Bonterra Transitional Care & Rehabilitation

F-F609]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50374

Residents Affected - Few Based on interview, record review, and review of the facility's policy titled, Incident Report- Documentation, Investigating, and Reporting and Drug Diversion Policy the facility failed to report misappropriation of property related to prescription narcotics for one of 36 sampled residents (R) (Resident R71) to the State Survey Agency (SSA).

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 REDACTED] documented Resident 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 Resident 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 Resident R71 was given all 15 pills in three days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 During an interview on 3/13/2025 at 3:20 pm, the DON stated she does not have the controlled drug sheet for February for Resident R71 and does not have the medication in her locked box. She stated she was told by staff Level of Harm - Minimal harm or that Resident R71 completed her medication. She further stated that the pharmacist has not been in the facility for a potential for actual harm while to discard any medications.

Residents Affected - Few During an interview on 3/13/2025 at 3:33 pm, LPN AAA stated Resident R71 came in with 15 tablets and was administered three pills for the three days. She stated that once the medication is over, the protocol is to gather the medication card and narcotic sign-in and sign-out sheets, and turn them in to the DON. Also, if the medication has a discontinued order, they give the leftover medication with the sheet to the DON and state that they do not keep the narcotics.

During an interview with the DON on 3/14/2025 at 10:54 am, she stated that she had not found Resident 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 Resident 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 Resident R71 came

in from the hospital with 15 tablets of her oxycodone. She stated the facility reached out to her, informing her Resident R71 had finished up her medication and needed to switch her to Tramadol (pain reliever). She revealed the DON did not notify her of Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50272 potential for actual harm Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Residents Affected - Few Preadmission Screening and Annual Resident Review (PASARR) Policy, the facility failed to obtain a level II PASARR screening for two of 36 sampled residents (R) (Resident R55 and Resident R76).

Findings included:

A review of the facility's policy titled Preadmission Screening and Annual Resident Review (PASARR) Policy, revised 3/19/2024, section titled Policy Statement revealed that the facility will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been completed and the recommendations allow for a nursing facility admission and the facility's ability to provide the specialized services determined in the Level II screen.

1. A review of Resident R55's electronic medical record (EMR) revealed Resident R55 was admitted to the facility on [DATE REDACTED], and pertinent diagnoses included but were not limited to other sequelae of cerebrovascular disease, mental disorder, and schizoaffective disorder, bipolar type.

A review of Resident R55's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed that a Brief

Interview for Mental Status (BIMS) was not considered, which indicates Resident R55 is rarely or never understood; that Resident R55 displayed verbal behavioral symptoms directed toward others, such as threatening, screaming at others, and cursing at others, which occurred one to three days; and that Resident R55 was dependent on staff for all activities of daily living (ADL) care.

A review of Resident R55's care plan dated 5/17/2024 indicated a focus on a screen related to cognitive impairment. Goals included reducing the frequency and duration of screaming behavior. Interventions included, but were not limited to, documenting a summary of episodes, removing the resident from the public area where behavior is disruptive or unacceptable, and praising or rewarding the resident for demonstrating consistent desired and acceptable behavior.

A review of Resident R55's Physician's Orders included, but was not limited to, an order dated 1/29/2024 for quetiapine fumarate 50mg via G-tube two times a day and an order dated 1/29/2024 for Klonopin one 0.5mg tablet via G-tube two times a day.

2. A review of the EMR for Resident R76 revealed Resident R76 was admitted to the facility on [DATE REDACTED], and pertinent diagnoses included, but were not limited to, other sequelae of other cerebrovascular disease, mood disorder due to a known physiological condition with mixed features, and post-traumatic stress disorder (PTSD).

A review of Resident R76's MDS assessment dated [DATE REDACTED] revealed that a BIMS was not considered, which indicates Resident R76 is rarely or never understood, and that Resident R76 displayed delusions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 A review of Resident R76's care plan dated 2/26/2025 indicated a focus on negative feelings regarding self and social relationships characterized by: low self-esteem, anxiety, mistrust, conflict/anger, depressive tendencies, Level of Harm - Minimal harm or ineffective coping related to display of disturbing behavior, yells out at staff when assistance is offered. Often potential for actual harm states, I am a man, I don't need help, signs of PTSD and cognitive decline. Additionally, the problematic manner in which the resident acts is characterized by inappropriate behavior; use of profanity with staff, and Residents Affected - Few resistance to treatment/care related to refusing showers/baths, possibly related to PTSD.

