Bonner Springs Nursing & Rehab Center

In the surveyor’s words

From the most serious findings on record at Bonner Springs Nursing & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 23, 2024

  The 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. […]

• Actual harm, isolatedF686Apr 16, 2025

  The 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. […]

• Actual harm, isolatedF600Sep 18, 2024

  The 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. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of alcoholic cirrhosis of the liver, dysphagia (swallowing difficulty), dementia (a progressive mental disorder characterized by failing memory and confusion), mental disorder, mood affective disorder (category of mental health problems,… […]

• Actual harm, isolatedF600Sep 21, 2023

  The 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. Findings included: - R1 admitted to the facility on [DATE] and discharged to the hospital on 09/17/23. […]

• Actual harm, isolatedF689Apr 25, 2022

  The facility identified a census of 34 residents. The sample included three residents reviewed for accidents. Based on record review, interview, and observation, the facility failed to maintain an environment free from safety hazards. On 04/19/22 staff propelled Resident (R)1 down the hallway in her wheelchair without foot pedals. R1's right foot became entangled in the recessed area around the drain access, which caused R1's foot to bend underneath her wheelchair. Staff failed to recognize R1's foot was caught on the recessed area and continued to propel R1 forward in her wheelchair which resulted in R1's foot bending underneath the wheelchair, which resulted in a fracture to R1's right tibia (larger long bone of the lower leg) and right fibula (smaller long bone of the lower leg ). […]