Federal inspectors cited the facility for immediate jeopardy in March, determining that administration's failure to manage regulatory compliance "caused or had the likelihood to cause serious injury, harm, impairment, or death to residents."
The inspection report identifies the resident only as R165, noting he was receiving an altered diet when staff provided him the sandwich that led to his emergency hospitalization and subsequent death.
Inspectors found the facility's administrator and director of nursing failed to effectively manage compliance with federal quality of care requirements. The immediate jeopardy citation represents the most serious level of violation federal regulators can issue.
The facility operates 112 beds and had multiple violations during the March inspection, including a resident who endured weeks of severe dental pain without treatment.
R77 told inspectors his loose tooth caused pain he rated "ten on a scale of ten" and demonstrated how easily the tooth moved when he pressed it with his tongue. He said he reported the problem to nurses daily but had not seen a dentist since admission.
"A tooth needs to come out," R77 told inspectors during interviews on March 10, 12, and 13. "I have told a nurse about this every day."
The facility's own dental assessment forms from earlier dates showed nurses had marked "yes" when asked if R77 had loose teeth. But the forms left blank the critical question: "Referral needed to dentist: Yes or No (if yes, give copy to social worker)."
Licensed Practical Nurse DDDD confirmed during inspection that R77 had one loose tooth and was missing all upper teeth. She observed R77 experiencing pain and confirmed this would indicate a referral to the dentist.
Unit Manager LPN EE acknowledged R77 had physician orders for dental consultation and treatment "as indicated" - which she clarified included oral pain, cavities, and loose teeth. She confirmed the documented assessment showing R77's loose tooth should have been completed fully and given to the Social Services Director for dental referral.
The Social Services Director told inspectors she was unaware of any referral request for R77 or knowledge of his loose teeth, despite R77 qualifying for the facility's Medicaid dental benefits program.
Director of Nursing staff acknowledged that failing to make timely dental referrals could lead to pain or weight loss for residents.
Kitchen operations also violated federal standards. Staff preparing pureed food for six residents on mechanically altered diets failed to follow recipes, potentially creating dangerous consistency variations.
During a March 11 observation, kitchen worker FF was preparing pureed carrots for residents but had no formal recipe for guidance. She initially planned 15 scoops for 10 servings, then changed to 9 scoops for 7 servings when she realized there were insufficient carrots.
FF poured unmeasured chicken broth into the mixture, stating she relied on experience rather than measurements. When asked about consistency, she said "mashed potatoes," while the Dietary Kitchen Manager corrected that it should be "mousse-like."
FF acknowledged she should measure the broth and showed inspectors a recipe binder, but the recipe didn't match the number of servings or ingredients she was using.
The Dietary Kitchen Manager confirmed no recipe was followed and stated the facility was transitioning between menu systems. She acknowledged that not following recipes could result in wrong food consistency and potential harm to residents.
Food safety violations throughout the facility created additional risks for all 112 residents receiving oral nutrition. Inspectors found multiple unlabeled items in the pantry including opened vinegar, peanut butter, quick oats, and creamy wheat with no expiration dates.
The cooler contained two bags of cut cabbage, one bag of cut carrots, wilted spinach, and opened hot dogs - all without expiration dates. A bag of green peas in the freezer was improperly sealed.
The ice machine contained debris despite facility policy requiring monthly cleaning. The Maintenance Director, responsible for cleaning the machine twice monthly, confirmed the debris when shown photographs by inspectors.
The Dietary Manager acknowledged that improperly labeled food items meant staff couldn't determine when products should be used or how long they had been stored.
Facility policies required all food items to be appropriately labeled and dated, with opened items properly covered and stored to prevent contamination. The policies also mandated quarterly ice machine cleaning and sanitization.
The Administrator confirmed that staff should follow recipes to achieve proper consistency for pureed foods and properly label all food items with opening and expiration dates.
For R77's dental case, the facility had an established process: nurses conduct oral assessments looking for loose teeth, oral pain, or other problems, then notify social services for referrals when needed. The facility offers on-site Medicaid dental services quarterly and arranges outside appointments for residents who don't qualify.
But the system broke down completely. Despite documented loose teeth, daily pain reports from R77, and physician orders for dental consultation, no referral was ever made to either the on-site or outside dental providers.
The Administrator acknowledged that delayed dental referrals could result in weight loss, pain, or inability to eat or chew properly.
R77's case illustrates how administrative failures cascade through multiple departments. Nurses documented problems but didn't complete referral processes. Social services never received notifications about dental needs. Management systems failed to catch the breakdown despite resident complaints and documented assessments.
The immediate jeopardy citation for R165's death represents the most severe consequence of these management failures. While the inspection report provides limited details about R165's case, it establishes that administration's inability to ensure regulatory compliance directly contributed to a resident's death.
Federal inspectors determined the facility's noncompliance created conditions that caused or could cause serious injury, harm, impairment, or death to residents - the legal standard for immediate jeopardy citations.
The combination of violations - from life-threatening dietary errors to untreated dental pain to contaminated food storage - reveals systematic breakdowns in basic resident care and safety protocols at the 112-bed facility.
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.
Additional Resources
- View all inspection reports for Bonterra Transitional Care & Rehabilitation
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