Bonterra Transitional Care & Rehabilitation

Findings included: A review of the facility's policy titled Cleaning and Disinfecting Residents' Rooms with the revision date of November 2020 revealed that the walls, blinds, and window curtains in residence areas will be cleaned when these surfaces are visibly contaminated or soiled.

The staff will clean curtains, window blinds, and walls when they are visibly soiled or dusty.

A review of the facility's policy titled 5-Steps to Room Cleaning revealed that the facility staff will spot clean walls daily using a clean rag, spot clean light switches, door handles, and walls.

During observations on 3/10/2025 at 11:25 am, room [ROOM NUMBER] was observed with brown stains on the wall located to the left of the entrance.

During an interview conducted on 3/10/2025 at 11:25 am, R19 stated that the brown stains on the wall are feces from his roommate throwing feces against the wall. R19 further stated that the stains have been there for a while.

During an observation on 3/11/2025 at 10:02 am, room [ROOM NUMBER] was observed to still have brown stains on the wall located to the left of the entrance During an interview on 3/12/2025 at 11:30 am, Housekeeping Aide EEE revealed she has been working at the facility for a year and that her job responsibilities include cleaning, sweeping, mopping, and cleaning the edges of the rooms and walls.

She stated she did not pay attention to the brown stains on the wall, and that is why they were not cleaned.

During an interview conducted on 3/13/2025 at 10:09 am, the Housekeeping Director revealed that he has been working in the facility for about three months. He stated that it is expected that if the housekeeping aides find spots on the walls, they are expected to clean them.

During an interview conducted on 3/19/2025 at 5:39 pm, the Administrator revealed her expectations to be that the resident's walls are cleaned and maintained in a clean, sanitary environment.

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Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

During an interview on [DATE] at 5:49 pm, the DON confirmed R71 should be administered one tablet dose of oxycodone.

While looking at the MAR, physician's orders, and timecard, the DON confirmed that LPN DD would have been the last nurse to administer R71's medication.

She confirmed while looking at the MAR for February, there is no documentation to determine that medication was administered on [DATE], along with LPN HH's written statement stating she had given R71's medication. DON stated LPN HH probably forgot to click on the PRN tab in the MAR when she administered the medication.

The DON verified the administered medication count and the amount of pills that should be remaining, and this should be investigated and reported.

During an interview on [DATE] at 9:59 am, LPN HH revealed the facility called her on [DATE] and told her she had to return to the facility and write a statement stating she gave R71 oxycodone on [DATE].

She stated that when she returned to the facility, they told her she forgot to sign off on the MAR. LPN HH further asked where the control drug sheet was, stating she gave R71 the medication because that would help her verify if she gave the medication. In return, the facility told LPN HH that the problem is that the control drug sheet is missing. LPN HH continued to express to the facility that she does not recall her giving the medication and told her she still had to write a statement.

During an interview on [DATE] at 5:27 pm, the DON revealed that the receiving nurse is responsible for following the orders as they come in.

She stated she expects the nurses to count each shift, the manager conducts their audits weekly.

During an interview on [DATE] at 5:31 pm, the Administrator revealed that the DON is responsible for ensuring processes are followed.

She expects the Nursing Department to follow the diversion policy and ensure the medication is secured, dispensed according to the orders, and documented. [Cross Reference - F-F609]

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Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

During an interview with the DON on 3/14/2025 at 10:54 am, she stated that she had not found R71's control drug sheet for her oxycodone medication.

During a telephone interview on 3/14/2025 at 11:39 am, the Pharmacy stated they received the hospital discharge order from the facility and changed the order to oxycodone 10 tablets for two days every four hours.

The pharmacy stated this order was signed for 2/6/2025 and 5:30 am.

During an interview on 3/15/2025 at 9:27 am with R71, she stated that she took three pills of her oxycodone, but the nurses did not inform her how many days she was supposed to be taking the medication and the dose amount.

