Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bonner Springs Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with multiple health conditions and high risk for pressure ulcers did not receive appropriate preventative interventions, such as pressure-relieving devices or a turning program, and developed a Stage 3 pressure ulcer on the heel. After the ulcer developed, the resident was not consistently provided with protective boots, and the Registered Dietitian was not notified to provide nutritional recommendations for wound healing. Staff interviews and observations confirmed gaps in care planning and implementation.
The facility did not submit accurate nurse staffing data through the PBJ system, with reports showing multiple dates without licensed nurse coverage despite payroll records and staff interviews confirming that a nurse was present at all times. Administrative staff managed scheduling, but PBJ submissions were handled by the corporate team, leading to discrepancies between actual staffing and reported data.
The facility did not maintain a QA&A Committee that met at least quarterly with all required members present, as only one meeting's attendance roster was available and key members, such as the Medical Director, were not consistently in attendance. This failure was identified through review of meeting records and staff interviews.
The facility did not implement the required antibiotic stewardship program, as evidenced by incomplete infection control surveillance logs that lacked organism identification, antibiotic duration, and infection details for multiple months. An administrative nurse identified that the previous infection preventionist had not completed the necessary monthly logs, resulting in a failure to monitor and trend antibiotic use as outlined in facility policy.
A resident with multiple comorbidities and high risk for pressure ulcers did not have a comprehensive care plan addressing skin breakdown prevention. The care plan lacked specific interventions, and staff did not consistently implement or communicate pressure ulcer prevention measures, resulting in the development and progression of a stage 3 pressure ulcer. Dietary staff were also unaware of the resident's wound, and no additional nutritional support was provided.
A resident with a history of stroke, hemiplegia, and anxiety continued to receive Seroquel, an antipsychotic, without an allowable diagnosis or documented clinical rationale, after the Consultant Pharmacist recommended physician review. The physician did not respond to the pharmacist's recommendation, and the facility did not ensure the required documentation or consideration of a gradual dose reduction, as outlined in facility policy.
Two residents received antihypertensive medications despite physician orders to hold these drugs when vital signs were outside specified parameters. Medication administration records and staff interviews confirmed that medications were given when heart rates or blood pressures were below the ordered thresholds, and staff did not consistently notify licensed nurses when this occurred. This failure to follow physician orders resulted in the administration of unnecessary medications.
A resident with multiple chronic conditions and severely impaired cognition was administered blood pressure medications by a CMA despite a heart rate below the physician-ordered threshold for holding the medication. The CMA was unaware of the heart rate parameter and did not notify a nurse, resulting in a medication administration error.
Two residents receiving hospice care did not have complete or coordinated care plans, as required by facility policy. The care plans lacked essential information such as hospice contact details, the scope of hospice services (including supplies, equipment, and medications), visit schedules, and clear communication processes between the facility and hospice provider. Nursing staff acknowledged these omissions, and the absence of this information placed the residents at risk of not receiving necessary care.
Two residents in a facility engaged in an altercation in the dining room, resulting in one resident throwing a ceramic mug and causing a broken nose to the other. The incident occurred due to inadequate supervision, as staff were either absent or distracted, failing to prevent the escalation. Both residents have histories of behavioral issues, and the facility's policies on monitoring and abuse prevention were not effectively followed.
The facility did not have a qualified director of food and nutrition services, risking residents' dietary and nutritional needs. Social Services X, without a Certified Dietary Manager (CDM) qualification, temporarily covered kitchen duties due to the absence of the full-time cook. Administrative Staff A and B were overseeing the kitchen while seeking a CDM. The facility's policy required a CDM-certified manager, but the position had been vacant for months.
The facility failed to provide sufficient staff with appropriate skills in the food and nutrition service, leading to unrecorded temperature logs and resident complaints about food quality and availability. Residents reported issues with overcooked and stale food, and the facility lacked a dedicated cook for the evening shift, relying on administrative and social services staff to cover kitchen duties.
