Named in care planning and medication monitoring |
Inspection Report
Follow-Up
Deficiencies: 10
Date: Jun 11, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies were reviewed and marked as corrected on the revisit date of 2013-06-11. The report confirms completion of corrective actions for multiple regulatory citations.
Deficiencies (10)
Regulation 483.13(c): Previously cited deficiency corrected as of 06/11/2013.
Regulation 483.20(b)(1): Previously cited deficiency corrected as of 06/11/2013.
Regulation 483.20(g)-(j): Previously cited deficiency corrected as of 06/11/2013.
Regulations 483.20(d)(3) and 483.10(k)(2): Previously cited deficiencies corrected as of 06/11/2013.
Regulation 483.20(d): Previously cited deficiency corrected as of 06/11/2013.
Regulation 483.25(h): Previously cited deficiency corrected as of 06/11/2013.
Regulation 483.60(c): Previously cited deficiency corrected as of 06/11/2013.
Regulation 483.75(e)(8): Previously cited deficiency corrected as of 06/11/2013.
Regulation 483.75(l)(1): Previously cited deficiency corrected as of 06/11/2013.
Regulation 483.75(m)(2): Previously cited deficiency corrected as of 06/11/2013.
Inspection Report
Re-Inspection
Census: 49
Deficiencies: 14
Date: Apr 12, 2013
Visit Reason
Health Resurvey and Extended Health Resurvey to evaluate compliance with federal regulations.
Findings
The facility had multiple deficiencies including failure to complete pre-employment background checks, maintain a clean environment, conduct comprehensive assessments, develop individualized care plans, maintain accurate and accessible clinical records, monitor medication effectiveness, maintain safe water temperatures, and provide required staff training.
Deficiencies (14)
F 226: The facility failed to provide evidence of reference verification prior to hire for 5 of 5 new employees reviewed.
F 253: The facility failed to maintain a clean and comfortable environment; issues included unlabeled towel bars, urine odors, unlabeled care equipment, missing drawer handles, wall scrape marks, and stained carpets.
F 272: The facility failed to comprehensively assess the use of psychotropic drugs for 2 residents; Care Area Assessments lacked documentation of causal factors for psychotropic medication use.
F 278: The facility failed to provide an accurate Minimum Data Set (MDS) assessment for one resident; the MDS did not reflect antidepressant medication use.
F 279: The facility failed to develop individualized comprehensive care plans for 5 residents, including plans for shaving, hospice care, activities, and prevention of constipation.
F 280: The facility failed to revise/update the care plan for one resident after a fall, omitting recommendations for safety and education on equipment use.
F 286: The facility failed to maintain Minimum Data Set assessments for the previous 15 months readily accessible to all professional staff for 2 residents.
F 323: The facility failed to monitor and maintain water temperatures below 120 degrees Fahrenheit, placing residents at immediate jeopardy for burns; abatement actions were taken.
F 329: The facility failed to provide blood pressure monitoring parameters and failed to monitor blood pressure and behavioral medication effectiveness for multiple residents.
F 428: The facility's pharmacy consultant failed to identify and report lack of blood pressure monitoring parameters and lack of monitoring for effectiveness of behavioral medications for residents.
F 441: The facility failed to sanitize a community counter after a resident performed a blood sugar test and failed to properly store nebulizer masks for 2 residents, risking infection transmission.
F 497: The facility failed to provide 12 hours of annual inservice training for nurse aides; only 10 hours were documented in the past year.
F 514: The facility failed to maintain complete, accurate, and accessible clinical records for 5 residents; medication administration records and other key documents were missing or not filed timely.
F 518: The facility failed to train 3 employees on emergency procedures when hired.
Report Facts
Resident census: 49
New employees without reference checks: 5
Inservice training hours: 10
Water temperature: 159
Missing MDS assessments: 2
Residents with deficient care plans: 5
Residents with incomplete clinical records: 5
Residents monitored for BP less than ordered: 1
Residents monitored for behavioral meds less than ordered: 2
Nurse aides lacking emergency training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse J | Licensed Nurse | Lacked evidence of emergency procedure training at hire |
| Direct care staff O | Direct Care Staff | Lacked evidence of emergency procedure training at hire |
| Direct care staff P | Direct Care Staff | Lacked evidence of emergency procedure training at hire |
| Administrative staff A | Administrator | Reported responsibility for care plan development and record filing issues |
| Administrative nursing staff D | Administrative Nursing Staff | Reported issues with record filing, care plan development, and water temperature monitoring |
| Administrative nursing staff E | Administrative Nursing Staff | Reported care plan development and monitoring expectations |
| Licensed nursing staff L | Licensed Nurse | Reported blood pressure monitoring practices |
| Pharmacy consultant II | Pharmacy Consultant | Failed to identify lack of monitoring parameters and medication effectiveness monitoring |
Inspection Report
Plan of Correction
Deficiencies: 15
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 state and federal 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 plans are described for each deficiency.