She stated that all she knew was that one day they informed her she did not have any more.

During an interview on 3/18/2025 at 10:28 am, the Medical Director (MD) revealed she was aware R71 came in from the hospital with 15 tablets of her oxycodone.

She stated the facility reached out to her, informing her R71 had finished up her medication and needed to switch her to Tramadol (pain reliever).

She revealed the DON did not notify her of R71 narcotic situations.

The Medical Director continued to state that the DON is responsible for monitoring narcotics and ensuring audits are conducted weekly.

Lastly, if there are any concerns, the DON should report them.

During an interview on 3/19/2025 at 5:27 pm, the DON confirmed misappropriation of property related to narcotics is a reasonable offense that should be reported.

Any other investigation for missing narcotics would be reported to the SSA immediately.

During an interview on 3/19/2025 at 5:31 pm, the Administrator confirmed that misappropriation of property related to narcotics should be reported to the SSA.

115555 03/19/2025

Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

During an interview conducted on 3/18/25 at 10:25 am, DON stated PASARR Level II is determined on admission and as needed, and residents are referred over to psychiatric services if they have any mental disorder or intellectual disability.

The DON revealed the inter-disciplinary team (IDT) is responsible for determining who is eligible for PASSAR Level II and stated the SW has the sole responsibility for determining which residents are eligible for PASSAR Level II.

She stated she was not aware that PTSD was a mental disorder.

The DON stated her expectations are that the SW follows the facilities policy regarding PASARR Level II, and a possible negative outcome could be that residents don't receive the correct services.

During an interview on 3/19/2025 at 5:34 pm, the Administrator stated that the process for conducting the PASARR for new residents includes that a PASARR Level I is completed on the resident prior to admission. If the resident triggers based on mental health or intellectual disabilities, with the caveats of a diagnosis of Alzheimer's or dementia, that could cancel out the need for a PASARR Level II.

She further stated that this should be done prior to admission because the purpose is to identify proper placement related to the conditions of the residents.

The Administrator further stated that if the resident does not have Alzheimer's or dementia, he or she certainly should have PASARR Level II.

She further stated that potential negative outcomes include that the facility may not be an appropriate placement and might not receive services that could benefit the residents.

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Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

jeopardy to resident health or residents who received appropriate meal trays. safety A review on 7/26/2024 revealed that the Snack Distribution Aduit was completed at 100% for all

A review of the all-staff education documented Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy were reviewed and completed by the Food Service Director and Director of Nursing.

A review of the QAPI Committee minutes revealed all audit findings were discussed and in place.

A review of the sign-in sheet revealed that the Ad Hoc QAPI meeting was held on 7/25 2024.

• New interventions will be monitored by the DON daily for six months for effectiveness using the

audit tools Daily Diet Verification Audit, and Snack Distribution Audit to ensure this deficient practice does not reoccur. If a problem is identified, it will be addressed by the Food Service Director, Administrator, DON, and Medical Director.

All parties including the resident, the resident's responsible party, the Medical Director, the Administrator, the DON, and the Food Service Director will meet to discuss the policy's violation. If there is a problem and all parties cannot agree, there will be an Ad Hoc QAPI meeting with the Consultant Operations Consultant and possible corrective action.

An interview was conducted on 3/18/2025 at 1:15 pm with the administrator revealed the DON is responsible for overseeing the daily audits.

Interview on 3/18/2025 at 2:53 pm with DON, she stated there were no errors.

She said no one received the incorrect tray during the audits.

• All dates of corrective action for staff will be completed on 7/29/2024.

The facility alleged that the IJ was removed on 7/30/2024.

All dates of corrective actions were completed on 7/29/2024.

The facility's IJ was determined to be Past Noncompliance, removed on 7/30/2024.

115555 03/19/2025

Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

Findings included: A review of the facility's policy titled, ADL Care-Bath (Shower) Hygiene Care with a revised date of April 2024, documented under the section action (8), encourages residents to do as much of his/her own care as possible, supervise and assist residents as necessary.

