Bonterra Transitional Care: Medication Safety Failures - GA
The creams were sitting on his nightstand when inspectors arrived in March. They had no business being there.
Federal inspectors documented the situation during a March 12, 2025 visit with the resident, identified in the report as R20. He told inspectors he could not remember when he had returned from a hospital stay, but he was clear about the medications: creams for his feet, his hands, his arms. The skin occasionally felt raw, he said, so he used them morning and night for the rashes. He also said that staff had never once assessed him for his ability to apply the cream himself.
He was right. A review of his physician orders, printed March 11, 2025, showed no orders on file for Triamcinolone Acetonide Ointment, a corticosteroid cream, or for Nystop Topical Antifungal Powder, or for Milk of Magnesia. His electronic health record contained no self-administration assessment. The medications existed in his room, in use, entirely outside the facility's knowledge of what he was supposed to be taking.
Triamcinolone is not a minor product. It is a prescription corticosteroid. Used incorrectly or on the wrong skin conditions, it can cause skin thinning, infections, and systemic absorption. The antifungal powder carries its own risks if applied to conditions it is not intended to treat. Neither was ordered. Neither had been reviewed.
When the Director of Nursing was interviewed that afternoon, she walked inspectors through what the process was supposed to look like: a competency assessment to confirm the resident could safely apply the medication, a physician order authorizing self-administration, and a review by the interdisciplinary team before any approval. She then pulled up R20's electronic health record herself and confirmed that none of those steps had been taken.
She walked with inspectors to R20's room. The medications were on the nightstand, in plain sight.
The DON told inspectors that all staff are responsible for making rounds to check that medications are not left unsecured in residents' rooms, and that she expects staff to bring those concerns to her. She said R20 would need to be assessed.
He had not been.
The inspection report notes that staff were aware of the situation before inspectors arrived. At some point, staff had told R20 about the importance of compliance and the risks of taking medications that could be contraindicated. He had declined to hand them over. That conversation apparently ended there. No assessment followed. No physician order was sought. No escalation to the DON occurred, or if it did, nothing changed.
The facility did not dispute the findings.
The harm level was listed as minimal harm or potential for actual harm, a designation that reflects the absence of a documented injury rather than the absence of risk. A resident applying a prescription corticosteroid to his skin twice daily without any clinical oversight, for an indeterminate period of time, represents exactly the kind of gap that assessments exist to catch.
What the inspection does not say is how long the creams had been on that nightstand. R20 told inspectors he could not remember when he came back from the hospital. The medications were part of his daily routine. Staff had already had at least one conversation with him about surrendering them.
The DON's own summary of what should have happened makes the gap plain. There is a policy. There is a process. There is a form that should have been completed before any of this began.
None of it was done. And when inspectors left R20's room that afternoon, the creams were still there.
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
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 5, 2026 · Our methodology
BONTERRA TRANSITIONAL CARE & REHABILITATION in EAST POINT, GA was cited for violations during a health inspection on March 19, 2025.
The creams were sitting on his nightstand when inspectors arrived in March.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.