Bonner Springs Nursing & Rehab Center

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide a clean, home-like environment for the residents who resided in the facility.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to complete the Care Area Assessment (CAA) analysis of findings, related to a Comprehensive Minimum Data Set (MDS), for Residents (R) 1, in order to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to develop a person-centered baseline care plan for Resident (R) 1, which included pain management.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to develop a person-centered comprehensive care plan for Resident (R) 1, which included pain management.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to ensure staff provided effective pain management as ordered for Resident (R) 1, who received a as needed opioid (a class of medication used to treat pain).

Inspectors wroteBased on interviews, observation, and record review, the facility failed to ensure the accurate reconciliation of controlled drugs administered to the controlled drug receipt/record/disposition form for Resident (R) 1, who received a as needed opioid (a class of medication used to treat pain).

Inspectors wroteThe facility had a census of 34 residents. The sample included 12 residents, with three reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to act upon an identified risk for pressure ulcers and implement preventative interventions for Resident (R) 33, who had edema (swelling resulting from an excessive accumulation of fluid in the body tissues) in her leg and required staff assistance with activities of daily living (ADL). Subsequently, R33 developed a Stage 3 (full-thickness tissue loss) pressure ulcer on her right heel. [...]

Inspectors wroteThe facility had a census of 34 residents. The sample included 12 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through Payroll-Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for inadequate nurse staff.

Inspectors wroteThe facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to maintain a Quality Assessment and Assurance Committee (QA&A) that met quarterly and had the required membership in attendance. The facility failed to maintain a QA&A Committee that met quarterly and had the required membership in attendance.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program, including antibiotic stewardship for the residents of the facility.

Inspectors wrote- R36's Electronic Medical Record (EMR) documented diagnoses of type 2 diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and neoplasm (tumor) of the lung. R36's admission Minimum Data Set (MDS) dated 12/17/24 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R36 needed set-up to partial assistance from staff for his functional abilities. R36 used a walker to assist with ambulation. R36's overall goal was to discharge to the community within three months or less. [...]

Inspectors wroteThe facility had a census of 34 residents. The sample included 12 residents with five reviewed for hospitalizations. Based on observation, record review, and interview, the facility failed to provide four residents, Resident (R) 2, R6, R21, and R36 with written information regarding the facility bed hold policy when they were transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility.

Inspectors wroteThe facility had a census of 24 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan with resident-centered interventions to prevent pressure ulcers for one resident, Resident (R) 33. This placed the resident at risk for unmet care needs and skin breakdown.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that the physician responded to the recommendations made by the Consultant Pharmacist (CP) to ensure that Resident (R) 23's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication Seroquel had an appropriate Centers for Medicare and Medicaid Services (CMS) indication for use. These deficient practices placed R23 at risk of unnecessary medication administration and related complications.

Inspectors wroteThe facility had a census of 34 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold blood pressure medications per the physician-ordered parameters for two residents, Resident (R) 8 and R21. This placed the resident at risk for physical decline and other related complications.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure an appropriate diagnosis or a physician's statement of the risk versus benefit for the continued use of Seroquel (antipsychotic medication-a class of medications used to treat major mental conditions that cause a break from reality). These deficient practices placed R23 at risk of unnecessary medication administration and related complications.

Inspectors wroteThe facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility to prevent medication administration errors for Resident (R) 8 whose heart rate was out of physician-ordered parameters and he received four blood pressure medications. This placed the resident at risk for physical decline and other related complications.

Inspectors wroteThe facility had a census of 34 residents. The sample included two residents, with two reviewed for Hospice (specialized care that mainly aims to provide comfort and dignity to the patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a communication process between the hospice provider and the facility for Resident (R)26 and R16, which included a plan of care and a description of the services provided which included visit frequency, medications, and medical equipment. This placed the residents at risk of not receiving needed care.

Inspectors wroteThe facility identified a census of 29 residents. The sample included three residents reviewed for abuse. The facility failed to provide adequate supervision to ensure residents remained free from resident-to-resident abuse when Resident (R)1 threw a ceramic mug at R2 during an unsupervised altercation in the dining room. This resulted in a broken nose for R2 and placed the resident at risk for pain, impaired psychosocial well-being, and ongoing abuse.

Inspectors wroteThe facility identified a census of 31 residents. The facility had one main kitchen. Based on observation, record review and interview, the facility failed to ensure there was a director of food and nutrition services employed at the facility with the required qualifications. This placed residents at risk for unmet dietary and nutritional needs.

Inspectors wroteThe facility identified a census of 31 residents. The facility had one main kitchen. Based on observation, record review, and interview, the facility failed to ensure the facility had sufficient staff with the appropriate skill sets to carry out the functions of food and nutritional services. This deficient practice placed the resident at risk for impaired nutrition and decreased quality of life.

