Bonterra Transitional Care: Missing Oxycodone Unreported - GA
The resident, identified in inspection records only as R71, arrived at the facility with a hospital discharge order for oxycodone. The pharmacy confirmed it filled the order on February 6, 2025, dispensing 10 tablets to be taken every four hours over two days. R71 told inspectors she took three pills before a nurse told her one day that she simply had no more medication left. Nobody had explained her dosage to her, she said, or how many days the prescription was supposed to last.
"All she knew was that one day they informed her she did not have any more," the inspection report states.
The math doesn't resolve cleanly. The pharmacy sent 10 tablets. R71 says she took three. That leaves seven pills with no documented trail. The controlled drug sign-in and sign-out sheet that facilities use to track narcotics — the record that would show who administered each dose and when — was missing entirely. The Director of Nursing told inspectors on March 14 that she had not been able to find R71's control drug sheet for the oxycodone.
The Medical Director learned about the missing pills not from the Director of Nursing, but from inspectors. During an interview on March 18, she said she had known R71 arrived with 15 tablets total and that the facility had contacted her when the medication ran out, asking to switch R71 to Tramadol for pain. What she had not been told was that the control sheet had vanished or that the narcotic count was unresolved.
She was direct about whose job it was to tell her. The Director of Nursing, she said, is responsible for monitoring narcotics, ensuring audits are conducted weekly, and reporting any concerns up the chain.
The Director of Nursing acknowledged on March 19 that missing narcotics should be reported immediately to the state survey agency. The administrator said the same thing, in a separate interview four minutes later. Both confirmed that misappropriation of property involving narcotics is a reportable offense. Neither explained why no report had been made.
A nurse interviewed during the inspection described the facility's standard protocol for controlled substances: once a medication is finished, staff gather the medication card and the narcotic sign-in and sign-out sheets and turn them in to the Director of Nursing. If there's a discontinued order, the leftover medication goes to the Director of Nursing along with the paperwork. The facility does not keep narcotics on the floor.
That protocol, by the facility's own account, was not followed for R71.
CMS inspectors classified the violation as causing minimal harm or the potential for actual harm, with few residents affected. The inspection was completed March 19, 2025.
R71 finished her recovery without knowing how many pain pills she had been prescribed, without being told her dose, and without anyone at the facility accounting for what happened to the ones she never received. When the oxycodone ran out, the nurses switched her to something else. The paperwork that might have explained it all was nowhere to be found.
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.
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Last verified: November 4, 2026 · Our methodology
BONTERRA TRANSITIONAL CARE & REHABILITATION in EAST POINT, GA was cited for violations during a health inspection on March 19, 2025.
The resident, identified in inspection records only as R71, arrived at the facility with a hospital discharge order for oxycodone.
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.