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Bonterra Transitional Care Death: Choking Incident - GA
The resident was immediately transported to a local hospital following the incident....
Latest reports, citations, and penalties from CMS data
The resident was immediately transported to a local hospital following the incident....
The resident's medical history revealed a complex case requiring intensive monitoring....
The resident's medical history made accurate oxygen delivery particularly critical....
However, when the resident complained again about bilateral leg swelling three days later on February 24, the medication had still not been provided....
Suicidal behaviors in elderly residents require immediate assessment and ongoing monitoring....
Two residents received incorrect medications that posed serious health risks....
This incident represents a fundamental failure in the facility's duty to protect vulnerable residents from harm....
These committees must meet regularly to review data, investigate incidents, and implement corrective measures to ensure resident safety and well-being....
The violations centered on fundamental nursing care tasks that are considered standard practice in long-term care facilities....
On February 26, 2025, Resident 103 called police from the facility, reporting that she felt unsafe due to a CNA's behavior....
on the inspection date, the Director of Nursing (DON) stated she was completely unaware that R15 had experienced any bruising....
Inspectors found various prescription and over-the-counter medications improperly stored where residents could access them without supervision....
The facility had only submitted the basic Facility Reported Incident (FRI) form to the state agency, which contained minimal information about the incident....
## Regulatory Violations Found The inspection revealed that the facility failed to properly manage the use of bed side rails according to federal standards....
The violations centered around unlabeled, unrefrigerated perishable foods that posed risks of foodborne illness and pest attraction....
The Nursing Home Administrator confirmed during a June 27, 2024 interview that all five quarterly MDS assessments were indeed completed late....
Inspection records revealed that staff failed to administer prescribed breathing treatments on multiple occasions in March 2025....
One resident with atrial fibrillation, cardiomyopathy, and heart failure experienced repeated delays in receiving critical medications throughout June 2024....
Two residents experienced dangerous delays in receiving ordered laboratory work that could have detected serious health problems....
Multiple staff members interviewed during the overnight inspection confirmed the staffing crisis....