Bonnie Brae Skilled Nursing

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a diagnosis of schizoaffective disorder (mental disorder) bipolar type (a mental health condition characterized by significant mood swings), received the necessary behavioral health care by failing to ensure to: -Address Resident 1's episodes of aggressive behaviors. - Create individualized interventions for Resident 1's refusals of care. As a result, on 4/4/2026 at 4:57 PM, Resident 1 was involved in a verbal and physical altercation with Resident 2 and placed other residents (in general) and staff (in general) at risk for injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and per physician's orders for two out of five sampled residents (Resident 8 and Resident 12) on Low Air Loss Mattresses (LAL M- a pressure-relieving mattress used to prevent and treat pressure injuries). By failing to:Ensure Resident 8's physician's order for LALM dated 12/19/2025 indicated a specific setting for the LALM.Ensure Resident 8's physician's order for LALM dated 1/1/2026 indicated a specific setting for the LALM.This deficient practice placed Resident 8 and Resident 12 at risk for developing pressure injuries and complications from pressure injuries which could result in systemic infections that could lead to death.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to honor a resident's right to dignity (a person's worth as a human being, deserving of respect, honor, and fair treatment, regardless of their situation, status, or abilities) for one out of one sampled residents (Resident 17) when Certified Nursing Assistant 1 (CNA 1) stood over Resident 17 while assisting Resident 17 with his lunch on 1/5/2025. This failure had the potential to cause emotional distress, affect Resident 17's self-esteem (your overall opinion of yourself-how much you like, value, and respect yourself as a person), cause loss of dignity, and a decline in psychosocial wellbeing (feeling good and functioning well in your life, covering your mental, emotional, and social health).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of five sampled residents (Resident 5) was free from chemical restraints (a form of medical restraint in which a drug is used to restrict the freedom of movement of a patient or in some cases to sedate the patient) by failing to: -Ensure Resident 5's Medical Doctor obtained an informed consent (a process where someone voluntarily agrees after fully understanding the details, including its benefits, risks, and alternatives, ensuring they can make a free and educated decision) and to include the indication of the use of Seroquel (an antipsychotic [medications work by altering brain chemistry] used to treat mental health conditions) to Resident 5 or Resident 5's responsible party. This failure had the potential to restrict Resident 5's mobility (movement).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to implement the facility's policy and procedures (P&P) titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating, dated 7/2025 for one of one sampled resident (Resident 18) by failing to: -Ensure the Administrator (ADM) reported Resident 18's allegation of financial abuse to the local police timely and suspended Certified Nurse Assistant 2 (CNA2) on 1/5/2026. Resident 18 alleged that CNA2 took $500.00 dollars from Resident 18 (unidentified date) and the ADM was aware on 1/5/2026. The ADM reported Resident 18's allegation of financial abuse to the local police and suspended CNA2 on 1/6/2025. This failure had the potential for delays in the investigation process of Resident 18's allegation of financial abuse.

Inspectors wroteBased on interview and record review the facility failed to provide an accurate Minimum Data Set (MDS - a resident assessment tool) Assessment for one out of three sampled residents (Resident 1) as indicated in the facility's policy and procedures titled Resident Assessments, dated 7/31/2025. This failure resulted in the facility not accurately identifying Resident 1's Brief Interview for Mentals Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) and delivery of services.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to provide medically related social services, by failing to: Advocate for and obtain a public guardian (a court-appointed, government-funded helper or manager for adults who can't care for themselves because of severe mental or physical disabilities, often when no family or friends are available) when the one of three sampled residents (Resident 5) was assessed to not have the capacity to make or understand medical decisions on [DATE]. Ensure the ombudsman (a neutral, independent advocate to find fair resolutions) was notified prior to updating a Physician Order for Life-Sustaining Treatment (POLST: [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure 10 out of 18 (room [ROOM NUMBER], 3, 4, 5, 6, 12, 15, 18, 23, and 24) resident rooms met the required 80 square feet per resident. This deficient practice had the potential to result in inadequate space necessary to provide safe nursing care and privacy for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an effective pest control program to ensure the facility was free from pests (roaches). This failure had the potential for the spread of harmful bacteria (tiny cells that can cause infections and illnesses) and infection to residents in the facility.

