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Bonterra: Missing Narcotics, Choking Death GA
However, facility staff failed to follow these protocols....
Latest reports, citations, and penalties from CMS data
However, facility staff failed to follow these protocols....
Multiple residents reported waiting **30 minutes to over an hour** for their call lights to be answered, creating serious health and safety risks....
The violations affected staff across multiple departments, including certified nursing aides, housekeeping, and maintenance personnel....
A resident with dementia and other serious conditions had previously signed a Do Not Resuscitate (DNR) order requesting no CPR....
One particularly concerning case involved a resident who wandered into another resident's bedroom unsupervised on March 14, 2025....
However, the facility's care plan, initiated February 24, 2025, contained no documentation of the resident's need for or use of these mobility aids....
On October 3, 2024, nursing staff discovered maggots in the resident's right heel wound during a routine dressing change....
State inspectors found that kitchen staff routinely deviated from established recipes without proper authorization or documentation....
This regulation serves as a cornerstone of resident safety in long-term care facilities....
Three of these individuals had been employed in nursing roles since 2021, while two others had worked without proper licensing since 2023....
The resident reported experiencing pain at a 7 out of 10 level during wound dressing changes....
Despite this nurse providing a written statement about what she observed, facility administration conducted no thorough investigation....
This admission came after surveyors observed the protocol violation during their inspection....
The resident, who required complete staff assistance for movement and changing of incontinence products, was observed at 12:19 p.m., 4:29 p.m., and 4:51 p.m....
When blood oxygen saturation falls below 90%, tissues and organs begin receiving insufficient oxygen, a condition called hypoxemia....
No documentation was provided before the inspection concluded....
Resident 37, diagnosed with Huntington's Disease and dementia, had documented behaviors of banging their head against walls and punching walls....
Controlled substances require strict monitoring because of their potential for abuse and dependency....
The administrator, identified as S1ADM in the report, acknowledged to inspectors that **a 51-minute wait for changing soiled clothing was unacceptable**....
The inspection revealed systemic breakdowns in basic safety protocols affecting multiple areas of resident care....