EAST POINT, GA - Federal inspectors documented serious medication security breaches and transportation failures at Bonterra Transitional Care & Rehabilitation that put vulnerable residents at risk and caused actual harm to a post-surgical patient.
Multiple Medication Cart Security Failures
During a March 2025 inspection, Centers for Medicare & Medicaid Services surveyors observed three separate incidents where nursing staff left medication carts unlocked and unattended, with controlled substances accessible to residents.
The most concerning incident occurred on March 14 at 5:18 am when Licensed Practical Nurse BB left Medication Cart A unlocked outside the nurse station. Three male residents were sitting within reach of the cart, which contained psychotropic medications, diuretics, and narcotics. When questioned, LPN BB acknowledged the potential danger, stating residents "could take medication off the cart."
"She had all medication types on medication cart A, such as psychotropic, diuretic, and narcotics," the inspection report documented.
Minutes later at 5:25 am, inspectors found a second cart (Medication Cart B) left unlocked in the same area. Certified Medical Assistant CC admitted to being away from the cart for 10-15 minutes while working on a computer. Despite having received training five months earlier emphasizing that medication carts must remain "locked at all times," the CMA dismissed the potential risks.
Repeated Pattern of Non-Compliance
The medication security problems extended beyond a single shift or wing. On March 15, LPN FF left Medication Cart C unlocked on another wing while attempting to access a computer system. The Unit Manager had to intervene to secure the abandoned cart.
A fourth incident occurred March 16 when LPN GG, despite having years of nursing experience, left the same cart unlocked while treating a resident. The nurse initially believed the cart was secured but admitted the error when confronted by inspectors.
These violations directly contradict the facility's own policy, which requires staff to "maintain the medication cart locked at all times when unattended," according to documentation dated October 2024.
Medical Implications of Unsecured Medications
Unsecured access to prescription medications poses severe risks to nursing home residents, particularly those with cognitive impairments. Psychotropic medications can cause dangerous interactions, respiratory depression, or altered mental states when taken inappropriately. Diuretics can lead to dangerous dehydration or electrolyte imbalances, while narcotics carry risks of overdose and respiratory failure.
The facility's Director of Nursing acknowledged these dangers during the inspection, emphasizing that "all medications could potentially cause adverse reactions to residents if they were to access the unlocked cart." This admission underscores the gravity of leaving controlled substances accessible to vulnerable individuals.
Federal regulations require locked storage specifically because many nursing home residents may not understand the consequences of taking unfamiliar medications. Some residents may be drawn to colorful pills or mistake them for candy, while others might intentionally consume medications in attempts at self-harm.
Transportation Failure Causes Patient Harm
Beyond medication security issues, inspectors documented a transportation breakdown that resulted in actual harm to a double-amputee resident requiring post-surgical care.
Resident 71, who had undergone recent amputation surgery, missed critical follow-up appointments when the facility failed to arrange proper transportation. The patient was scheduled for staple removal on March 4, then rescheduled to March 11, but the facility canceled again due to "transportation issues."
"Staples became embedded in R71's amputation surgical site after the facility failed to provide transportation for post-operation appointments," the inspection report stated.
Consequences of Delayed Medical Care
The delayed staple removal had serious medical consequences. The resident's family member reported that the patient "was in pain and complained that her skin was tight around her staples." When surgical staples remain in tissue beyond the recommended timeframe, they can become embedded in growing tissue, cause infection, and create painful scarring.
Proper post-surgical care requires timely staple removal to prevent complications including:
- Tissue overgrowth around staples, making removal more difficult and painful - Increased infection risk as bacteria can accumulate around embedded hardware - Impaired wound healing and potential tissue necrosis - Chronic pain and mobility limitations for amputee patients
For double-amputee patients like Resident 71, proper wound healing is critical for eventual prosthetic fitting and rehabilitation. Delays in post-surgical care can significantly impact long-term mobility and quality of life.
Administrative Failures
The transportation breakdown revealed systemic problems in the facility's appointment coordination system. The East Wing Unit Clerk, responsible for coordinating transportation, was aware of the missed appointment but failed to ensure alternative arrangements. The clinic had to reschedule the critical appointment to March 18, causing a two-week delay in essential post-surgical care.
The facility's Director of Nursing acknowledged that missed appointments should trigger a grievance process and that transportation companies require 72-hour advance notice. However, these procedures clearly failed in this case, resulting in documented patient harm.
Staff Training Concerns
Despite multiple recent training sessions on medication security, the repeated violations suggest inadequate supervision and accountability. Several nurses interviewed during the inspection acknowledged receiving recent education on proper cart security but failed to implement basic safety protocols.
LPN BB mentioned receiving in-service training "a couple of weeks ago," while CMA CC had training five months prior. The persistence of these violations despite ongoing education indicates deeper systemic issues with compliance monitoring and enforcement.
Regulatory Standards and Expectations
Federal regulations require nursing homes to maintain strict medication security to protect vulnerable residents from accidental or intentional ingestion of prescription drugs. These standards exist because nursing home populations include individuals with dementia, depression, and other conditions that may impair judgment about medication safety.
Similarly, facilities must ensure residents can access necessary medical care through reliable transportation arrangements. For post-surgical patients, timely follow-up care is essential to prevent complications and promote healing.
The violations at Bonterra represent fundamental failures in basic safety protocols that put residents at unnecessary risk. Both medication security and transportation coordination are core responsibilities that directly impact patient safety and outcomes.
The facility must implement immediate corrective measures to prevent future incidents and protect residents from preventable harm. These incidents highlight the critical importance of consistent supervision, proper training implementation, and accountability systems in nursing home operations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bonterra Transitional Care & Rehabilitation from 2025-03-19 including all violations, facility responses, and corrective action plans.
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