Inspectors wroteBased on Observation, Interview, and record review the facility failed to protect the resident ' s right to be free from resident-to-resident verbal and physical abuse for two of two sampled residents (Resident 1 and Resident 2) by failing to: 1. Provide necessary behavioral health assessment monitoring and ordered psychiatrist/psychology referrals when Resident 1 was exhibiting behavioral health symptoms of entering other resident ' s rooms without their permission to shout at other residents. 2. Protect Resident 2 from Resident 1 ' s verbal abuse, when on 11/28/24 at 9:30 AM Resident 1 to yell and Resident 2 (roommate), leading a resident-to-resident physical altercation (fight). This deficient practice resulted in Resident 2 hitting Resident 1 with his phone on the right side of the face on 11/28/24 at 9:30 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two Certified Nursing Assistants (CNA 1 and 2), three Licensed Vocational Nurses (LVN 3, 4 and 5) and Registered Nurse (RN) 2 had a completed annual competency and annual performance evaluation. This deficient practice violated the facility's Competency and Performance Evaluations policy and had the potential for residents to not receive appropriate services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled, properly stored or discarded in accordance with current accepted professional standards of practice for insulin (medication used to regulate blood sugar levels), Aplisol (also known as Tubersol - medication used to diagnose tuberculosis [infection in the lungs]), and Pneumovax 23 (a vaccine that helps protect against serious infections of the ears, sinuses, lungs, blood and brain, especially in person's with high risk conditions and over the age of 65, such as pneumonia). In addition, the expired emergency medication kit (storage container for emergency use medications) in Medication room [ROOM NUMBER] was not removed or discarded. These deficient practices increased the risk that residents in the facility could receive medication that had become ineffective or toxic.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties for two of of 12 sampled residents (Resident 2 and 4). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 18's and Resident 25's) Minimum Data Set (MDS- a federally mandated resident assessment tool) accurately reflected the resident's diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and support the administration of psychotropic medications (drugs that affect the brain and mind, altering a person's thoughts, emotions, feelings, awareness, and perceptions). This deficient practice had the potential to result in a delay of the continuity of care such as monitoring signs and symptoms of adverse reactions and had the potential to negatively affect the resident's delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with limited range of motion (ROM movement of joints) receive quarterly joint mobility assessments for one of three sampled residents (Resident 11). This deficient practice caused an increased risk in the prevention and maintenance of mobility for Resident 11, with potential for contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of two sampled residents (Resident 18 and 34). Resident 18 and Resident 34 with diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), did not have a label or date on the resident's oxygen humidifier bottle (a device used to make supplemental oxygen moist). This deficient practice caused an increased risk in infection control when handling oxygen equipment, leading to resident discomfort and/or infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure two Certified Nursing Assistants (CNA 1 and 2) had a completed annual performance evaluation. This deficient practice caused an increased risk in identifying the staffs areas of weakness with the potential for residents to not receive appropriate services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of five (5) percent (%) or lower by having three medication errors out of 35 opportunities contributing to an overall error rate of 12% for two of four sampled residents (Resident 34 and 36) observed during Medication Administration. The medication errors were as follows: -Resident 34 was not instructed to seal their mouth over the mouthpiece of Qvar (a medication used for Chronic Obstructive Pulmonary Disease [COPD -a disease that blocks air flow and makes breathing difficult]) oral inhaler (a device containing the medication that is orally inhaled,) according to manufacturer instructions. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for one sampled residents (Resident 14) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use, by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites. This deficient practice increased the risk of adverse effects (unwanted, unintended result) from same site administration such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary care was provided consistently for one of three sampled residents (Resident 4), who was receiving hospice service (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease and offers physical, emotional, social, and spiritual support for residents and their families). For Resident 4, there was no coordination of personal care and nursing needs with the hospice staff. This deficient practice had the potential to result in a delay of care and delivery of hospice care and services to Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 34) was provided a safe and sanitary environment, when the resident's oxygen nasal cannula (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) was observed on the floor. This deficient practice resulted in contamination of Resident 34's oxygen nasal cannula and placed the resident at risk for infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure 10 of 22 (Rooms 1, 3, 4, 5, 6, 12, 15, 18, 13, and 24) met the required 80 square feet per resident and failed to ensure of two rooms (room [ROOM NUMBER]) met the required 100 square feet per resident. This deficient practice had the potential to result in inadequate space necessary to provide safe nursing care and privacy for residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had a history of fall, received care and supervision in accordance with the resident's individualized plan of care. This deficient practice resulted in Resident 1's fall on 1/19/2024, and a right-hand fracture.

Inspectors wroteBased on observation and interview, the facility failed to maintain a sanitary environment for three of eleven sampled residents (Resident 1, 12 and 20) by not cleaning the residents bed controls which had visible dirt. This deficient practice had the potential for cross contamination and for the resident to get an infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced the dignity of two of ten sampled residents (Resident 12 and Resident 38), by failing to: -Ensure the Certified Nursing Assistant (CNA) did not stand over Resident 12, while providing assistance during breakfast. -Ensure Resident 38's urinary collection bag (designed to collect urine drained from the bladder via a catheter) was covered with a privacy bag to afford dignity. These deficient practices had the potential to affect residents sense of self-worth, self-esteem, and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to complete the COVID-19 (respiratory illness caused by the coronavirus) vaccine informed consent form for two of five sampled residents (Resident 9 and 21). This deficient practice had the potential to result in the residents or residents representative not being informed of their rights regarding vaccine administration.

Inspectors wroteBased on interview and record review, the facility failed to obtain an Advanced Directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) per the facility's policy and procedure (P&P) for one of six sampled residents (Resident 15). This failure had the potential to result in Resident 15's predetermined medical decisions not being met.

Inspectors wroteBased on interview and record review, the facility failed to provide range of motion (how far you can move or stretch a part of your body, such as joint or muscle) exercises for one of three sampled residents (Resident 20) as ordered by the physician. This failure had the potential to result in contracture (permanent shortening of muscle) in the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident's (Resident 30) bed was locked. This failure had the potential to result in injury or harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent kitchen staff from storing personal food items in the main kitchen refrigerator. This failure had the potential for resident to be at risk for food borne illness (caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on interview and record review, the facility failed to follow it's policy and procedure titled, Change in Resident's Condition or Status, for one of three sampled residents (Resident 28). This deficient practice had the potential to lead to inadequate care of Resident 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure eight of 25 residents room measurements (Rooms # 1, 3, 5, 9, 12, 15, 23, and 24) met the 80 square feet (sq. ft.) requirement for each resident. The size of these rooms had the potential to not provide adequate space for resident care and mobility.