Bonterra Transitional Care: Missing Oxycodone Records - GA
Federal inspectors documented the incident at Bonterra Transitional Care & Rehabilitation during a March 2025 survey, and what they found raised questions that the facility's own director of nursing acknowledged needed to be investigated and reported.
The patient, identified in inspection records as Resident 71, told inspectors she had taken three oxycodone pills during her stay. Nobody had told her how many she was supposed to take, what the dose was, or how long the prescription ran. The first she knew it was over was when staff told her she had no more medication.
The director of nursing confirmed that the proper dose was one tablet. She pulled up the medication administration record for February and found no documentation showing the oxycodone had been given on the date in question. She also had in hand a written statement from LPN HH saying she had administered the medication. The DON told inspectors she believed LPN HH had simply forgotten to click on the PRN tab in the electronic record when she gave the pill.
That explanation began to fall apart when inspectors spoke with LPN HH directly.
The nurse said the facility had called her and told her she needed to return and write a statement saying she gave Resident 71 oxycodone on that date. When she arrived, staff told her she had forgotten to sign off on the medication administration record. LPN HH said she asked immediately where the controlled drug sheet was, because that was the document that would tell her whether she had actually dispensed the medication. The facility's response: the controlled drug sheet was missing.
LPN HH told inspectors she does not recall giving the medication. She said she told the facility that, and they told her she still had to write the statement.
The DON, in a separate interview, described the facility's standard process. Nurses count medications each shift. A manager conducts audits weekly. She said she expects nurses to follow the diversion policy and ensure medication is secured, dispensed according to orders, and documented. The administrator said the same thing in different words: the DON is responsible for ensuring processes are followed.
Neither interview addressed what happens when a controlled drug sheet disappears.
The inspection report cross-references F609, the federal tag covering a facility's obligation to report and investigate allegations of mistreatment, neglect, and misappropriation of resident property, which includes controlled substances.
What the record shows is this: a patient received opioid medication without being told her dose or her treatment duration. The documentation of whether that medication was given on at least one date does not exist. The secondary record that tracks controlled substances, the one that would resolve whether the pill was dispensed or not, is missing. And a nurse who said she could not confirm she gave the medication was called back to the building and asked to write a statement saying she did.
Resident 71 told inspectors she took three pills. The math of what should have remained in the facility's supply, the DON confirmed, needed to be investigated.
Whether that investigation happened, and what it found, is not recorded in the inspection documents.
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 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 patient, identified in inspection records as Resident 71, told inspectors she had taken three oxycodone pills during her stay.
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.