During an interview conducted on 3/12/2025 at 10:00 am, the SW stated she has been working in the facility for [AGE] years. SW states residents are generally admitted into the facility with a PASARR Level II from the hospital, and rarely convert when they are admitted . SW stated that if residents have entered the facility without a PASARR Level II, then they would submit one. SW states generally she would collaborate with the DON to submit the PASARR Level II. SW verified Resident R76's diagnosis and stated she was not aware that PTSD was an eligible diagnosis for a PASARR Level II. SW confirmed Resident R76 does not have a PASARR Level II.

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.

50803

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51853 safety Based on record reviews, staff interviews, and a review of the facility's policy titled Care Plan Policy, the Residents Affected - Few facility failed to implement the care plan for one of 26 sampled residents (R) (Resident R165) related to nutrition. Specifically, the facility provided Resident R165 a sandwich which resulted in him being sent out to the local emergency room (ER) and admitted to a hospice facility where he expired on [DATE REDACTED].

On [DATE REDACTED] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.

The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) for

F-F697]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50803 potential for actual harm Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Residents Affected - Few Dental Services Policy, the facility failed to provide dental services for one of 36 sampled residents (R) (Resident R77).

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 Resident R77's electronic medical record (EMR) revealed that Resident R77 was admitted to the facility on [DATE REDACTED] 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 REDACTED] revealed Resident 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 Resident R77 had an Activities of Daily Living (ADL) deficit. Interventions included that staff would provide extensive assistance in personal hygiene and oral care for Resident R77.

A review of Resident 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 Resident R77's EMR revealed a document titled Oral Dental assessment dated [DATE REDACTED] 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 Resident R77's EMR revealed a document titled Oral Dental assessment dated [DATE REDACTED] 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, Resident 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, Resident R77 stated that his tooth had been loose for about one month. An observation at this time revealed Resident R77 demonstrated the loose tooth by pressing his tongue against it, and the tooth easily moved.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 During an interview on 3/13/2025 at 1:20 pm, Resident R77 stated that his oral pain is a ten out of ten and demonstrated his tooth moving with the push of his tongue. He further stated he told a staff member about it Level of Harm - Minimal harm or again on the night of 3/12/2025, but still nothing is being done. potential for actual harm

During an interview on 3/13/2025 at 2:13 pm, the Social Services Director (SSD) stated that in order for a Residents Affected - Few resident to obtain dental services, she would need the nurse assessment to determine if a referral is needed for a dentist consultation.

During an interview on 3/18/2025 at 9:57 am, Certified Nursing Assistant (CNA) BBB revealed that CNAs do not perform oral assessments; only the nurses do assessments. She further stated 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 Resident 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 Resident R77 had one loose tooth and was missing all upper teeth. Resident 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 Resident R77 has not had a referral to the dentist. She confirmed that Resident 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 REDACTED], where the nurse marked yes, indicating Resident 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 Resident R77 or of any loose teeth for Resident R77. She further confirmed that Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 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 Level of Harm - Minimal harm or resident does not qualify for this program, appointments would be made with an outside dentist to serve the potential for actual harm 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. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0800 Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Level of Harm - Minimal harm or potential for actual harm 50272

Residents Affected - Some Based on observation, record review, staff interviews, and review of facilities policy titled Therapeutic Diets,

the facility failed to use a recipe when preparing pureed food. This deficient practice has the potential to affect six residents on a pureed diet.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 50272

Residents Affected - Some Based on observations, staff interviews, record review, and a review of the facility's policies titled Receiving, Food Storage: Dry Goods, Food Storage: Cold Foods, and Ice, the facility failed to properly label food items with expiration dates, properly cover opened food items, and keep the ice machine free of debris. This deficient practice had the potential to affect 112 residents who received food orally.

Findings included:

A review of facility policy titled Receiving with a revision date of February 2023 documented that all food items will be appropriately labeled and dated either through manufacturer packaging or staff notation.

A review of the facility policy titled Food Storage: Dry Goods with a revision date of February 2023 documented that the storage areas will be neat, arranged for easy identification, and the date marked as appropriate.

A review of the facility policy titled Food Storage: Cold Foods with a revision date of February 2023 documented that all food will be stored wrapped or in covered containers, labeled and dated, and arranged in

a manner to prevent cross-contamination.

A review of facility policy titled Ice with a revision date of October 2022 documented that the dining services director will coordinate with the maintenance director to ensure that the ice machine will be disconnected, cleaned, and sanitized quarterly and as needed, or according to manufacturer guidelines. 3. The exterior of

the ice machine will be cleaned weekly.

An observation on 3/10/2025 at 9:30 am with the Dietary Manager (DM) revealed the following items in the pantry:

* 1 bottle of vinegar was opened and not labeled with an expiration date.

* 1 jar of creamy peanut butter was opened and not labeled with an expiration date.

* 1 container of quick oats was opened and not labeled with an expiration date.

