KANSAS CITY, Mo. — Federal and state health investigators cited Brighton Gardens of Prairie Village for a range of “deficiencies” in its response and responsibilities related to a COVID-19 cluster at the long-term care facility.
The Kansas Department on Aging and Disability Services performed a Complaint and Targeted Infection Control/COVID-19 Survey on May 11 at Brighton Gardens to determine whether the facility was in compliance with federal Medicare and Medicaid nursing home programs requirements.
After it was determined the “facility was not in substantial compliance with the participation requirements,” the U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services also conducted an investigation of the Johnson County facility.
It was the Department on Aging’s opinion that “the conditions in your facility constituted Immediate Jeopardy to resident health or safety,” according to a letter sent May 18 to Brighton Gardens Administrator Lisa Barnes.
Johnson County health authorities also intervened at Brighton Gardens, which sent an email to the family of residents May 14 — within days of the Immediate Jeopardy designation — that said Barnes would “transition from” her role as director by the end of May.
The Department on Aging investigation determined that Brighton Gardens, which is owned and operated by Virginia-based Sunrise Senior Living, failed in its duties related to infection control and to monitoring staff for COVID-19 symptoms, according to a Statement of Deficiencies and Plan of Correction report issued May 13 by the department.
“Based on observation, interview and record review, the administrator failed to ensure the provision of a safe, sanitary environment for residents by the failure to properly implement procedures to control the spread of COVID-19 based on staff screening processes,” the report read.
There have been 83 confirmed COVID-19 cases, with the most recent diagnosed May 21, and 17 deaths at Brighton Gardens — far and away the most for any long-term care facility in Johnson County, according to the Department of Health and Environment.
The Department on Aging report goes on to note oversights and other problems with staff screening forms, including missing dates for screening forms and the failure to take or properly record temperature-taking information.
According to the report, Brighton Gardens “failed to identify and take appropriate actions of sending staff home” when they showed signs of COVID-19 and also didn’t prevent staff who admitted to flouting “infection control measures outside of work,” including social-distancing and mask-wearing recommendations, from working in direct contact with residents.
“For all residents in the assisted living/memory care areas of the facility, the administrator failed to ensure the facility followed their COVID-19 Mitigation and Response plan related to team member screening,” the Department on Aging report read.
A review of staff screening reports cross-referenced with employee time-punch records showed six instances in which housekeeping or direct-care staff worked full shifts despite acknowledging COVID-19 symptoms between April 16 and May 5.
That includes allowing a Certified Nurses Aid to work directly with patients April 16 and 17 in Brighton Gardens’ “Blueberry Unit” despite self-reporting COVID-19 symptoms. That employee tested positive April 19 for the virus, according to a report from the Centers for Medicare and Medicaid Services dated May 11.
“The facility failed to ensure staff presenting with signs and symptoms of COVID-19 did not work in the facility,” the report said. “This deficient practice increased the risk for transmission and /or development of COVID-19 which placed all the residents on the ‘Blueberry’ unit in Immediate Jeopardy.”
Three residents the CNA came into contact with subsequently tested positive for COVID-19.
An employee identified as “Administrative Staff A” at Brighton Gardens in the report told Health and Human Services investigations that “she expected the Director of Nursing to review all the screening sheets.”
However, “Administrative Nurse D” told investigators “she did not know if anyone looked at the employee screening sheets.” Staff filled out the form and “assessed their own temperatures” — a violation of Brighton Gardens’ mitigation strategy — then went to work “if the concierge or nurse was not there.”
Nursing Director Brooke Nickles will serve as interim director at Brighton Gardens after Barnes' "transition" from the director's position, according to email from Sunrise Senior Living,
“The facility's failure to take appropriate action and send employees home based on the staff screening form, placed all residents who lived in the assisted living and memory care area in Immediate Jeopardy related to the spread of COVID-19, a potentially fatal respiratory illness,” the Department on Aging report said.
Brighton Gardens’ “administrator” also failed to follow and enforce procedures for proper use and reuse of personal protective equipment, or PPE, inside the facility, including the absence of sanitizing spray for medical gowns and improper disposal of potentially infected PPE, according to the Department on Aging.
The Centers for Medicare and Medicaid Services report cited Bright Gardens for failing “to adequately clean and disinfect common areas to reduce the transmission of infection.”
Housekeeping staff were observed frequently failing to leave Virex disinfectant spray on surfaces the recommended 10-minute “wet” time before wiping it back off on doors and handrails, but Brighton Gardens had no policy related to the spray’s use.
The immediate jeopardy designation was removed May 12 shortly after Brighton Gardens received and “provided a plan to ensure the staff screening forms were filled out completely and correctly with appropriate actions taken if needed to ensure the minimization of the spread of COVID-19 illness.”
Sunrise Regional Vice President of Operations Denise Falco provided a statement Wednesday to 41 Action News:
Brighton Gardens of Prairie Village immediately corrected the May 11 IJ deficiency, which was cleared by the surveyor the same day. We swiftly executed on the necessary corrective actions including retraining all team members on screening protocols, repeating screenings on each shift and fortifying plans to assess and cohort residents in our skilled neighborhood to prevent the spread of COVID-19.
Johnson County Department of Health and Environment was aware of all of our actions and did not make any new recommendations relative to team member screening. We continue to work with them closely to support our cherished residents.
Among the changes Brighton Gardens made at that time was the addition of a “designated screener” for each shift, limiting entry and exit access for skilled nursing staff.
The family of a former Brighton Gardens resident who died May 1 from COVID-19 complications has sued the facility.