Failure to Prevent and Manage Pressure Ulcer in High-Risk Resident
Penalty
Summary
A resident with multiple comorbidities, including schizophrenia, dementia, bipolar disorder, hypertension, acquired absence of toes, and peripheral vascular disease, was identified as being at high risk for pressure ulcers. Despite this, the resident did not have pressure-relieving devices for her bed or chair, was not on a turning or repositioning program, and her care plan lacked interventions to prevent skin breakdown. The Braden Scale assessments consistently documented a very high risk for developing pressure ulcers, and the Pressure Ulcer Care Area Assessment directed staff to observe and report any skin changes, but these preventative measures were not implemented. The resident developed a Stage 3 pressure ulcer on her right heel. Documentation showed that staff observed a fluid-filled blister, and a low-air-loss mattress was ordered after the ulcer developed. Physician orders were given for wound care and the use of heel protectors, but there was evidence that the resident was not consistently wearing the protective boots as required. Observations confirmed that the resident was found in bed and in the living room without the protective boots on, and staff interviews revealed a lack of awareness regarding the interventions in place before and after the ulcer developed. Additionally, after the development of the pressure ulcer, there was no documentation that the Registered Dietitian was notified or involved for nutritional recommendations to promote wound healing. The clinical record lacked evidence of a dietitian evaluation or recommendations during the period following the onset of the pressure ulcer. Dietary staff were unaware of the resident's skin breakdown, and the resident was not receiving any additional protein or supplements for wound healing. The facility's policy required routine preventative care, including proper positioning, use of pressure relief devices, and maintaining adequate nutrition, but these measures were not consistently implemented for this resident.
Failure to Accurately Report Nurse Staffing in PBJ Submissions
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through the Payroll-Based Journal (PBJ) system as required by CMS. Review of PBJ reports for multiple fiscal quarters indicated that there were several dates recorded with no licensed nurse coverage. However, examination of the facility's licensed nurse payroll data for those dates showed that a licensed nurse was on duty 24 hours a day, seven days a week. Administrative staff confirmed that nurses were always scheduled for each 12-hour shift, including the use of agency staff when necessary. Interviews with administrative and nursing staff revealed that while scheduling was managed internally, the actual PBJ submission was handled by the corporate team. The facility's policy required accurate electronic reporting of staffing and census information, including agency and contract staff, to CMS. The failure to submit accurate PBJ data resulted in records that did not reflect the actual nurse staffing present in the facility.
QA&A Committee Lacked Required Quarterly Meetings and Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QA&A) Committee that met at least quarterly with the required members in attendance. During the survey, the facility was only able to provide an attendance roster for one meeting, and could not produce documentation for other required meetings. Administrative staff confirmed that while meetings were being held monthly, the Medical Director only attended quarterly, and there was no attendance sheet available for the most recent meeting. The facility's own QAPI policy indicated that the committee should meet monthly to review reports, evaluate data, and monitor QAPI-related activities, but the lack of documentation and inconsistent attendance by required members led to the deficiency.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement the core elements of antibiotic stewardship as part of its infection prevention and control program. Specifically, a review of the Infection Control Surveillance Log from January 2024 through March 2025 revealed missing documentation for several months, including the absence of organism identifications, duration of antibiotic prescriptions, and the specific infections treated for February, April, May, September, November, and December 2024. This lack of documentation meant that the facility was not adequately tracking or trending infections and antibiotic use as required by its own policies. An administrative nurse reported that upon assuming responsibility for the infection control program, she discovered that the previous infection preventionist had not been completing the monthly antibiotic stewardship surveillance logs. The facility's policies, dated October 2021, outlined the need for monitoring antibiotic use and conducting surveillance to identify infection trends and guide interventions. However, these procedures were not followed, resulting in incomplete records and a failure to ensure effective antibiotic stewardship for the residents.
Failure to Develop and Implement Comprehensive Pressure Ulcer Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan with specific interventions to prevent pressure ulcers for one resident. The resident had multiple diagnoses, including schizophrenia, dementia, bipolar disorder, hypertension, acquired absence of toes, and peripheral vascular disease, and was assessed as having severely impaired cognition and high risk for pressure ulcers. Despite these risk factors, the care plan did not include a care area or interventions for skin breakdown, and there was no turning or repositioning program in place. The resident required substantial assistance with activities of daily living and was dependent on staff for bed mobility and personal care. Clinical documentation showed that the resident developed a fluid-filled blister on the right heel, which progressed to an open, stage 3 pressure ulcer. Physician orders and wound clinic assessments directed the use of a low air-loss mattress, heel protectors, and specific wound care treatments. However, observations revealed that the resident was not consistently wearing protective boots while in bed, and staff were not always aware of or able to articulate the interventions in place to prevent or treat the pressure ulcer. Additionally, dietary staff were unaware of the resident's skin breakdown and no additional dietary interventions or supplements for wound healing were provided. Interviews with nursing and dietary staff confirmed gaps in communication and implementation of care interventions. The administrative nurse acknowledged the absence of a pressure ulcer care plan, and staff education on the importance of offloading and pressure relief was documented but not consistently followed. The facility's policy required the development of an individualized, comprehensive care plan within seven days of assessment, but this was not completed for the resident in question.