* 1 container of quick creamy wheat was opened and not labeled with an expiration date.

A continuous observation was conducted on 3/10/2025 at 9:30 am with the Dietary Manager and revealed

the following items in the cooler:

* 2 bags of cut cabbage with no expiration date.

* 1 bag of cut and peeled carrots with no expiration date.

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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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 * 1 bag of spinach that was wilted and with no expiration date.

Level of Harm - Minimal harm or * 1 bag of hot dogs was opened and not labeled. potential for actual harm

A continuous observation was conducted on 3/10/2025 at 9:30 am with the DM and revealed the following Residents Affected - Some items in the freezer:

* 1 bag of Sysco green peas was not properly sealed

An observation and interview conducted on 3/11/2025 at 9:45 am revealed debris inside the ice machine. An

interview with DM stated she doesn't know how it was missed, and it is normally cleaned once a month.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47947 jeopardy to resident health or safety Based on interviews, record reviews, and a review of the documents Administrator and Director of Nursing,

the Administration failed to effectively and efficiently manage facility compliance with federal regulatory Residents Affected - Few requirements related to Quality of Care for one of 26 sampled residents (R) (Resident R165) receiving an altered diet. Specifically, the facility provided Resident R165 a sandwich, which resulted in him being sent out to the local emergency room (ER) and admitted to a hospice facility where he expired on [DATE REDACTED].

On [DATE REDACTED], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.

The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) for

F-F774]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49673 Residents Affected - Some Based on observations, staff interviews, and a review of the facility policy titled Administration of Medications, the facility failed to properly lock and secure three of four medication carts (Medication Carts A and B on the East Wing and Medication Cart C on the [NAME] Wing).

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 4. During an observation and interview on 3/16/2025 at 11:08 am, Medication Cart C on the [NAME] Wing was observed unlocked, and no nurse was observed in the hallway. After a few minutes, LPN GG came out Level of Harm - Minimal harm or of a resident's room and confirmed the cart was unlocked and was left unattended. LPN GG stated that it potential for actual harm was her first day on the floor, and she had been in the resident's room for two minutes, but she thought she had locked the medication cart. LPN GG stated that she has been a nurse for [AGE] years, and she received Residents Affected - Some in-service training on ensuring that the medication carts are locked when the cart is not within view. LPN GG mentioned that the possible negative outcome is that a patient, staff member, or family member can get into

the medication cart.

During an interview on 3/14/2025 at 5:33 am, the supervisor, Registered Nurse (RN) DD, revealed that the medication cart should be locked if staff are away. RN DD confirmed that it does not matter how long the staff was away; they should have ensured that the medication cart was locked. RN DD mentioned the procedure was to have the carts locked, but if he finds a cart unlocked, he will lock it and ask the staff why it was unlocked. RN DD explained, We have completed in-service on medication carts and will continually educate and always monitor. RN DD shared that all medications could potentially cause adverse reactions to residents if they were to access the unlocked cart.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0774 Help the resident with transportation to and from laboratory services outside of the facility.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50374

Residents Affected - Few Based on interviews and record review, the facility failed to schedule transportation arrangements for a medical appointment for one of 36 sampled residents (R) (Resident R71), resulting in a missed post-operation (post-op) appointment after a surgical procedure. Actual Harm was identified on 3/13/2025, when staples became embedded in Resident R71's amputation surgical site after the facility failed to provide transportation for post-operation (post-op) appointments.

Findings included:

A review of the electronic medical record (EMR) revealed that Resident R71 was admitted to the facility on [DATE REDACTED] with a diagnoses of encounter for orthopedic aftercare following surgical amputation, acquired absence of right leg below knee, acquired absence of left above knee, type 2 diabetes mellitus with other skin conditions, infection following a procedure, other surgical site subsequent encounter, unspecified complication of procedure subsequent encounter, atherosclerosis of native arteries of extremities with rest pain, right leg, partial traumatic amputation of right foot, level unspecified subsequent encounter.

A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] documented Resident R71 had a Brief

Interview for Mental Status (BIMS) score of 14, indicating little to no cognitive impairment; both lower extremity impairment; and that Resident R71 had pain a medication regimen, PRN (as needed) for pain, non-medication interventions for pain, occasionally in pain, moderate pain intensity, and major orthopedic surgery.

A review of the care plan dated 2/12/2015 documented Resident R71 has potential for pain related to a recent surgical/medical procedure.

A review of the Grievance Letter dated 1/21/2025 by a family member of Resident R71 stated, On 1/13/2025, it came to my attention that Resident R71's appointment with her vascular doctor, scheduled for 10:30 am, had been changed without informing me or any family member. The appointment was moved to a different doctor on 1/16/2025, and we were not notified of this change. The appointment was canceled due to a late/no-show arriving an hour after the scheduled appointment.