Clean and trim nails as needed.

A review of the electronic medical record (EMR) revealed that R47 was admitted to the facility on [DATE] with a diagnosis of non-ST-elevation myocardial infarction (heart attack) and metabolic encephalopathy (impaired brain functioning).

A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that R47 presented with a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment and was dependent on staff for personal hygiene care.

A review of the care plan dated 1/19/2025 revealed R47 had a preference of refusing activities of daily living (ADL) care, bathing, and changing clothes as follows: R47 will change clothes once a week.

Prefers not to shave or trim beard, refuses podiatry care. He has long fingernails and toenails.

Refuses showers also.

During an observation on 3/10/2025 at 12:06 pm with R47 in his room, revealed that his fingernails were observed to be long and curled with a dark substance underneath. He states his fingernails have been long for a while, and he has expressed to staff he would like them to cut. He stated that the staff would tell him, Oh, your nails are really long, but they do not do anything about it.

During an observation on 3/11/2025 at 9:49 am with R47 revealed his fingernails were long with dark substance underneath. R47 confirmed that he does not refuse to get his fingernails cut or refuse nail care. He stated someone came into his room that morning and attempted to cut the tips of his nails, but did not cut them all the way down, and did not clean underneath the nails.

The nails were observed to still be long with dark substance underneath.

During an interview on 3/12/2024 at 12:05 pm, Certified Nurse Assistant (CNA) BBB stated that ADL care consists of nail care, hair care, and bathing. CNA BBB stated nails should be cut every two weeks, and depending on the resident, nail care is carried out by podiatry, or if the resident is diabetic, then the nurses have to cut their fingernails. CNA BBB continued to state she is familiar with R47 and has noticed his nails are long with dark substance underneath.

She revealed she is not sure what the dark substance underneath his nails is, it could possibly be food.

Furthermore, CNA BBB confirmed R47's nails did not look like they were cut within two weeks, and they were still long with a dark substance underneath.

During an interview on 3/19/2025 at 5:20 pm, the Director of Nursing (DON) revealed R47 was care planned for refusals and stated he won't allow the staff to get them down.

She further stated ADLs should be done daily, and staff should attempt to conduct fingernail care if the resident allows.

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Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

diets, and all the issues found were discussed in the QAPI meeting.

She stated the audits were

jeopardy to resident health or safety 7.

All dates of corrective action for staff were alleged by the facility to be completed on 7/29/2024.

The facility alleged that the IJ was removed on 7/30/2024.

All dates of corrective actions were validated as completed on 7/29/2024.

The facility's IJ was determined to be Past Noncompliance, removed on 7/30/2024.

115555 03/19/2025

Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

During an interview on 3/12/2025 at 11:41 am, R20 stated he could not remember when he went to the hospital and stated that the medications are cream for his feet, hands, and arms. He states they occasionally feel raw, and he uses it daily and nightly on his rashes. He continued to state that the staff have never assessed him for being able to administer the cream on himself.

During an interview on 3/12/2025 at 4:09 pm, the DON stated that the facility has a policy for self-administration of medications in the event a resident would like to administer their own medication.

She stated that the process would involve that an assessment would be conducted for the residents to ensure they can safely administer or apply it correctly, an order from the Medical Director (MD) for self-administration, and discussion with the IDT team before approval.

Further, the DON reviewed R20's EHR and confirmed he does not have an assessment for self-administration of medication.

During an observation with the DON of R20's room, it was confirmed that there was prescribed medication on his nightstand.

The DON informed that R20 would need to be assessed to self-administer the medications.

She further confirmed that all staff are responsible for making rounds to ensure medications are not in the residents' rooms, and she expects her staff to inform her of these concerns.