Failure to Ensure Physician Response to Pharmacist's Antipsychotic Medication Recommendation
Penalty
Summary
The facility failed to ensure that the attending physician responded to the Consultant Pharmacist's (CP) recommendation regarding the use of an antipsychotic medication for a resident. The CP identified that the resident was receiving Seroquel, an antipsychotic, without an allowable diagnosis to support its use and requested a clinical rationale from the physician. Despite this recommendation, the physician did not provide a response or documentation addressing the CP's concern. The resident's medical record showed ongoing administration of Seroquel for mood management, with no evidence of a gradual dose reduction being considered or implemented since admission. The resident involved had a history of cerebral infarction, hemiplegia, anxiety, and symptoms involving emotional state, but maintained intact cognition and independence in functional abilities. The care plan directed staff to administer medications as ordered and monitor for side effects and behaviors. The facility's policy required timely physician response to CP recommendations, including documentation of review and actions taken, but this process was not followed in this case, resulting in the continued use of an antipsychotic without appropriate clinical justification.
Failure to Hold Blood Pressure Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that blood pressure medications were held according to physician-ordered parameters for two residents. For one resident with multiple diagnoses including traumatic brain injury, dementia, diabetes, and hypertension, physician orders specified that certain antihypertensive medications should be withheld if the systolic blood pressure or heart rate fell below set thresholds. Despite these orders, medication administration records showed that the resident received losartan, amlodipine, and Coreg on multiple occasions when the heart rate was below the specified parameters. Observation confirmed that a Certified Medication Aide administered these medications without recognizing the need to hold them due to a low heart rate. Another resident with diagnoses including heart failure, anxiety, and diabetes had a physician order for metoprolol to be held if the systolic blood pressure was below a certain level or if the pulse was under a set rate. Medication administration records indicated that this resident received metoprolol on several occasions when the systolic blood pressure was below the ordered threshold. Staff interviews revealed that Certified Medication Aides were expected to notify licensed nurses when vital signs were out of range, but this process was not consistently followed. The facility's own medication therapy policy required that medication regimens be consistent with physician orders and supported by appropriate care processes. However, the failure to adhere to physician-ordered parameters for holding medications resulted in the administration of unnecessary drugs, as defined by the facility's policy and federal regulations.
Medication Administration Error Due to Failure to Hold Antihypertensives for Low Heart Rate
Penalty
Summary
A resident with multiple diagnoses, including traumatic brain injury, dementia, depression, diabetes mellitus type two, and hypertension, was dependent on staff for all activities of daily living and received several daily medications, including diuretics, antidepressants, and insulin. The resident's care plan and physician's orders required staff to monitor blood pressure and heart rate, and to hold specific blood pressure medications if the systolic blood pressure was below 110 mmHg or the heart rate was below 60 or 65 beats per minute, depending on the medication. On the day of the incident, a Certified Medication Aide (CMA) measured the resident's heart rate at 55 beats per minute but proceeded to administer all prescribed blood pressure medications, failing to recognize that the heart rate was below the physician-ordered parameters for holding the medication. The CMA stated that they were only aware of the blood pressure parameter and not the heart rate requirement. The Licensed Nurse later confirmed that CMAs were expected to notify a nurse when vital signs were out of range, as some orders required physician notification. The administrative nurse also stated that staff were expected to follow physician orders and hold medications when vital signs were out of parameters. The facility did not provide a policy for medication errors when requested.