A review of the Patient Appointment Reminder dated 1/2/2025 documented that this is a reminder. You have

an appointment at 10:00 am on Monday, 1/13/2025.

All appointment and transportation forms for January 2025 were requested on 3/14/2025 at 12:49 pm from

the [NAME] Wing Unit Clerk. As of the exit date of the survey, this information was not provided.

During a telephone interview on 3/12/2025 at 9:20 am with a family member of Resident R71, it was revealed that Resident R71 had an appointment on 3/11/2025 to remove her staples from her recent surgery, and the facility canceled her appointment. She stated she went to the clinic to meet Resident R71 for her appointment, and she never arrived.

She further revealed Resident R71 stated the facility never scheduled transportation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0774 During a telephone interview on 3/14/2025 at 9:53 am with the vascular clinic representative stated Resident R71 had

a post-operation (post-op) appointment originally scheduled on 3/4/2025 to remove the staples from her Level of Harm - Actual harm amputation surgery, but was cancelled due to the provider's request and was rescheduled for 3/11/2025.

She continued to state that the facility called and cancelled Resident R71's appointment for 3/11/2025 due to Residents Affected - Few transportation issues, and the facility rescheduled the appointment for 3/18/2025.

During an interview on 3/14/2025 at 1:55 pm, the East Wing Unit Clerk stated she coordinates the transportation for appointments on the East Wing and was aware Resident R71 had an appointment that was rescheduled for 3/11/2025. The East Wing Unit Clerk assumed the clinic called Resident R71 regarding her missed appointment. She further stated she was aware that Resident R71 was supposed to have her staples removed and that Resident R71 informed the staff that she was in pain and complained that her skin was tight around her staples.

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-F835 on [DATE REDACTED] at 12:48 pm. The noncompliance related to the IJ was identified to have existed on [DATE REDACTED].

An Acceptable IJ Removal Plan was received on [DATE REDACTED] related to Comprehensive Care Plans, C.F.R. 483. 21; Quality of Care, C.F.R. 483.25; and Administration, C.F.R. 483.70.

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 REDACTED].

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 Resident R165 related to nutrition.

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

An interview on [DATE REDACTED] at 9:30 am with the Administrator revealed she was aware of the incident on [DATE REDACTED] related to Resident R165. She stated that she viewed the facility camera and saw Certified Nursing Assistant (CNA) AA hand Resident R165 a sandwich. The Administrator revealed that she expected Resident 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 Resident R165 had been transferred out to a hospice facility on [DATE REDACTED] and expired on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 The facility implemented the following corrective action in response to the deficient practice, which occurred

on [DATE REDACTED]: Level of Harm - Immediate jeopardy to resident health or 1. On [DATE REDACTED] at 1:00 pm, an Ad Hoc Quality Performance Improvement (QAPI) meeting was held with the safety Administrator, Social Services Director (SSD), the DON, Corporate Operations Consultant (COC), and Food Service Director (FSD) to identify the root cause of failure to follow Resident R165's care plan. The facility's Modified Residents Affected - Few Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy were reviewed; no changes were made.

A review of the AD-Hoc QAPI meeting dated [DATE REDACTED] reviewed the following policies, and no changes were required: Modified texture and Food policy, Care Plan policy, Resident food preferences policy, Heimlich maneuver, Choking policy, and Abuse and Neglect policy. A review of the identified root cause of failure for

the Resident R165 care plan was completed.

2. On [DATE REDACTED], the Administrator's job description was reviewed with the Administrator, FSD, SSD, and DON by the COC. No revisions were made.

A review of the Administrator Job description: duties and responsibilities, committee functions, personnel functions, staff development functions, safety and sanitation functions, equipment and supply functions, budget and planning functions, working conditions, education, experience, specific requirements, physical and sensory requirements, job position analysis information, were acknowledge and signed off by the Administrator and COC on [DATE REDACTED].

3. On [DATE REDACTED], the COC in-serviced the Administrator, DON, FSD, and SSD on how to implement a process

on how to verify diet orders before distributing resident meal trays, how to track and trend to determine a root cause analysis, and communication among departments on reviewing and updating resident care plans timely. The facility's QAPI policy was reviewed specifically regarding how to determine root cause analysis (RCA).

A review of facility QAPI meeting minutes dated [DATE REDACTED] revealed Chief Operating Officer (COO) conducted a one-hour meeting on What is QAPI, When should QAPI be conducted, Who should attend QAPI, What is an RCA, all signatures confirmed. A review of the Attendance Record revealed COO completed in-service on

the subject Implementation of a process to verify diet orders, tracking and trending of root cause of incident, updating care plans, policy review. During an interview with the DON, it was confirmed that she attended.

