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Bonterra Transitional Care: Dental Care Neglect - GA
What they found was not a complicated system failure....
Latest reports, citations, and penalties from CMS data
What they found was not a complicated system failure....
The form shapes what services a resident is offered and what follow-up evaluations get triggered....
Resident 72, whose diagnoses included dementia, hypertension, and failure to thrive, had a physician's order requiring Hydralazine 100 mg three times a day....
None of those findings were new....
The violation was classified as causing minimal harm or potential for actual harm and was found to affect some residents....
The citation, issued August 11, 2025, fell under the category of environmental deficiencies....
The nursing director, identified in inspection records as DON-B, explained to a surveyor on March 4 how the binder came to be used in the first place....
None of it matched what the nursing assistant or the floor nurse said actually happened....
The ice machine problem surfaced first....
CNA #4 described what happened when the count dropped to two: aides would try to track down a nurse to help....
That is what a federal inspection in March 2025 found at the 211 S....
The resident, identified in inspection records only as R13, wanted to be out of bed by 6:30 AM....
That happened on February 8, 2025, at New Riverdale Rehab and Nursing on West 230th Street....
RN N, as the nurse is identified in the inspection report, walked inspectors through the logistics....
The Director of Nursing confirmed it herself, in an interview on March 20, 2025, at 10:30 in the morning....
The resident also had hypertension and anemia....
The resident, identified in inspection records only as Resident 53, was on dialysis and taking levetiracetam, a medication used to prevent seizures....
When staff on the 11:00 PM shift were asked about it, they confirmed it....
Inspectors from the Centers for Medicare and Medicaid Services visited the facility at 535 McFarland Road on March 17, 2025, and found the lapse themselves....
Federal inspectors documented the practice during a March 19 survey of the facility at 153 Johns Court....