115555 03/19/2025

Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

During an interview on 3/11/2025 at 9:08 am, LPN LL revealed that the nursing staff are supposed to check physician orders for oxygen rate and then check the concentrator when they go into the resident's room to ensure it is set at the correct rate.

During an interview on 3/11/2025 at 9:26 am, LPN JJ revealed that the nursing staff checks the physician's order to confirm that the oxygen concentrator is set to the correct rate per the physician's order.

She stated they ensure that the oxygen tubing and the humidification bottle are connected properly.

During an interview on 3/12/2025 at 11:15 am, the DON confirmed that the nursing staff are responsible for checking oxygen rates.

She stated that all residents on oxygen should be checked daily by the nurse on the unit in which they reside.

115555 03/19/2025

Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

During an interview on 3/19/2025 at 5:39 pm, the Director of Nursing (DON) stated that all residents are assessed for pain via the pain scale every shift, and if there are any changes in condition, they proceed with a pain assessment.

She stated R71 has several interventions and medications in place related to her pain post-surgery.

She stated that if a resident's pain is unmanageable, they will be sent to the emergency department.

During an interview on 3/19/2025 at 5:39 pm, the Administrator confirmed that if pain is not properly managed, it can result in potential harm to a resident.

She stated that she expects staff to conduct pain assessments, notify the physician, follow the physician's recommendations, speak with the resident, and monitor the effectiveness of the pain management. [Cross Reference F-F774]

115555 03/19/2025

Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

During an interview on 3/14/2025 at 11:39 am, the Director of Nursing (DON) revealed that the medication carts should be locked at all times when staff are away from the cart unless they are stocking the cart.

The DON explained that residents should not go into a cart, and staff should be present to ensure that.

The DON revealed that she expected the medication carts to be locked and secured when out of the eyesight of the nurses and CMAs, and that medications should not be left unsecured.

The DON emphasized that the procedure was to keep the medication cart secure, and that she and the Staff Development Nurse had completed in-service.

115555 03/19/2025

Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

During an interview on 3/19/2025 at 5:25 pm, the Director of Nursing (DON) stated that if appointments are missed, a grievance should be filed.

They will contact the center to reschedule any missed appointments, but a lot of their residents make their own appointments, and the transportation company needs a 72-hour advanced notice.

She further revealed that the Unit Clerks should have a log on the unit that is provided to the Unit Manager to ensure appointments are made and are accurate. [Cross Reference - F-F697]

115555 03/19/2025

Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

During an interview on 3/18/2025 at 9:57 am, Certified Nursing Assistant (CNA) BBB revealed that

CNAs assist with brushing residents' teeth and report any broken, loose, or damaged teeth and oral pain to the nurse.

She stated she was not aware that R77 had any loose teeth.

During an interview on 3/18/2025 at 10:05 am, Licensed Practical Nurse (LPN) DDDD revealed that nurses conduct oral assessments for residents and should check daily for bad breath, lesions, missing teeth, loose teeth, rotten teeth, and any oral pain, which could lead to discomfort.

She further stated that if a resident has any of these, it should be charted to make a referral to the dentist.

During an observation at this time, LPN DDDD confirmed that R77 had one loose tooth and was missing all upper teeth. R77 told LPN DDDD that he was experiencing pain at this time. LPN DDDD confirmed this would indicate a referral to the dentist.

During an interview on 3/18/2025 at 10:17 am, Unit Manager LPN EE confirmed that R77 has not had a referral to the dentist.

She confirmed that R77 had physician orders that state a dental consultation and treatment as indicated and clarified that these indications include oral pain, cavities, and loose teeth. LPN EE stated that nurses are responsible for oral assessments, and this should be done quarterly.

She further confirmed the documented dental assessment dated [DATE], where the nurse marked yes, indicating R77 had a loose tooth. LPN EE confirmed that this should have been completed fully, indicating if a referral is needed.

She further stated that if there was a loose tooth indicated in the assessment, this oral assessment should have been given to the Social Services Director (SSD)for a dental referral.

