Bonnie Brae Skilled Nursing

In the surveyor’s words

From the most serious findings on record at Bonnie Brae Skilled Nursing, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF686Jan 8, 2026

  Based 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… […]

• No harm, potential for more than minimal, patternF925Jul 28, 2025

  Based 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.Findings:During a review of Resident 4's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (a long term lung condition that makes it hard to breathe), hypertension (high blood pressure), epilepsy (a brain disorder that causes recurring seizures), old myocardial infarction (a heart attack sometime in the past), heart failure (heart… […]

• No harm, potential for more than minimal, patternF726Nov 27, 2024

  Based 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. Findings: A review of CNA 1's employee file indicated the date of hire was 4/23/2016 and the competency evaluation was last completed on 8/16/2023. A review of CNA 2's employee file indicated the date of hire was 8/13/2020 and the competency evaluation was last completed on 10/23/2021. […]

• No harm, potential for more than minimal, patternF761Nov 27, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF880Jan 11, 2024

  Based 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. Findings: a. A review of Resident 20's admission record indicated the facility admitted Resident 20 on 4/30/2020, with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) affecting the left non-dominant side. […]