Bonnie Brae Skilled Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. These deficient practices increased the risk that residents in the facility could receive medication that had become ineffective or toxic. Findings: During an observation on 11/25/24 10:42 a.m., in Medication Cart 1, in the presence of Licensed Vocational Nurse (LVN) 2, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and gastrostomy (a surgical opening fitted with a device to allow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: a. A review of Resident 18's admission Record indicated the resident was originally admitted to the facility on [DATE]. A review of Resident 18's History and Physical dated 2/20/2023 indicated the resident had a diagnosis of COPD and had capacity to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: A review of Resident 11's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including muscle weakness. A review of Resident 11's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/19/2024, indicated the resident had intact cognitive skills for daily decision-making and was dependent on staff with bed mobility, transfer, toilet use, personal hygiene, and bathing. A review of the Joint Mobility Assessment form dated 7/24/2024 indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: a. A review of Resident 18's admission Record indicated the resident was originally admitted to the facility on [DATE]. A review of Resident 18's History and Physical dated 2/20/2023 indicated the resident had a diagnosis of COPD and had capacity to understand and make decisions. A review of the Physician's Order dated 2/13/2023, indicated Resident 18 received oxygen at two liters per minute via nasal cannula as needed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings: A review of CNA 1's employee file indicated that their date of hire was 4/23/2016 and there was no performance evaluation was noted in file. A review of CNA 2's employee file indicated the date of hire was 8/13/2020 and there was no performance evaluation was noted in file. During a concurrent interview and record review with the Administrator (ADM) on 11/27/2024 at 12:24 PM, the employee files of CNA 1 and 2 were reviewed with the ADM. The ADM stated that all performance evaluations should be done annually for the CNA's. The ADM stated the Director of Staff Development (DSD) was responsible for ensuring the performance evaluations were completed on time and updated in the employee files. The ADM confirmed that there were no updated performance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. -Resident 36 received pantoprazole (medication used to treat acid in the stomach) oral packet at a different time and received a form of ferrous sulfate (a medication used to produce a protein in red blood cells that carries oxygen throughout the body) that was different than the Physician's Order. These failures had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: A review of Resident 14's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Type II diabetes mellitus (DM II - [a condition where there are high blood sugar levels]). A review of the Physician's Order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: A review of Resident 4's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including senile degeneration of the brain (a progressive decline in cognitive function that can lead to memory loss, impaired thinking, and a loss of independence) and schizophrenia (a mental illness that is characterized by disturbances in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: A review of Resident 34's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD). A review of the Physician's Order dated 2/13/2023, indicated Resident 34 received oxygen at two liters per minute via nasal cannula as needed for shortness of breath and oxygen saturation less than 90%. A review of Resident 34's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 10/26/2024, indicated the resident was cognitively intact (no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 1/17/2024, with diagnoses including history of falling, and muscle weakness. A review of Resident 1's physician History and Physical (H&P) dated 1/18/2024, indicated the resident could make needs known but could not make medical decisions. A review of Resident 1's Fall Risk assessment dated [DATE], indicated Resident 1 had intermittent (comes and goes) confusion or poor safety awareness, had 1-2 falls in the past three months, was ambulatory and incontinent. The fall risk assessment indicated Resident 1 had a total score of 18, as a score of 10 or greater indicated the resident was considered a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. A review of Resident 20's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/29/2023, indicated Resident 20 had intact cognition (able to make decisions of daily living), was dependent for showering and required substantial assistance for personal hygiene and toileting. During an observation on 1/8/2024 at 8:45 AM in Resident 20's room, Resident 20's bed control had white tape…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: a. A review of Resident 12's admission record (Face Sheet) indicated the facility originally admitted Resident 12 on 2/28/2019, and readmitted on [DATE], with diagnoses including muscle weakness and bipolar disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function). A review of Resident 12's Minimum Data Set (MDS - a standardized assessment and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: a. A review of the admission record indicated the facility admitted Resident 9 to the facility on [DATE], with diagnoses including Type II diabetes mellitus with hyperglycemia (high blood sugar). A review of Resident 9's COVID-19 Consent / Declination Form, dated 12/8/2023, indicated the Section 2 Screening for the Vaccine Eligibility and Section 3 for consent were not completed. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/21/2023, indicated Resident 9 had moderate cognitive (conscious mental activities such as thinking, remembering, reasoning) skills for daily decision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings: A review of the admission record (Face Sheet) indicated the facility admitted Resident 15 on 11/14/2012, with diagnoses including Type II diabetes mellitus (a condition that happens because of a problem in the way the body controls and uses sugar as a fuel) and essential hypertension (high blood pressure without a known cause that affects the body's arteries). A review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 12/2/2023, indicated Resident 15 had intact cognition (decisions consistent/reasonable) and required partial or moderate assistance for personal hygiene,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings: 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 left non-dominant side. A review of Resident 20's care plan dated 6/25/2023, indicated Resident 20 was at risk for further decline in functional status due to hemiplegia and had range of motion deficits related to hemiplegia and hemiparesis secondary to cerebral vascular accident (CVA, an interruption in the flow of blood to the cells in the brain). The care plan goal was for Resident 20 to maintain and improve current functional status as well as prevent further contracture or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings: A review of Resident 30's admission record (Face Sheet) dated 1/2/2024, indicated the facility admitted Resident 30 on 1/11/2023, with diagnoses including Alzheimer's disease (progressive disease that destroys memory and other important mental functions) with late onset, unsteadiness on feet, and paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 30's history and physical (H&P) dated 1/23/2023, indicated Resident 30 had the capacity to understand and make medical decisions. A review of Resident 30's Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 10/26/2023, indicated Resident 30's cognition was intact (being able to follow two simple commands) and was independent with personal hygiene, transfers and walking, but required supervision and setup for oral hygiene,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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). Findings: During a concurrent observation and interview on 1/8/2024 at 8:14 AM, with the facility's [NAME] in the kitchen, it was observed there was a plastic bag with food inside the main kitchen refrigerator with a staff members name on it. The [NAME] stated, That shouldn't be in there. During an interview on 1/8/20024 at 3:32 PM, the Dietary Supervisor (DS) stated if staff leave personal items in the refrigerator, it can cause cross contamination and food borne illness to residents. During an interview on 1/8/2024 at 3:44 PM, the facility's Administrator (ADM) stated, As far as I know, staff belongings should be placed in the staff fridge. A review of the facility's policy and procedure (P&P) titled, Staff Belongings, dated 12/2023, indicated kitchen staff may not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: A review of Resident 28's admission record (Face Sheet) indicated the facility originally admitted Resident 28 on 4/1/2022, and readmitted on [DATE], with diagnoses including muscle weakness, and Alzheimer's disease (a physical illness which damages a person's brain). A review of the Physician's Order dated 12/7/2023 at 1 PM, indicated to transfer Resident 28 to the General Acute Care Hospital 1 (GACH 1) due to a productive cough (when you have a cough that produces mucus or phlegm [sputum]) and severe congestion (stuffy nose), with poor oral intake, and shortness of breath. A review of Resident 28's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 12/26/2023, indicated Resident 28 had moderately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings: On 1/9/2024 at 10 AM, during the Resident's Council Meeting, there were no concerns brought up by residents regarding the size of their rooms. During the recertification survey from 1/9/2024 to 1/11/2024, a general observation of the facility and resident rooms was conducted. The residents residing in the room with a variance application had sufficient space to move freely in their rooms. Each room had beds, side tables, and drawers for each resident. There was adequate room for the operation and use of equipment such as wheelchairs. The nursing staff provided care to these residents and the room variance did not affect the care and services provided to the residents. During an interview on 1/11/2024 at 11 AM, the Director of Nursing (DON) stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.