Inspectors wroteThe facility identified a census of 35 residents. The sample included three residents reviewed for elopement (when a cognitively impaired residents exits the facility without staff knowledge and supervision). Based on observation, record review, and interview, the facility failed to identify likely avenues of exit, including windows, and failed to ensure the windows were secured to prevent cognitively impaired Resident (R) 1, who was at high risk for elopement, from exiting the facility through the window. On 12/28/23 at 01:45 PM Certified Nurse Aid (CNA) M observed R1 pacing in his room. At 02:13 PM Dietary Staff BB returned to the facility after lunch and observed R1 walking down the street approximately 150 feet from the facility. The temperature outside was approximately 40 degrees Fahrenheit (F) at that time. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included four residents reviewed for abuse. Based on record review and interviews, the facility failed to prevent physical abuse when Certified Nurse Aide (CNA) M hit cognitively impaired Resident (R) 1, who had history of traumatic head injury, in the face on 09/08/23. This deficient practice resulted in impaired psychosocial well-being and placed R1 at risk for continued abuse.

Inspectors wroteThe facility identified a census of 35 residents. The sample include 14 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representative to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial wellbeing. Finding Included: -On 07/31/23 at 07:05AM an inspection of the facility revealed no designated grievance box or forms available in the areas accessible to the 35 residents of the facility or their representatives. On 08/01/23 at 10:50AM, the Resident Council members reported they were not aware if the facility provided a way to complete an anonymous grievance. The council reported they were unaware if the facility had an official grievance process. The council reported Social Services X was responsible for complaints. [...]

Inspectors wroteThe facility had a census of 35 residents. The sample included 14 residents with seven residents reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to secure hazardous materials in a safe, locked area, and out of reach of the seven cognitively impaired, independently mobile residents. The facility additionally failed to safely transfer Resident (R)7 utilizing the appropriate mechanical lift and staff. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 08/01/23 at 07:09AM an inspection of the facility's west hallway revealed an unsecured emergency treatment cart. The cart contained a full sealed bottle of Tylenol 325 milligram (mg) tablets (medication used for pain relief) and Geri-Dryl 25mg tablets (geriatric brand Benadryl- allergy medication) in the top drawer. [...]

Inspectors wroteThe facility identified a census of 35 residents. Based on record review, observation, and interview, the facility failed to ensure narcotic reconciliation which included regular narcotic counts of all narcotics, including the narcotics scheduled for destruction or a system which required two qualified staff for access to a fixed and locked medication bin. This deficient practice placed the residents at risk for misappropriation and drug diversion.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 14 residents with three residents identified by the facility on enhanced barrier precautions. Based on record review, observations, and interviews, the facility failed to maintain sanitary infection control practices related to laundry delivery and trash removal. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 07/31/23 at 07:04AM a walkthrough of the facility revealed three small-sized trash bags on the floor of the east hallway and two small trash bags sat on the west hallway floor filled with trash with no bin or protective barrier. On 07/31/23 at 02:12PM Housekeeping Staff V pushed a laundry cart filled with multiple resident's personal clean clothing down the west hall with no cover. [...]

Inspectors wroteThe facility identified a census of 35 residents. The sample included 14 residents with three residents reviewed for beneficiary notices review. Based on record review and interviews, the facility failed to provide Resident (R)23 and R27 with completed Advanced Beneficiary Notice of Non-coverage (ABN Form CMS-10055). This deficient practice placed the residents at risk for impaired decisions and treatment options due to lack of information. Findings Included: - A review of R23's Beneficiary Protection Notification Review completed on 08/01/23 indicated she started Medicare Part A skilled services on 05/06/23. The form designated her last covered day (LCD) was 05/30/23. The form indicated the facility initiated her discharge from skilled with benefit days remaining. The form indicated she remained in the facility and received an ABN form. [...]