4. On [DATE REDACTED], the COC reviewed and approved the facility's audit forms and Plan of Correction (PoC) for any further areas of concern. Name of Audits- Daily Diet Verification Audit and Snack Distribution Audit. Residents' diets and care plans were discussed with the Administrator, DON, and FSD. Interventions were put into place, such as removing accessible snacks from the nurse stations; snacks were placed inside the pantry and available upon request. A snack diet reference sheet was initiated and placed inside the pantry.

An observation was conducted on [DATE REDACTED] at 2:43 pm, residents were seen eating pudding and sandwiches, and one CNA was seen with a tray of snacks that contained fig [NAME] bars, vanilla pudding, peanut butter and jelly sandwiches, and fruit cups. When asked how she knew what type of snacks residents could eat,

she went to the binder where it had residents' names and the type of diet types.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 5. On [DATE REDACTED], the Corporate Nurse Consultant (CNC) and DON audited the resident's diet orders and meal tray cards from [DATE REDACTED] through the current. The audits are named Daily Diet Verification Audit and Snack Level of Harm - Immediate Distribution Audit. The Administrator, DON, and FSD will discuss all diet order changes in the morning and jeopardy to resident health or the clinical meeting to ensure all care plans are updated and accurate. Documentation will be monitored safety through the Abuse Performance Improvement Plan (PIP) and reported during QAPI by the DON and Administrator. Residents Affected - Few

The SSA reviewed and compared Diet Master from the Dietary Department and the Facility's Diet Type Report for all residents in the facility on [DATE REDACTED] was completed no discrepancies were found.

6. The COC met with the Administrator and DON to review the process of providing direct oversight of 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 [DATE REDACTED].

The SSA reviewed in-service education related to the QAPI meeting and RCA dated [DATE REDACTED] with no concerns.

7. The corrective actions were completed on [DATE REDACTED], and the facility alleges that the immediate jeopardy was removed on [DATE REDACTED].

All dates of corrective actions were completed on [DATE REDACTED]. The facility's IJ was determined to be Past Noncompliance, removed on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 50272 potential for actual harm 50374 Residents Affected - Some Based on observations, record review, staff interviews, and review of the facility's policy titled Infection Prevention and Control Program Overview, the facility failed to provide proper surveillance and monitoring for infections and communicable diseases for 114 out of 114 residents residing in the facility. Furthermore, the facility failed to remove personal clothing items from the unit linen cart and failed to cover the resident's clean clothing while transporting the laundry cart.

Findings included:

1. A review of the facility's policy titled Infection Prevention and Control Program Overview dated 4/1/2018, documented that the goals of the infection prevention program are to decrease the risk of infection to residents and personnel; to monitor for occurrences of infection; and to implement appropriate control measures. The major activities of the program are surveillance of infections, with the implementation of control measures and prevention of infections. There is ongoing monitoring for infections among residents and personnel, and subsequent documentation of infections that occur. Reporting mechanisms for infection prevention: Residents' infection cases are monitored by the Infection Preventionist (IP). The IP completes

the line listing of infections and monthly reporting forms, and: (1) Reports to the infection preventionist committee. (2) Report to the Director of Nursing (DON)/Designee and others as directed. (3) Provide feedback to staff as needed. (D) The IP Administrator/Designee and appropriate department managers

review the compliance monitoring and initiate appropriate actions.

A review of the Infection Control Book on 3/18/2025 revealed the facility did not have infection criteria (McGeer's), evidence for collecting accurate data for infection, monitoring, and tracking for colored coded infections on the facility map, and missing surveillance for the months of September 2024 and November 2024.

During an interview on 3/18/2025 at 3:28 pm, the IP Nurse confirmed she did not have the infection criteria (McGreer) sheets in the infection control book, but she does follow their criteria. While looking through the book, the IP Nurse acknowledged that the monitoring and tracking were not accurate, there were missing color codes for the monitoring on the maps, and the months of September 2024 and November 2024 maps were not in the book.

During an interview on 3/19/2025 at 5:06 pm, the DON stated the IP Nurse should be submitting her listening weekly to the Regional Nurse Consultant (RNC). She stated her expectations are for the IP Nurse to follow

the policy and the infection control process to 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 staff to follow the facility's Infection Control policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2. During an observation and interview on 3/11/2025 at 3:34 pm, the Assistant DON revealed that the East Wing linen cart stored a resident's personal clothing items, and she was unsure why the resident's clothing Level of Harm - Minimal harm or was inside the linen cart. She continued to confirm resident's personal clothing items should not be stored on potential for actual harm the unit's linen cart.