During an interview on 3/18/2025 at 10:25 am, the SSD revealed that a resident must qualify to be a part of the in-house Medicaid dental program, otherwise, the facility would need to refer to an out-of-house dentist or the emergency room, depending on the urgency of need.

She stated the Medicaid program is the only in-house dental program, and this dentist comes in quarterly.

The SSD confirmed she was not aware of any referral to the dentist for R77 or of any loose teeth for R77.

She further confirmed that R77 qualifies for Medicaid dental benefits.

During an interview on 3/19/2025 at 5:00 pm, the Director of Nursing (DON) revealed oral assessments are done annually, but the facility conducts these more often than annually.

She stated that in the oral assessments, nurses look for any new missing teeth, oral pain, or loose teeth.

She further stated that potential negative outcomes for not having a dentist referral made timely manner for a resident could lead to pain or weight loss.

During an interview on 3/19/2025 at 5:32 pm, the Administrator revealed the facility offers a dental program funded by the resident's Medicaid. If a resident qualifies for this program, the dentist comes on-site. If a resident does not qualify for this program, appointments would be made with an outside dentist to serve the resident.

The Administrator further stated that potential negative outcomes for not having a dentist referral made for a resident include potential weight loss, pain, or not being able to eat or chew.

115555 03/19/2025

Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

Findings included: A review of the facility's policy titled Therapeutic Diets with a revision date of September 2017, it was documented that a mechanically altered diet means one in which the texture of the diet is altered.

When the texture is modified, the type of texture must be specific and part of the physician's or delegated registered or licensed dietician's order.

Diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care.

During an observation on 3/11/2025 at 1:54 pm, [NAME] FF was observed prepping for the puree observation and the Dietary Kitchen Manager (DKM) was observing KC FF.

The DKM revealed [NAME] FF was pureeing boiled carrots. [NAME] FF stated she was pureeing carrots for 10 servings, and she was going to use 15 scoops. No formal recipe for guidance was noticed.

When asked how she was measuring the scoops she stated she was using a 4 oz ladle scoop. As [NAME] FF was scooping the carrots it was observed there was not enough carrots and she changed her serving size to 7 servings and 9 scoops of boiled carrots. [NAME] FF stated that the carrots were cooked in chicken base broth, and it was observed that there was jug of yellow broth. [NAME] FF proceeded to puree the carrots, and she was seeing pouring some of the chicken base broth without measuring and proceeded to puree again.

When asked what consistency she was pureeing she stated, mashed potatoes consistency, then DKM manager proceeded to say it is supposed to be mousse-like consistency.

When asked how she measured the broth to know how much to add She indicated that, based on her experience working in the kitchen for a long time, she simply knows how much to add. [NAME] FF acknowledged she is supposed to measure the broth and stated she will measure it in the future.

When asked what recipe she was using she pulled a binder from underneath the table and showed the recipe she stated she was following.

However, the recipe provided did not coincide with the number of servings pureed or ingredients.

During an interview conducted on 3/18/2025 at 9:37 am, the DKM stated that they are in the process of changing their menu system from one system to another. DKM confirmed that there was no recipe followed, and the recipe provided was no longer used since they don't use thickeners. DKM stated a possible negative outcome for not following a recipe is not getting the right consistency of food and that it may cause harm to the residents During an interview conducted on 3/19/2025 at 5:40 pm, the Administrator revealed the kitchen staff should follow a recipe to get the right consistency when preparing pureed food.

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Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

During an interview conducted on 3/18/2025 at 9:37 am, DM revealed that the expectation is that the staff members date and label items in the pantry, cooler, and freezer.

The DM stated that some possible negative outcomes from food items not being properly labeled could be that staff members don't know when to use the product they have and how long it's been in-house.

During an interview conducted on 3/18/2025 at 3:03 pm, the Maintenance Director stated he is responsible for cleaning the ice machine twice a month and that it is the facility's policy to do it at a minimum once a month.