Deficiencies (15)
F000: The plan of correction operates as a written credible allegation of compliance with federal Medicare and Medicaid requirements.
F226: Employee references have been verified and documented; human resource personnel were in-serviced on proper reference check procedures.
F253: Towel bars labeled, bathrooms with urine odors deep cleaned, care equipment labeled, and maintenance issues addressed with ongoing monitoring.
F272: Care Area Assessments for residents #24 and #46 revised to identify causal factors for psychotropic medication use.
F278: MDS for resident #10 revised to reflect days receiving antidepressant medication.
F279: Care plans for residents #1, #32, #23, #27, and #20 revised to individualize needs and preferences.
F280: Care plan for resident #24 updated for fall on 4-6-13 with monitoring of interventions.
F286: MDS organized and stored for accessibility to nurses and doctors after hours with monitoring.
F323: Water temperatures checked and excessive temperatures isolated to 4 rooms; hot water shut off and monitored with a preventative maintenance plan.
F329: Physician-signed blood pressure parameters obtained for resident #24; behavior monitoring forms updated for residents #46 and #20.
F428: Pharmacy consultant to monitor medication administration records and behavior forms for compliance.
F441: Nebulizers stored in plastic bags for residents #35 and #24; staff in-serviced on proper storage and procedures.
F497: In-Service Training Calendar posted for 2013; administrator to monitor in-service documentation.
F514: Clinical records for residents #1, #23, #46, #24, and #10 completed, organized, and accessible with monitoring.
F518: Two employees attended in-service on disaster preparedness; new hires to be trained and monitored on emergency procedures.
Report Facts
Affected resident rooms: 4
Date: Apr 26, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SACARABROOKS | Administrator | Named as submitter of the Plan of Correction and responsible for oversight of corrective actions |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jun 22, 2012
Visit Reason
This document is a Plan of Correction prepared in response to a complaint investigation at Brighton Place West.
Complaint Details
This Plan of Correction is related to Complaint 061412 at Brighton Place West.
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.
Deficiencies (3)
F203-D: Resident no longer resides in the facility. Residents with legal representation could be affected by deficient discharge notification practices.
F205-D: Resident legal representation has been provided a bed hold notice. Deficient procedures affect residents with planned or unplanned leave of absence.
F425-D: Resident no longer resides in facility. Deficient practice in obtaining orders for disposition of medications upon discharge.
Report Facts
Deficiencies cited: 3
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 of the revisit date.
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 June 22, 2012.
Deficiencies (3)
Regulation 483.12(a)(4)-(6): Previously cited deficiency corrected as of 06/22/2012.
Regulation 483.12(b)(1)&(2): Previously cited deficiency corrected as of 06/22/2012.
Regulation 483.60(a),(b): Previously cited deficiency corrected as of 06/22/2012.
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 concerning the facility's compliance with transfer/discharge notice requirements, bed-hold policy notifications, and pharmaceutical service procedures.
Complaint Details
The deficiencies resulted from investigations of complaints #57320, #57600, and #56875. The complaint investigation found failures in notification of discharge to legal representatives, bed-hold policy notices, and pharmaceutical service procedures.
Findings
The facility failed to notify a legal representative prior to discharge for one resident, failed to provide timely bed-hold notices to residents' legal representatives for two residents, and failed to obtain physician's orders regarding disposition of medications for one resident. Documentation and communication deficiencies were noted regarding discharge notices and medication handling.
Deficiencies (3)
F203: The facility failed to notify a legal representative of a resident's discharge prior to the discharge, violating transfer/discharge notice requirements.
F205: The facility failed to provide written notice of the bed-hold policy duration within 24 hours of transfer to hospital for two residents, violating bed-hold notification requirements.
F425: The facility failed to obtain a physician's order regarding disposition of medications for a resident discharged involuntarily and failed to document medication dosages delivered to a behavioral unit.
Report Facts
Resident census: 48
Sample size: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089012 POC S0YJ11
Visit Reason
This document is a Plan of Correction related to a prior inspection or deficiency report for the facility identified by State ID N089012 and Event ID S0YJ11.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089012 POC
Visit Reason
This document is a Plan of Correction related to a facility identified by State ID N089012 and ASPEN Event ID 2567.
Findings
No deficiency records or findings are included in this Plan of Correction document.
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