Residents Affected - Some 3. During an observation and interview on 3/18/2025 at 3:16 pm, Laundry Aide (LA) WW was observed pushing an uncovered laundry cart with clothing items exposed down the hallways. She stated the process for transporting laundry was to return the clothing items to the resident's room. During the interview, LA WW confirmed the clean items on the chart were not covered and pointed to the white folded sheet on top of the laundry cart. She stated that the sheet should cover clean clothes.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50374 potential for actual harm Based on observations, record review, staff interviews, and review of the facility policy titled, Antibiotic Residents Affected - Many Stewardship, the facility failed to establish and maintain an Antibiotic Stewardship program related to clinical signs and symptoms, laboratory reports, stop dates on antibiotics, and monitoring systems in place for residents returning to the hospital. This had the potential to affect all 114 residents residing in the facility.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50374 potential for actual harm Based on observations, interviews, record reviews, and review of the facility's policy titled Call System/Light Residents Affected - Few Policy, the facility failed to ensure that the nursing call light was answered and accessible for one of 36 sampled residents (R) (Resident R33).

Findings included:

A review of the facility's policy titled Call System/Light Policy, dated 4/16/2024, documented that the purpose of the residents' call system shall allow residents to call for staff assistance through a communication system that relays the call directly to a staff member or a centralized staff work area. Answer all call lights in a prompt, calm, courteous manner for assurance of the resident's safety, aiding, and to promote a home-like environment by reducing noise levels.

During an observation on the [NAME] Wing on 3/10/2025 at 12:13 pm, Registered Nurse (RN) LLLL was heard repeatedly telling Resident R33, Don't push for nothing, Don't push for nothing, and Don't push for nothing. She was observed to exit the resident's room. During an interview at this time, she stated that she was trying to tell Resident R33 that lunch was not ready yet, and he kept pressing the call device for a snack.

A review of the electronic medical record (EMR) revealed that Resident R33 was admitted to the facility on [DATE REDACTED] with diagnoses of a history of falling, other symptoms and signs involving cognitive functions following unspecified cerebrovascular disease (blood vessels in the brain), symbolic dysfunctions (difficulty reading and spelling), and major depressive disorder moderate.

A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] documented Resident R33 presented with a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment, that Resident R33 had impairment on both sides of the upper and lower extremities, and that Resident R33 was dependent on staff for activities of daily living (ADL) care.

A review of the care plan dated 1/31/2025 documented that Resident R33 had an ADL self-care performance deficit related to the disease process (history of cerebrovascular accident) (stroke), and impaired balance, the resident needs extensive assistance with most of the ADL care tasks, and to encourage the resident to use

the bell to call for assistance.

During an interview on 3/10/2025 at 12:24 pm with Resident R33's roommates (Resident R60 and Resident R104), they both confirm RN LLLL came into the room to tell Resident R33 to stop pressing the call light.

During an observation on 3/10/2025 at 12:26 pm, the nursing call system cord in Resident R33's room was extracted from his wall, causing the system to be unfunctional.

During an interview on 3/10/2025 at 12:32 pm, RN LLLL apologized and stated that she did not mean to be rude to Resident R33. She stated that Resident R33 had the call device in his hand, and he kept pushing it repeatedly to the point where staff would not come to answer it. She confirmed they are not supposed to keep the call device away from him, so she was telling him to stop pressing it because she had already given him a snack.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 During an interview on 3/19/2025 at 5:17 pm, the Director of Nursing (DON) stated that the call light system is identified by the rooms, and the staff are to answer the call lights. She confirmed that all call lights should Level of Harm - Minimal harm or remain in place and that staff should not be telling residents not to press the call device. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0949 Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50272 potential for actual harm Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Residents Affected - Some Education and Training Requirements, the facility failed to provide an effective behavioral health training program consistent with the facility assessment and person-centered care for three of 36 samples residents (R) (Resident R55, Resident R66, and Resident R76).

Findings included:

A review of the facility's policy titled Education and Training Requirements, revised August 2024, revealed that the facility's objective is to provide competent care based on the identified needs of the resident population, based on findings from the facility resource assessment. Educational needs can be identified by

the utilization of the Facility Resource Assessment Tool.

1. A review of Resident R55's electronic medical record (EMR) revealed Resident R55 was admitted to the facility on [DATE REDACTED] with diagnoses of, but not limited to, cerebrovascular disease, mental disorder, and schizoaffective disorder/bipolar type.