After being shown a photo of the debris found in the ice machine, the Maintenance Director confirmed it was debris.

During an interview conducted on 3/19/2025 at 5:42 pm, the Administrator revealed that staff members should be properly labeling food items with an open date and expiration date according to the policy.

Further interview also revealed the Maintenance Director is responsible for cleaning the ice machine and stated she expected that the ice machine to be cleaned according to the cleaning schedule, which was at least monthly or as needed.

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Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

jeopardy to resident health or Type Report for all residents in the facility on 3/17/2025 was completed no discrepancies were safety found.

the following correct processes in the building as it relates to following care plans for resident diet orders.

There is ongoing educational training for all members of the facility through the company's online courses.

The Administrator was also in-service on how to conduct a QAPI meeting and how to identify and complete an RCA by the COC on 7/24/2024.

The SSA reviewed in-service education related to the QAPI meeting and RCA dated 7/24/2024 with no concerns.

• The corrective actions were completed on 7/29/2024, and the facility alleges that the immediate

jeopardy was removed on 7/30/2024.

All dates of corrective actions were completed on 7/29/2024.

The facility's IJ was determined to be Past Noncompliance, removed on 7/30/2024.

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Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

During an interview on 3/18/2025 at 3:19 pm, the IP Nurse confirmed that the laundry cart hauling resident clean clothing should be covered.

She stated her expectations are for the housekeeping department to comply with infection control practices.

115555 03/19/2025

Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

Findings included: A review of the facility's policy titled Antibiotic Steward in April 2024 documented that the purpose of the antibiotic stewardship program is to monitor the use of antibiotics in our residence.

Prescribers will provide complete antibiotic orders including the following elements: (c) frequency of administration; (d) duration of treatment; start and stop date or number of days of therapy.

When a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for the current antibiotic/anti-infective order.

A review of the Infection Control Book on 3/18/2025 at 3:28 pm revealed that residents were missing lab orders, no resolved dates for antibiotics, duration of the antibiotic orders, and monitoring of residents with infections who were admitted or transferred from the hospital.

During an interview on 3/18/2025 at 3:38 pm with the Infection Preventionist (IP) Nurse confirmed she did not have the [NAME] requirements in the infection control book to determine true infections.

The IP Nurse stated that most of the time, she does not do lab follow-up on infections because she does not do repeated labs, which is why there are no resolved dates for antibiotics. In addition, she confirmed there were missing clinical signs and symptoms, along with some of the clinical signs and symptoms that were present. In addition, IP confirmed that residents who were admitted into the facility, infections were not being tracked or monitored.

During an interview on 3/19/2025 at 5:06 pm, the Director of Nursing (DON) stated that the IP Nurse should be submitting her listings weekly to the Regional Nurse Consultant.

She stated that she expects the IP Nurse to follow the policy and that the infection control process be complete with no missing items.

The DON further confirmed that the lack of information can increase the risk of infections and infections not being treated accordingly.

During an interview on 3/19/2025 at 5:56 pm, the Administrator stated that the DON oversees the Infection Control Program and her expectations are for the IP Nurse to follow the facility policy.

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Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

call lights should remain in place and that staff should not be telling residents not to press the call

During an interview on 3/19/2025 at 1:59 pm, LPN UUU revealed that she is a PRN employee and has worked at the facility for about a year.

When asked about her behavioral health training, she stated that she has not had any at the facility.

She further stated that she has not had any training related to schizophrenia, mental disorders, or PTSD.

During an interview on 3/19/2025 at 2:11 pm, Laundry Aide (LA) XXX revealed that she has been working at the facility for eight years.

She stated she has not had in-service on behavioral health.

During an interview on 3/19/2025 at 4:58 pm, the Director of Nursing (DON) stated the facility uses online software as the corporate system for annual training and upon anniversaries for every staff member.

She further stated that for agency staff, the facility asks to read the information in the agency training binder.