Inspectors wroteThe facility identified a census of 35 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to ensure staff kept Resident (R) 36, a cognitively impaired resident, free from resident to resident abuse. This deficient practice placed R36 at risk of possible harm or injury and impaired quality of life.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 14 residents with four residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer for Resident (R) 32. This deficient practice placed the resident at risk of delayed care or uncommunicated care needs.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to ensure a care plan was revised to address Resident (R) 14's skin care needs. This deficient practice placed R14 at risk for skin breakdown and possible skin infections.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 14 residents with one resident reviewed for discharge. Based on observation, record review, and interviews, the facility failed to document a discharge summary and recapitulation of the facility stay upon discharge from the facility for Resident (R) 40, which placed R40 at risk for an interruption in the continuity of care.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 14 residents with four resident reviewed activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to ensure a shower/bath was provided for Resident (R) 24, R16, and R11 who required extensive assistance with ADLs. This deficient practice placed these residents at risk for the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial wellbeing.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to follow a physician order for daily weights to monitor for fluid overload for Resident (R) 33. The facility also failed to ensure weekly nurse skin assessments were completed for R14, who developed moisture associated skin damage (MASD). These deficient practices placed these residents at risk for delay in treatment related to fluid overload, skin related complications and untreated illness.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 14 residents with two residents reviewed for bowel and bladder incontinence. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 32 received treatment and services to maintain or improve his urinary continence to the highest extent possible. This deficient practice placed R32 at risk of urinary related complications, for the potential skin breakdown and/or skin complications due to poor personal hygiene, and impaired psychosocial wellbeing.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 14 residents with one resident, Resident (R) 10, sampled for dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to). Based on observation, record review and interview, the facility failed to ensure dialysis communication with the dialysis center regarding R10's health status with each procedure. This deficient practice placed R10 at risk for complications related to dialysis.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 14 residents with one reviewed for trauma informed care. Based on observation, record review, and interviews, the facility failed to complete screening on Resident (R)25 to provide trauma informed care. This deficient practice placed R25 at risk for decreased psycho-social wellbeing and increased behaviors. Findings Included: - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of vascular dementia (progressive mental disorder characterized by failing memory, confusion), adjustment disorder (difficulty in managing the stressful life changes), major depressive disorder (major mood disorder), and psychosis (any major mental disorder characterized by a gross impairment in reality). [...]

Inspectors wroteThe facility identified a census of 35 residents. The sample included 14 residents with one reviewed for behavior management. Based on observation, record review, and interviews, the facility failed to implement behavioral care interventions to prevent identified triggers for Resident (R)25. This deficient practice placed R25 at risk for behavioral outburst and injuries. Findings Included: - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of vascular dementia (progressive mental disorder characterized by failing memory, confusion), adjustment disorder (difficulty in managing the stressful life changes), major depressive disorder (major mood disorder), and psychosis (any major mental disorder characterized by a gross impairment in reality). [...]

Inspectors wroteThe facility identified a census of 35 residents. The sample included 14 residents with five residents sampled for medication review. Based on observation, record review and interview, the facility failed to ensure the physician responded to the Consultant Pharmacist (CP) recommendation that Resident (R)10 required an appropriate indication for use, or the required physician documentation, for the antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) medication Seroquel (quetiapine). This deficient practice placed this resident at risk of unnecessary medication administration and possible adverse side effects.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to identify and notify physician of antihypertensive (treat high blood pressure) medication not administered as ordered and given for inappropriate indication for Resident (R) 32. This deficient practice placed R32 at risk for unnecessary medication administration thus leading to possible harmful side effects.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 14 residents with five residents sampled for medication review. Based on observation, record review and interview, the facility failed to ensure Resident (R)10 and R32 had an appropriate indication for use, or the required physician documentation, for the antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) medication Seroquel (quetiapine). This deficient practice placed this resident at risk of unnecessary medication administration and possible adverse side effects.

Inspectors wroteThe facility had a census of 35 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to discard expired insulin (hormone which regulates blood sugar) vial for Resident (R)13, albuterol sulfate (used to prevent and treat breathing difficulties) for R23, tuberculin vial (injection used in testing for tuberculosis - an illness that mainly affects the lungs) and failed to secure medications on a treatment cart. This placed the affected residents at risk for injury and ineffective medications.

Inspectors wroteThe facility identified a census of 35 residents. Based on interview, and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ), when the facility failed to submit staffing hour data for all nursing personnel by the required deadline.

Inspectors wroteThe facility reported a census of 30 residents. Based on interview and record review, the facility failed to provide sufficient nursing staff to ensure nursing and related services to attain or maintain the highest physical, mental, and psychosocial well-being of the residents residing in the facility.

Inspectors wroteThe facility reported a census of 30 residents. Based on observation, interview and record review, the facility failed to provide annual evaluations to nursing staff of the facility to assess strengths and weakness for providing resident care as required.

Inspectors wroteThe facility reported a census of 30 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the spread of food borne illnesses to the residents of the facility.

Inspectors wroteThe facility reported a census of 30 residents. Based on observation, interview, and record review, the facility failed to maintain a quality assurance committee that developed and implemented appropriate plans of action to correct identified infractions of resident rights, quality of care, and quality of life concerns for all residents of the facility.

Inspectors wroteThe facility reported a census of 30 residents. Based on interview and record review, the facility failed to ensure nursing staff followed the principles of antibiotic stewardship by nursing staff to ensure antibiotics used in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance in an ongoing, proactive manner.