A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident R55's Brief Interview for Mental Status (BIMS) score was not considered, which indicates Resident R55 is rarely or never understood; Resident R55 displayed verbal behavioral symptoms directed toward others such as threatening, screaming at others, and cursing at others which occurred one to three days during the lookback period; and that Resident R55 was dependent

on staff for all care.

A review of the care plan dated 5/17/2024 revealed that Resident R55 presented with the behavior of screaming related to cognitive impairment, and the goals included reducing the frequency and duration of screaming behaviors. Interventions included, but were not limited to, documenting a summary of episodes, removing the resident from the public area where behavior is disruptive or unacceptable, and praising or rewarding the resident for demonstrating consistent desired and acceptable behavior.

A review of Resident R55's physician orders included, but was not limited to, an order dated 1/29/2024 for quetiapine fumarate 50 mg (milligrams) via gastrostomy tube (G-tube) two times a day and an order dated 1/29/2024 for Klonopin one 0.5 mg tablet via G-tube two times a day.

2. A review of Resident R66's EMR revealed Resident R66 was admitted to the facility on [DATE REDACTED] with a diagnosis of, but not limited to, schizophrenia.

A review of Resident R66's quarterly MDS assessment dated [DATE REDACTED] revealed a BIMS score of 15, indicating that Resident R55 was cognitively intact and that Resident R66 displayed verbal behavioral symptoms occurring one to three days during

the lookback period.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0949 A review of the care plan dated 9/27/2024 revealed that Resident R66 presented with behavioral problems related to a diagnosis of schizophrenia, including being easily annoyed, displaying some verbal aggression, accusing Level of Harm - Minimal harm or others of taking his money and belongings, and seeking attention daily. Interventions included, but were not potential for actual harm limited to, administering medications as ordered, anticipating the resident's needs, calmly approaching Resident R66, and documenting behaviors and the resident's response to interventions. Residents Affected - Some

A review of the care plan dated 10/3/2024 revealed Resident R66 presented with verbal or physical aggression related to anger towards others if he could not get his opinion expressed or agreement from others. Interventions included, but were not limited to, allowing the resident time to respond to directions or requests.

A review of the care plan dated 11/19/2024 revealed Resident R66 presented with suicidal behavior related to psychiatric illness and verbal threats to harm himself. Interventions included, but were not limited to, utilizing any available resources for treatment and documenting summaries of each episode.

A review of the physician orders revealed Resident R66 was ordered: 2/4/2025 olanzapine 5 mg at bedtime for schizophrenia; 11/13/2024 trazodone 100 mg two times a day for schizophrenia, and 11/13/2024 Abilify 10 mg at bedtime for schizophrenia.

3. A review of EMR revealed Resident R76 was admitted to the facility on [DATE REDACTED] with diagnoses including, but not limited to, sequelae of other cerebrovascular disease, mood disorder due to known physiological condition with mixed features, and post-traumatic stress disorder (PTSD).

A review of Resident R76's MDS assessment dated [DATE REDACTED] revealed that a BIMS score was not considered, which indicates Resident R76 is rarely or never understood and presented with behaviors of delusions.

A review of the care plan dated 2/26/2025 indicated Resident R76 presented with negative feelings regarding self and social relationships characterized by low self-esteem, anxiety, mistrust, conflict/anger, depressive tendencies, ineffective coping related to display of disturbing behavior, yells out at staff when assistance is offered. It was noted that Resident R76 often states, I am a man, I don't need help. Resident R76 presented with signs of PTSD and cognitive decline. Additionally, the problematic manner in which the resident acts is characterized by inappropriate behavior, use of profanity with staff, and resistance to treatment/care related to refusing showers/baths, possibly related to PTSD.

A review of the Facility assessment dated [DATE REDACTED] revealed common diagnoses of residents in the facility included, but were not limited to mental disorder, schizophrenia, and PTSD.

A review of in-services for the last twelve months revealed one in-service record titled Behaviors: Managing Crisis dated 3/7/2024 and facilitated by an outside source addressing behaviors related to schizophrenia or mental disorders.

A review of in-services for the last twelve months revealed one in-service record titled Behavior Management dated 2/16/2024, which revealed no education specific to schizophrenia or mental disorders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0949 A review of the undated orientation agenda revealed training subjects titled Mood and behavior, PTSD, and past life trauma management and Behavior Management Policy Overview for Licensed Practical Nurses Level of Harm - Minimal harm or (LPNs) and Registered Nurses (RNs) only. These training subjects were not included in the orientation topics potential for actual harm for Certified Nursing Assistants (CNAs), Dietary, Social Services/Activities, Environmental Services, Maintenance, and laundry staff. Residents Affected - Some

A review of the agency training binder revealed no behavioral health training or any training related to schizophrenia, mental disorder, or PTSD.

