Bonterra Transitional Care: Staple Removal Delayed - GA
The resident, identified in inspection records as R71, had a medical appointment scheduled for March 11, 2025, to have her staples removed. She missed it because of transportation problems. Federal inspectors who arrived at the facility on March 19 found that the appointment had never been rescheduled, that R71 had told staff she was in pain, and that her skin had grown tight around the staples still in her body. The Centers for Medicare and Medicaid Services rated the lapse as causing actual harm.
The East Wing Unit Clerk, the staff member responsible for coordinating transportation for appointments on that unit, told inspectors on March 14 that she knew about the missed appointment. She knew R71 was supposed to have her staples removed. She knew R71 had complained of pain and that her skin felt tight around the staples. What she had done with that knowledge was assume the clinic had called R71 directly to reschedule.
The clinic had not called. The appointment had not been rescheduled. R71 remained in pain.
When the Director of Nursing spoke with inspectors on the final day of the survey, March 19, she described a system that existed on paper. Missed appointments, she said, should trigger a grievance. Unit Clerks should maintain a log of appointments, which gets passed to the Unit Manager to verify everything is on track. The transportation company requires 72 hours advance notice. A lot of residents, she added, make their own appointments.
R71 had not made her own appointment. She had told staff her skin was tight. She had told them she was in pain. The Unit Clerk had heard her and done nothing beyond assuming the problem had resolved itself somewhere down the line.
There is a particular kind of institutional failure that doesn't involve anyone acting with malice. It involves a unit clerk who coordinates transportation deciding, without checking, that a clinic had probably called a resident back. It involves a log that should exist on a unit. It involves a Director of Nursing explaining, after the fact, what the process is supposed to look like. None of it required cruelty. It required only that no one followed through.
The inspection report does not say when R71's staples were finally removed, or what condition her skin was in by the time inspectors arrived eight days after the missed appointment. It does not say how long she had been telling staff she was in pain before the March 11 appointment was missed in the first place. What it says is that she told the people around her that something was wrong, and that the people around her assumed someone else was handling it.
The Director of Nursing told inspectors the facility would contact the center to reschedule missed appointments. That is what she said the process requires. The Unit Clerk on the East Wing knew about the missed appointment and the pain and the tight skin and did not contact anyone. Those two facts sat side by side in the inspection record without resolution.
R71's staples needed to come out. She said her skin was tight. She said she was in pain. The appointment had been on the books, then it wasn't, and no one at Bonterra Transitional Care made sure it got put back.
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 as R71, had a medical appointment scheduled for March 11, 2025, to have her staples removed.
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.