Bonterra Transitional Care & Rehabilitation
BONTERRA TRANSITIONAL CARE & REHABILITATION in EAST POINT, GA — inspection on March 19, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
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The facility failed to implement the care plan for R165 related to nutrition.
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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