Bonner Springs Nursing & Rehab Center

F-F801)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 175401

F-F802)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 5 175401 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175401 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bonner Springs Nursing & Rehab Center 520 E Morse Street Bonner Springs, KS 66012

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47834

Residents Affected - Many The 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.

Findings included:

- Review of the facility's Resource: Refrigerator/Freezer Temperature Log for May revealed no temperatures were recorded for the morning shift for the following (21) days [DATE REDACTED] - [DATE REDACTED] and no recorded temperatures for evening shift for the following (6) days [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED] and [DATE REDACTED].

Review of the facility's Resource: Refrigerator/Freezer Temperature Log for June revealed no temperatures were recorded for the morning shift for the following (28) days [DATE REDACTED] - [DATE REDACTED] and no recorded temperatures for evening shift on the following (12) days [DATE REDACTED] - [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED] and [DATE REDACTED].

Review of the Food Temperatures Log for May revealed no food temperatures recorded for the following (9) days for the dinner period: [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED] and [DATE REDACTED].

Review of the Food Temperatures Log for July revealed no food temperatures recorded for one or more meals on the following (6) days: [DATE REDACTED] - [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED].

The Resident Council meeting minutes, dated [DATE REDACTED], documented a grievance for the kitchen that the bread seemed stale and hard at times, and lettuce needed to be chopped up more for salads.

The Resident Council meeting minutes, dated [DATE REDACTED], documented the food committee stated the kitchen was running out of products such as sweet n low, sugar packets and saltshakers.

A Resident Grievance/Complaint Investigation Report Form dated [DATE REDACTED] documented a resident complaint that bacon was too hard, and a resident was unable to eat it.

On [DATE REDACTED] at 12:40 PM Resident R1 stated he believed the facility was following the posted menus for the most part, but further stated sometimes he gets things that are different than what was posted on the menu and that it occurred a few times a week. Resident R1 stated the facility will make accommodations if they have items available,

he stated last week the facility made grilled cheese, but then had no bread to make other options. Resident R1 stated sometimes the food is overcooked and it becomes too hard, and he cannot eat it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 5 175401 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175401 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bonner Springs Nursing & Rehab Center 520 E Morse Street Bonner Springs, KS 66012

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 On [DATE REDACTED] at 12:50 PM Resident R2 stated everyone gets what is on the menu, but he can request a cheeseburger or sandwich if he doesn't want what is served; however, Resident R2 stated sometimes the kitchen runs out of some Level of Harm - Minimal harm or items so he just eats what is given to him. Resident R2 stated sometimes the food is over cooked and is hard to eat potential for actual harm and sometimes the bread is stale.

Residents Affected - Many On [DATE REDACTED] at 01:14 PM Resident R3 stated they don't eat in the dining room often. Resident R3 stated the kitchen has hamburgers, hotdogs and sandwiches, but for someone that doesn't have teeth those things are hard to eat. Resident R3 stated sometimes the kitchen runs out of some food items. Resident R3 stated she isn't able to eat many different foods, so if the kitchen runs out of something she can eat she feels frustrated. Resident R3 stated sometimes the food is too hard or dry and that they have a hard time eating it.

On [DATE REDACTED] at 02:30 PM Administrative Staff B stated she mostly does the ordering for the facility with help from the representative from the food company they order from. Administrative Staff B stated ordering is based on census and the recipes for the week. She stated a list is printed that records what will be used based on that information, so they know how much to order. Administrative Staff B stated they rarely run out of food items but do at times. Administrative Staff B stated if they do run out of something they will pick it up from the store. Administrative Staff B stated she follows the recipe book and each recipe has the temperature and what is required and if she still has questions then she would contact the dietitian. Administrative Staff B stated if the kitchen was fully staffed then they should have one cook and one dietary aide for each shift. She stated right now she has had to stay late to help cover in the evening as there is no cook on evening shift. Administrative Staff B had also stated that the facility currently only had one full time cook and one part time cook that worked day shift.

On [DATE REDACTED] at X 2:39 PM Social Services X stated she helps cook if one of the cooks are not working. She stated a dietary aide works in the evening and they can serve dishes, and clean up in the kitchen. She stated

the dietary aide can also help cook if needed. Social Services X stated she had a ServSafe certification for food safety through the United States Department of Agriculture (USDA); however, she stated the certification had expired. She stated that she follows the recipes when preparing the meals and the required temperatures are listed on the recipe and a scoop, serving size chart was on the wall to reference to ensure servings were correct. Social Services X stated if the kitchen was fully staffed there should be one cook and one dietary aide on day shift and then at night it's just a dietary aide.

On [DATE REDACTED] at 02:45 PM Administrative Staff A stated if the kitchen was fully staffed there should be one CDM and one dietary aide for day shift and a cook and dietary aide for evening shift. Administrative Staff A stated Administrative Staff B and Social services X were working and overseeing the kitchen before she started at the facility and wasn't sure of their training, or education related to working in the kitchen. Administrative Staff A stated they both stated they had worked in the kitchen before and offered to jump in and help. Administrative Staff A stated when the registered dietitian was at the facility recently, the dietitian provided some education to Administrative Staff A and Administrative Staff B about menus and scoop sizes. Administrative Staff A stated dietary aides do not cook and that they only do prep and bus tables.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 5 175401 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175401 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bonner Springs Nursing & Rehab Center 520 E Morse Street Bonner Springs, KS 66012

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 The facility provided Food and Nutrition Services policy with a revised date of [DATE REDACTED], documented the food services manager will be CDM certified or enrolled in an accredited CDM program and on pace for Level of Harm - Minimal harm or completion. In the absence of a Food Services Manager, the duties will be assigned to other available staff potential for actual harm members with input and direction from the dietician. Reasonable efforts will be made to accommodate resident choices and preferences. The food and nutrition staff will be available and adequately staffed to Residents Affected - Many assist residents with eating as needed along with staff from all other departments in order to start within applicable budget.

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. (Refer to