Inspectors wroteThe facility reported a census of 30 residents with 14 residents sampled, of whom three were reviewed for Medicare Services. Based on interview and record review, the facility failed to provide appropriate Beneficiary Protection Notification CMS (Center for Medicare/Medicaid Services) to ensure the residents' right to appeal Medicare part A services upon discontinuation for two of the three Residents (R)10 and R 11, reviewed.

Inspectors wroteThe facility reported a census of 30 residents. Based on observation, record review and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for residents in the facility for 10 of the 20 resident rooms and one of the two shower rooms, six resident wheelchairs, and several areas in the therapy room.

Inspectors wroteThe facility reported a census of 30 residents with 14 residents included in the sample. Based on observation, record review and interview, the facility failed to review and revise the care plans for seven of the 14 residents sampled; including two Residents (R) 8 and R17, regarding falls; three residents R 10, R 19 and R 3, regarding lack of wheelchair foot pedals; one resident R 7, regarding communication with dialysis and the lack of hypertensive (HTN) medications; one resident R 28, regarding interventions to keep his groin wounds dry, and one resident R17 for safety with transfers.

Inspectors wroteThe facility reported a census of 30 residents with 14 selected for review which included five residents reviewed for activities of daily living. Based on observation, interview and record review, the facility failed to ensure adequate personal grooming opportunities for four of the five residents including, (R)8, R25, R28, and R10.

Inspectors wroteThe facility reported a census of 30 residents with 14 residents sampled, including five residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide safety for the five sampled residents including; failure to provide safe transfers for two Resident R10 and R17; failed to provide safe wheelchair transports for three residents R10, R19, and R3; and failed to initiate appropriate interventions following falls for two residents R8 and R17.

Inspectors wroteThe facility reported a census of 30 residents. Based on observation, interview, and record review, the facility lacked a system to minimize potential loss or diversion of the resident's discontinued medications.

Inspectors wroteThe facility reported a census of 30 residents. Based on observation, interview, and record review, the facility failed to provide adequate housekeeping services to maintain a sanitary clean floor in the facility kitchen.

Inspectors wroteThe facility reported a census of 30 residents with 14 selected for review, which included one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to ensure one resident (R)17 was dressed in a dignified manner on two occasions.

Inspectors wroteThe facility reported a census of 30 residents with 14 residents sampled, including one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide the one Resident (R)10 and/or their representative, with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's transfer to the hospital.

Inspectors wroteThe facility reported a census of 30 residents with 14 selected for review. Based on observation, interview and record review, the facility failed to complete a baseline care plan for one resident (R)17 as required.

Inspectors wroteThe facility reported a census of 30 residents with 14 selected for review which included 1 resident reviewed for discharge. Based on interview and record review, the facility failed to complete a discharge summary for one resident (R)34, who discharged to home.

Inspectors wroteThe facility reported a census of 40 residents with 14 selected for review, which included one resident reviewed for activities. Based on observation, interview and record review, the facility failed to provide person centered activities for one resident (R)17.

Inspectors wroteThe facility reported a census of 30 residents with 14 selected for review, which included four residents reviewed for skin issues. Based on observation, interview and record review, the facility failed to provide wound care in a sanitary manner for two residents (R)4 and R28 to promote healing and failed to monitor and treat multiple abrasions on R10's lower extremities to promote healing.

Inspectors wroteThe facility reported a census of 30 residents with 14 residents sampled, including one resident reviewed for dialysis. Based on observation, interview, and record review, the facility failed to ensure appropriate adequate communication between the dialysis center and the facility, for the one Resident (R)7, regarding a lack of regular dialysis communication sheets, with the facility.

Inspectors wroteThe facility reported a census of 30 residents with 14 selected for review which included five residents selected for review for unnecessary medications . Based on observation, interview and record review, the facility failed to act upon the pharmacist recommendations for two of the five residents reviewed, including Resident (R)4 for topical Diclofenac (an anti-inflammatory medication) gel dose and R7 for as needed Clonidine (an antihypertensive) administration.

Inspectors wrote- The Physician Order Sheet (POS), dated 10/04/21, for Resident (R)7, documented a diagnosis of hypertension (HTN-elevated blood pressure). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The care plan for HTN, dated 08/28/21, instructed staff to give the resident his medications, as ordered and to monitor for side effects of the medication. Review of the resident's electronic medical record (EMR), under the Orders tab, revealed a physician order for Clonidine (a hypertensive medication) 0.1 milligrams (mg), by mouth (po), every 4 hours, as needed (PRN) for systolic blood pressure (SBP-top number) greater than 180 or diastolic blood pressure (DBP-bottom number) greater than 100, ordered 04/02/21. [...]

Inspectors wroteThe facility reported a census of 30 residents. Based on record review and interview, the facility failed to ensure the Daily Staff Postings included the number of actual hours worked by nursing staff for each of the three shifts as required.