Bonterra Transitional Care: Oxygen Monitoring Failures - GA
The inspection, completed March 19, 2025, identified the failure as a deficiency affecting a small number of residents. Inspectors rated the level of harm as minimal or potential for actual harm, the lower end of the federal scale. But the finding exposed a gap between what nurses said they were supposed to do and what was actually happening on the unit.
Three licensed practical nurses, interviewed separately over two days, each described the same protocol. A nurse going into a resident's room on oxygen was supposed to check the physician's order, confirm the concentrator was set to the correct rate, and verify that the tubing and humidification bottle were connected properly. One of the nurses, identified in the report as LPN JJ, described it plainly: check the order, confirm the concentrator matches, make sure the equipment is connected.
The director of nursing said the same thing when inspectors interviewed her on March 12. All residents on oxygen should be checked daily by the nurse on their unit. That was the expectation.
What the inspection found was that it wasn't happening consistently.
Oxygen concentrators work by pulling air from the room and filtering out nitrogen, delivering concentrated oxygen to the resident through a tube. The rate, measured in liters per minute, is set by a physician based on what the resident's lungs need. A concentrator set too low means a resident isn't getting the oxygen their doctor determined they required. A concentrator set too high carries its own risks. Neither outcome is what the physician ordered, and neither is what the resident was supposed to receive.
The inspection report notes that nursing staff were responsible for checking the oxygen rate, the resident's oxygen saturation, the date on the tubing, and the humidification bottle. LPN HH, interviewed on the morning of March 11, described this as standard nursing practice at the facility. LPN LL, interviewed about twenty minutes later, said nurses were supposed to check the concentrator every time they entered a resident's room.
Three nurses giving identical answers about what the protocol requires, and a director of nursing confirming it, is not evidence that the protocol was being followed. It is evidence that everyone knew what they were supposed to do.
The inspection report does not name the residents who were affected, does not specify how long concentrators were set at incorrect rates, and does not describe what the residents experienced. The deficiency tag attached to this finding covers ensuring that residents receive proper treatment and care for respiratory conditions, including the accurate delivery of oxygen at physician-ordered rates. The report notes the deficiency affected few residents.
Bonterra Transitional Care & Rehabilitation is located at 2801 Felton Drive in East Point, a city southwest of Atlanta in Fulton County. The facility operates as a transitional care and rehabilitation center, meaning many of its residents are recovering from surgeries, strokes, or other acute medical events and may have compromised respiratory function that makes accurate oxygen delivery more consequential, not less.
The director of nursing confirmed to inspectors that daily oxygen checks by floor nurses were the facility's standard. She did not dispute the finding.
For the residents on oxygen at Bonterra during the period inspectors examined, the question of whether their concentrators were set correctly was one that nurses were supposed to answer every single day. The inspection found that question was going unanswered.
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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Last verified: November 6, 2026 · Our methodology
BONTERRA TRANSITIONAL CARE & REHABILITATION in EAST POINT, GA was cited for violations during a health inspection on March 19, 2025.
The inspection, completed March 19, 2025, identified the failure as a deficiency affecting a small number of residents.
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.