EAST POINT, GA - Federal inspectors found immediate jeopardy to resident health and safety at Bonterra Transitional Care & Rehabilitation after a resident who required a mechanically altered diet was given a regular sandwich, leading to their hospitalization and subsequent death.
Fatal Dietary Violation Triggers Federal Investigation
During a March 2025 inspection, federal surveyors discovered that facility staff had failed to follow the care plan for Resident 165, who was prescribed a mechanically altered diet but received inappropriate food. Video surveillance reviewed by the facility administrator showed a Certified Nursing Assistant handing the resident a regular sandwich instead of the required pureed snack.
The resident was immediately transported to a local hospital following the incident. However, instead of returning to the nursing facility as expected, Resident 165 was transferred to a hospice facility and died shortly thereafter. The administrator confirmed during interviews that she was aware of the incident and had personally reviewed the facility's security footage.
This violation represents one of the most serious categories of nursing home deficiencies - immediate jeopardy - indicating that the facility's actions or inactions created a situation where residents faced the risk of serious injury, harm, impairment, or death.
Understanding Mechanically Altered Diets and Safety Protocols
Mechanically altered diets are prescribed for residents who have difficulty swallowing safely, a condition known as dysphagia. These modified textures - including pureed, minced, or soft foods - are critical safety measures designed to prevent choking and aspiration pneumonia, which occurs when food or liquid enters the lungs instead of the stomach.
When residents with swallowing difficulties consume regular-textured foods like sandwiches, they face significant risks. The airway can become blocked, leading to choking. Even if immediate choking doesn't occur, small particles can enter the respiratory system, potentially causing life-threatening pneumonia. These complications can rapidly become medical emergencies requiring immediate intervention.
Medical protocols mandate that dietary restrictions be strictly followed without exception. Care teams must verify each resident's dietary requirements before meal service, ensure all staff understand specific restrictions, and implement multiple safety checks throughout the food distribution process.
Widespread Infection Control Deficiencies
Inspectors identified systemic failures in the facility's infection prevention and control program affecting all 114 residents. The Infection Preventionist failed to maintain essential surveillance documentation, including missing infection criteria sheets, incomplete monitoring data, and gaps in tracking for September and November 2024.
The facility's antibiotic stewardship program showed significant deficiencies in monitoring protocols. Essential elements were missing including laboratory follow-up orders, resolution dates for antibiotic treatments, complete clinical documentation of signs and symptoms, and tracking of infections in residents admitted from hospitals.
These infection control failures create serious risks for vulnerable nursing home populations. Without proper surveillance, outbreaks can spread rapidly through facilities. Inadequate antibiotic monitoring can lead to antimicrobial resistance, treatment failures, and prolonged infections. Missing laboratory follow-up means infections may go undetected or untreated, potentially progressing to life-threatening complications like sepsis.
Effective infection control requires systematic data collection, consistent monitoring protocols, and regular analysis of infection patterns. The facility's gaps in these fundamental processes left residents exposed to preventable health risks.
Call Light System Violations Compromise Safety
Inspectors documented concerning violations related to the facility's call light system, which serves as a critical safety lifeline for residents requiring assistance. Staff were observed telling a cognitively impaired resident "Don't push for nothing" repeatedly when he used his call device, and the call system cord was later found disconnected from the wall.
The affected resident had severe cognitive impairment with a Brief Interview for Mental Status score of six, indicating significant limitations in understanding and communication. His care plan specifically instructed staff to "encourage the resident to use the bell to call for assistance," yet nursing staff actively discouraged its use.
Call light systems represent the primary communication method between residents and caregivers, particularly for individuals who cannot walk or speak clearly. When these systems are compromised or access is restricted, residents face increased risks of falls, medical emergencies going unnoticed, and inability to request help with basic needs like toileting or pain management.
Federal regulations require that call systems remain accessible and functional at all times. Staff responses should be prompt and respectful, recognizing that frequent calls may indicate unmet needs rather than inappropriate behavior.
Inadequate Behavioral Health Training Creates Care Gaps
The facility demonstrated systematic failures in providing appropriate behavioral health training despite serving residents with complex mental health conditions including schizophrenia, post-traumatic stress disorder, and schizoaffective disorders. Multiple staff members across all departments confirmed they had received no training specific to these conditions.
Facility records showed only one behavioral health training session in the past year, conducted by an outside company in March 2024. Staff interviews revealed widespread knowledge gaps: a Certified Nursing Assistant who had worked nine years stated she had "never discussed schizophrenia" in training, while others asked "What is that?" when questioned about PTSD training.
This training deficit is particularly concerning given the facility's resident population. Care plans documented residents with complex behavioral presentations including verbal aggression, suicidal ideations, and trauma-related responses. Without proper training, staff cannot recognize warning signs, implement appropriate interventions, or respond effectively to behavioral crises.
Evidence-based care for residents with mental health conditions requires specialized knowledge about triggers, de-escalation techniques, and person-centered approaches. Staff must understand how conditions like PTSD can affect daily care activities and develop strategies that respect residents' dignity while ensuring safety.
Additional Issues Identified
The inspection revealed several other concerning practices that compromised infection control and resident care standards. Housekeeping staff transported uncovered laundry carts through facility hallways, exposing clean clothing to potential contamination. Personal clothing items were inappropriately stored in unit linen carts, creating cross-contamination risks.
These seemingly minor violations reflect broader systemic issues with staff training and adherence to established protocols. Proper infection control requires consistent attention to detail across all departments, not just clinical staff.
Corrective Actions and Ongoing Oversight
Following the identification of immediate jeopardy, the facility implemented emergency corrective measures including staff retraining, enhanced oversight protocols, and systematic auditing of dietary services. The immediate jeopardy designation was removed after inspectors verified that adequate corrective actions had been implemented.
However, the scope and severity of violations identified during this inspection highlight the importance of sustained quality improvement efforts and ongoing regulatory oversight to ensure resident safety and appropriate care standards.
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.
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