She further stated that volunteers are trained as needed, depending on current events in the facility.

When asked what some negative outcomes are if there is insufficient training to meet the behavioral needs listed in the facility assessment, she stated that staff could not take care of residents as needed.

During an interview on 3/19/2025 at 5:30 pm, the Administrator stated that she expects to provide training to properly care for the residents and execute behavior monitoring and interventions.

She further stated that this should be for all people if they work directly with the residents.

When asked what some negative outcomes are if there is insufficient training to meet the behavioral needs listed in the facility assessment, she stated that residents may not be comfortable, and they may have outbursts.

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Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

Findings included:

A review of the facility's policy titled Incident Report- Documentation, Investigating, and Reporting with a revision date of February 2025, it was documented that all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator.

The Administrator/DON will notify the appropriate Regulatory Agency in accordance with reporting guidelines in the event the incident is reportable.

A review of the facility's policy titled Drug Diversion Policy dated 5/20/2024 documented that the facility shall comply with state and federal regulations regarding medication handling, storage, disposal, documentation, and security, including but not limited to controlled substances.

Performance of periodic reconciliation (as frequently as needed) by the DON Service of records, receipts, disposition, usage, and inventory for all controlled medications to prevent drug diversion, suspicion, or when loss is identified.

Determine findings; inform the local authorities at the Administrator's discretion.

Notify State Regulatory Authorities if applicable.

A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R71 had a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was cognitively intact; had both lower extremity impairment; had a pain medication regimen, including PRN (as needed) for pain, non-medication interventions for pain, occasionally in pain, moderate pain intensity, and major orthopedic surgery.

A review of the Hospital Discharge Medication Order dated 2/6/2025 revealed oxycodone (narcotic pain reliever) 5 milligrams (mg) immediate release oral tablet every four hours PRN (as needed).

Dispense 15 tablets and 0 refills.

A review of the Pharmacy Delivery Receipt dated 2/5/2025 revealed oxycodone 5 mg tablets, and 10 each, based on quantities shipped.

During a telephone interview on 3/12/2025 at 9:20 am, a family member of R71 revealed that the oxycodone was given to the facility, and by the third day, all 15 pills were gone.

She stated the facility informed her the oxycodone pills were taken and does not believe that R71 was given all 15 pills in three days.

115555

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 115555 B.

Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

Findings included:

A review of the facility's policy titled Dental Services Policy, revised 3/18/2024, revealed that routine and emergency dental services are available to meet the resident's oral health needs in accordance with the resident's assessment and plan of care and that dental assessments are conducted on an annual basis and as needed.

The assessing nurse will notify social services of dental concerns and the resident's need for dental services.

A review of R77's electronic medical record (EMR) revealed that R77 was admitted to the facility on [DATE] with diagnoses of, but not limited to, hemiplegia and hemiparesis, following cerebral infarction affecting the right dominant side.

A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R77 presented with a Brief Interview for Mental Status (BIMS) of 10, which indicated the resident had moderate cognitive impairment and required partial to moderate assistance for oral hygiene.

A review of the care plan dated 4/2/2024 indicated that R77 had an Activities of Daily Living (ADL) deficit.

Interventions included that staff would provide extensive assistance in personal hygiene and oral care for R77.

A review of R77's Physician's Orders included, but was not limited to, an order dated 4/2/2024 for a dental consultant for evaluation and treatment as indicated.

A review of R77's EMR revealed a document titled Oral Dental assessment dated [DATE] with the indicator loose teeth marked yes.

Further review revealed the assessment prompt, Referral needed to dentist: Yes or No (if yes, give copy to social worker), was left blank.

A review of R77's EMR revealed a document titled Oral Dental assessment dated [DATE] with the indicator loose teeth marked yes.

Further review revealed the assessment prompt, Referral needed to the dentist: Yes or No (if yes, give a copy to the social worker), was left blank.

