Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BRIGHTON PLACE WEST
TOPEKA, KS · 50 certified beds · Last Life Safety survey October 17, 2024
CMS Certification Number 175547 · first certified October 2014
Ownership
Operated by RECOVER-CARE HEALTHCARE · For profit - Corporation
- Ownership changed August 15, 2022 (change of ownership)to BRIGHTON PLACE WEST HEALTH CENTER from BRIGHTON PLACE WEST OPERATING COMPANY LLC
Position within KS
56 citations — more than 99% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 14 citations; the earlier surveys in the window averaged 21. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (June 2026 to August 2026), and past the point by which nine in ten KS facilities have been surveyed. This facility’s last Life Safety survey was October 2024. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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8 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
16 of the 56 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 56 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 56 |
| Median facility in KS | 27 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 1, 2021 | 17 |
| May 15, 2023 | 25 |
| October 17, 2024 | 14 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 3 | 2024-10-17 |
| E-0009 | Include a process for Emergency Preparedness collaboration. | 3 | 2024-10-17 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2024-10-17 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-10-17 |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | 3 | 2024-10-17 |
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2024-10-17 |
| K-0923 | Have proper medical gas storage and administration areas. | 2 | 2023-05-15 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2024-10-17 |
What the citations cover
- Smoke Deficiencies 18
- Emergency Preparedness Deficiencies 16
- Gas, Vacuum, and Electrical Systems Deficiencies 8
- Egress Deficiencies 5
- Other 9
| Category | Citations |
|---|---|
| Smoke Deficiencies | 18 |
| Emergency Preparedness Deficiencies | 16 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 8 |
| Egress Deficiencies | 5 |
| Miscellaneous Deficiencies | 5 |
| Services Deficiencies | 3 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 17, 2024 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (December 10, 2024) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (December 10, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (December 10, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 20, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 20, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (November 7, 2024) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 20, 2024) |
May 15, 2023 — 25 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (June 12, 2023) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (June 12, 2023) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (June 12, 2023) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (June 12, 2023) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (June 12, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (June 12, 2023) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 24, 2023) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (May 24, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0500 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (June 12, 2023) |
December 1, 2021 — 17 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (January 21, 2022) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (January 10, 2022) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (December 21, 2021) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (December 21, 2021) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (December 21, 2021) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (December 21, 2021) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (January 28, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (January 28, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 21, 2022) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (January 20, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 28, 2022) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (December 20, 2021) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 21, 2021) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (December 20, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 20, 2021) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 21, 2021) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (January 21, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.