Failure to Coordinate and Document Hospice Services for Residents
Penalty
Summary
The facility failed to ensure proper communication and coordination between the hospice provider and facility staff for two residents receiving hospice services. For one resident with multiple diagnoses including epilepsy, bipolar disorder, depression, hypertension, atrial fibrillation, and morbid obesity, the care plan documented enrollment in hospice but lacked essential information such as the hospice contact number, details on supplies, equipment, and medications provided by hospice, as well as the schedule and nature of hospice staff visits. The care plan only directed staff to document advanced directive reviews and maintain these directives, without specifying the scope of hospice involvement or coordination. Another resident, diagnosed with hypertension, trigeminal neuralgia, and major depressive disorder, also experienced a lack of detailed hospice care planning. The care plan indicated hospice enrollment and directed staff to honor advance directives, but did not provide instructions regarding the services hospice would supply, the services the facility would continue to provide, or the process for communication and documentation between the facility and hospice provider. There were no directions for staff on when to notify hospice of significant changes in the resident's status, clinical complications, transfers, or death, nor was there information on the frequency or timing of hospice visits. Interviews with administrative nursing staff confirmed awareness of these omissions, acknowledging that care plans were incomplete and lacked required information about hospice services. The facility's own hospice policy required coordinated care plans and clear communication with hospice providers, but this was not reflected in the care plans reviewed for the two residents, placing them at risk of not receiving needed care.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident abuse, resulting in an altercation between two residents in the dining room. Resident 1, who has a history of aggressive behavior and multiple mental health diagnoses, threw a ceramic mug at Resident 2, causing a broken nose. The incident occurred during a time when the dining room was unsupervised, as staff were either taking out trash or engaged in other tasks, leaving the residents without proper oversight. Resident 1's medical records indicate a history of dementia, mood disorders, and aggressive behavior, which required one-on-one monitoring and specific interventions to manage his behavior. Despite these documented needs, the facility's staff failed to maintain the necessary supervision, allowing the situation to escalate. Resident 2, who also has a history of being rowdy and mouthy, was involved in the altercation, which began with both residents throwing objects at each other. Interviews with staff revealed that there was a lack of adherence to the facility's policy requiring staff presence in the dining room during meals. Staff members were either absent or distracted, contributing to the failure to intervene before the altercation escalated. The facility's policies on abuse prevention and resident monitoring were not effectively implemented, leading to the incident and subsequent injury to Resident 2.
Lack of Qualified Food and Nutrition Services Director
Penalty
Summary
The facility failed to employ a director of food and nutrition services with the required qualifications, which placed residents at risk for unmet dietary and nutritional needs. The facility had a census of 31 residents and one main kitchen. Social Services X, who was not a Certified Dietary Manager (CDM), was temporarily covering the kitchen duties due to the absence of the full-time cook. Social Services X admitted to being unsure about the completion of food temperature logs and had an expired ServSafe certification. Administrative Staff B confirmed the absence of a CDM for a couple of months and stated that the administrator was also assisting in running the kitchen while they were in the process of hiring someone for the position. Administrative Staff A, who had been at the facility for about two and a half weeks, was actively seeking a CDM and had interviews scheduled. Both Administrative Staff A and B were splitting the responsibilities of overseeing the kitchen. The facility had a registered dietitian who visited once a month and was available as needed. The facility's policy required the food services manager to be CDM certified or enrolled in an accredited program, and in the absence of a manager, duties were to be assigned to other staff with input from the dietitian. However, the facility did not have a qualified director of food and nutrition services, leading to the deficiency.
Inadequate Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition service, which placed residents at risk for impaired nutrition and decreased quality of life. The facility, with a census of 31 residents, had one main kitchen but lacked adequate staffing. Observations and interviews revealed that the facility did not have enough staff with the appropriate skill sets, as evidenced by the absence of a cook on the evening shift and reliance on administrative staff and social services personnel to cover kitchen duties. This staffing shortage led to issues such as unrecorded refrigerator/freezer and food temperatures, which are critical for ensuring food safety. Residents expressed grievances about the quality and availability of food, indicating that the kitchen sometimes ran out of essential items like bread, sweeteners, and saltshakers. Complaints were also made about the food being overcooked, hard, or stale, making it difficult for some residents to eat. The Resident Council meeting minutes and individual resident interviews highlighted these concerns, with residents noting that the facility occasionally deviated from the posted menu and struggled to accommodate dietary preferences due to limited resources. Administrative staff acknowledged the staffing challenges, noting that the facility had only one full-time and one part-time cook for the day shift, with no dedicated cook for the evening shift. The facility's policy required a Certified Dietary Manager (CDM) or someone enrolled in an accredited CDM program to manage food services, but in the absence of such a manager, duties were assigned to other staff members with input from a dietitian. Despite efforts to follow recipes and maintain food safety standards, the lack of adequately trained and certified personnel contributed to the deficiency in food and nutrition services.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bonner Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kaw River Care And Rehab | 3.4 mi | ★★★★★ | 0 | 0 |
| Parkway Operator Llc | 3.4 mi | ★★★★★ | 0 | 0 |
| Edwardsville Care And Rehab | 3.4 mi | ★★★★★ | 2 | 2 |
| The Healthcare Resort Of Kansas City | 6.6 mi | ★★★★★ | 32 | 0 |
| Providence Place | 6.7 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.