During an observation and interview on 3/10/2025 at 11:09 am, R77 stated that a tooth needs to come out, that he has told a nurse about this every day, and that the pain from the tooth is ten on a scale of ten. He further stated that he has not seen a dentist since he has been at the facility.

During an interview on 3/12/2025 at 12:25 pm, R77 stated that his tooth had been loose for about one month. An observation at this time revealed R77 demonstrated the loose tooth by pressing his tongue against it, and the tooth easily moved.

115555

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 115555 B.

Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

Findings included:

A review of the facility policy titled Administration of Medications with a review date of October 2024 revealed that staff will maintain the medication cart locked at all times when unattended.

1.

During an observation and interview on 3/14/2025 at 5:18 am, Licensed Practical Nurse (LPN) LPN BB was observed on the East Wing using Medication Cart A.

She unlocked the medication cart (Medication Cart A) outside the nurse station with the outward side facing accessibility to three male residents sitting within distance. LPN BB left the cart and was observed sitting behind the nurse station on a computer. LPN BB confirmed she had just come from a resident's room, that a staff member stopped her, and she sat down to do something in a resident's charts.

The LPN BB confirmed that she had all medication types on medication cart A, such as psychotropic, diuretic, and narcotics. LPN BB explained that the possible negative outcome when leaving a medication cart unlocked with residents present is that the residents could take medication off the cart. LPN BB mentioned she had in-service on maintaining the medication carts a couple of weeks ago.

2.

During an observation and interview on 3/14/2025 at 5:25 am, Medication Cart B was observed on the East Wing, left unlocked outside of the nurse station, with the outward side facing three male residents sitting within distance. A Certified Medical Assistant (CMA) CC was observed sitting behind the nursing station, working on the computer.

During an interview, CMA CC confirmed she was away from Medication Cart B for roughly 10-15 minutes.

She stated that she does not see how the medication on cart B could have any possible negative outcome or any effects on the resident because she does not pass narcotics. CMA CC confirmed that she had training five months ago on Medication Storage and Administration, and it mentioned to make sure all medications are dated, the medication cart is locked at all times, and nothing is left on top of the medication cart.

3.

During an observation and interview on 3/15/2025 at 9:49 am, Medication Cart C on the [NAME] Wing was observed unlocked and unattended. LPN FF confirmed she was trying to get into the computer, but she was not able to get in, so she went into the back of the nurse's station to get into the computer, and she walked away from the medication cart, leaving it unlocked and unattended. LPN FF confirmed she left the medication cart unlocked.

During this observation, the Unit Manager/ LPN EE was observed locking Medication Cart C.

115555

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 115555 B.

Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344

Findings included:

A review of the document titled Administrator Job Description revealed under Duties and Responsibilities: Assume the administrative authority, responsibility, and accountability for all programs in the facility.

The document is noted to be signed by the Administrator and dated [DATE].

A review of the document titled Director of Nursing revealed the primary purpose of this position is to plan, organize, develop, and direct the overall operation of the nursing services department in accordance with current federal, state, and local standards, guidelines and regulations that govern the facility and as directed by the Administrator and the Medical Director to ensure the highest degree of quality care is always maintained.

*

The facility failed to implement the care plan for R165 related to nutrition.

*

The facility failed to provide a pureed snack to R165, ordered to receive a mechanically altered diet.

An interview on [DATE] at 9:30 am with the Administrator revealed she was aware of the incident on [DATE] related to R165.

She stated that she viewed the facility camera and saw Certified Nursing Assistant (CNA) AA hand R165 a sandwich.

The Administrator revealed that she expected R165 to return to the facility after being sent out to the local hospital, but when the facility checked with the local hospital, she found out that R165 had been transferred out to a hospice facility on [DATE] and expired on [DATE].

115555

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 115555 B.

Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bonterra Transitional Care & Rehabilitation 2801 Felton Drive East Point, GA 30344