Bonterra Transitional Care: Pureed Diet Failures - GA
No recipe. No measured broth. No consistent serving count.
Inspectors observed the preparation on March 11, 2025, at 1:54 in the afternoon. The worker, identified in the report only as a dietary food service employee, told inspectors she was making 10 servings and would use 15 scoops of boiled carrots. As she worked, she ran short of carrots and revised the plan on the spot, down to 7 servings and 9 scoops. When she added broth to the blender, she poured directly from a jug without measuring. Asked how she knew how much to add, she said she had worked in the kitchen a long time and simply knew.
The Dietary Kitchen Manager was standing in the room watching.
When inspectors asked the worker what consistency she was aiming for, she said mashed potatoes. The kitchen manager cut in to correct her: it was supposed to be mousse-like. The two descriptions are not the same, and the distinction matters. For residents on pureed diets, which are ordered by physicians or dietitians specifically because of swallowing or chewing difficulties, the wrong texture can mean a resident cannot safely eat the food placed in front of them.
The worker then reached under the table and produced a binder, telling inspectors it contained the recipe she had been following. It didn't. The recipe in the binder did not match the number of servings she had made, and it did not match the ingredients she had used.
Six residents at the facility were on pureed diets at the time of the inspection.
A week later, on March 18, the kitchen manager told inspectors the facility was in the middle of switching from one menu system to another. She confirmed there was no recipe being followed. She said the old recipe was no longer in use because the facility had stopped using thickeners. Asked what could go wrong without a recipe, the manager said residents might not get food at the right consistency, and that could cause them harm.
The facility's own policy, last revised in September 2017, states that modified-texture diets are prepared in accordance with an approved diet manual and each resident's individual plan of care. The type of texture modification is required to be specific and part of a physician's or dietitian's order.
On March 19, the last day of the inspection, the administrator told inspectors that kitchen staff should follow a recipe to get the right consistency when preparing pureed food.
Should. Not do. Should.
The violation was cited at the level of minimal harm or potential for actual harm, which in the language of federal inspections means no documented injury was found but the conditions created meaningful risk. For the six residents eating food prepared this way, the risk was real and recurring. Each meal prepared without a recipe was another instance of someone guessing at the texture their physician had ordered.
The kitchen manager knew the recipe wasn't being followed. The administrator knew staff should be using one. The worker knew, when asked directly, that she was supposed to measure the broth, and said she would start doing so in the future.
The carrots went into the blender anyway.
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 3, 2026 · Our methodology
BONTERRA TRANSITIONAL CARE & REHABILITATION in EAST POINT, GA was cited for violations during a health inspection on March 19, 2025.
Inspectors observed the preparation on March 11, 2025, at 1:54 in the afternoon.
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.