During an interview on 3/13/2025 at 10:56 am, CNA ZZZ revealed that she had worked at the facility since December 2024. She stated she has had no training regarding schizophrenia, and she is not familiar with whether residents have a schizophrenia diagnosis on the [NAME] or East wings.

During an interview on 3/14/2025 at 6:59 am, CNA AAAA revealed she had worked at the facility for about nine years. She stated that her in-service training had never discussed schizophrenia. She further stated that

she does not know if there are any residents in the facility with schizophrenia or a mental disorder, and that

the CNAs would have to ask the nurse for diagnoses.

During an interview on 3/14/2025 at 12:42 pm, CNA BBBB revealed she had worked at the facility for about one year. She stated she had not had training related to schizophrenia.

During an interview on 3/16/2025 at 10:35 am, RN CCCC, an agency nurse, revealed she primarily works at

the facility on the weekends and has been working at the facility as an agency nurse since October 2024.

She stated she had not had training on behavioral health, schizophrenia, mental disorders, or suicidal ideations. She was not aware of any residents with a schizophrenia diagnosis in her assignment.

During an interview on 3/16/2025 at 11:10 am, Housekeeping WWW revealed that she has worked at the facility since April 2024. She stated she has not had in-service on schizophrenia, suicidal ideation, or mental disorders.

During an interview on 3/18/2025 at 9:51 am, Dietary Aide (DA) LLL revealed she had been working in the facility for one year. She stated she has not had any training on behavioral health, schizophrenia, mental disorders, or PTSD.

During an interview on 3/18/2025 at 9:57 am, CNA BBB revealed she had worked for five years at this facility. She stated she has not had any training specific to schizophrenia or mental disorders.

During an interview on 3/18/2025 at 10:05 am, LPN DDDD revealed she had worked at the facility for four months. She stated that most of her behavioral training covered Alzheimer's and dementia, and possibly touched on schizophrenia and mental disorders. She stated she does not think any residents in the [NAME] wing have a diagnosis of schizophrenia or a mental disorder.

During an interview on 3/18/2025 at 2:17 pm, CNA EEEE revealed she has been in the facility since January 2025. She stated she has not received in-service regarding PTSD.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0949 During an interview on 3/18/2025 at 2:22 pm, LPN GGG revealed he had been working in the facility on a PRN basis since November 2024 as agency staff. He stated he has not received training regarding PTSD. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/18/2025 at 2:58 pm, the Activities Assistant revealed that she had been working in

the facility since February 2025. She stated she has not had any training specific to schizophrenia. She Residents Affected - Some stated that she knows there are some residents with a mental disorder diagnosis. When asked how she would know any problematic behaviors to look out for, she stated that she knows based on her observations.

During an interview on 3/19/2025 at 9:36 am, CNA VVV revealed she had been working at the facility for about two years. When asked about her behavioral health training regarding schizophrenia, mental disorders, or PTSD, she asked, What is that? She further stated she knows about PTSD, but she has not had the training for PTSD at the facility.

During an interview on 3/19/2025 at 9:42 am, CNA QQQ revealed she had been working at the facility for about three months. She stated she has not had training on schizophrenia.

During an interview on 3/19/2025 at 12:08 pm, the Activities Director (AD) revealed she has worked at the facility for ten years. She stated that some volunteers are scheduled to come to the facility regularly, and some volunteers come to the facility as needed. She further stated that volunteers report to her. When asked about the volunteers' training, she stated that she cannot say she has trained them; she has only trained them in what to do with specific residents. When asked about the volunteers' behavioral health training, the AD further stated that the volunteers have not had behavioral health training, there is no signature documentation or acknowledgements of training, and the volunteers just show up and help out. The AD further stated that her online training mentioned schizophrenia and PTSD, focusing more on the approach to residents with these conditions. She further stated she has had no training specific to mental disorders and that it has been a while since she has done the online training. When asked if the AD has activities specific to residents with mental disorders, she stated that she does not have activities specific to mental disorders.

She further stated that she has huge board games and tries to see what these residents respond to.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0949 During an interview on 3/18/2025 at 3:19 pm, the Staff Development Coordinator (SDC) stated that in-service forms include face-to-face, using online software, and using outside sources. The SDC stated she has not Level of Harm - Minimal harm or conducted a lot of training on behavior. She further stated that they try to document behaviors to know what potential for actual harm the behaviors are for the residents, so they know the triggers, and they try to in-service staff on knowing the triggers. The SDC stated that during orientation, she speaks about residents who get admitted with Residents Affected - Some behaviors. When asked if the facility provides training specific to schizophrenia, mental disorders, and PTSD,

the SDC stated that an outside behavioral health services company provided in-service training to staff in March 2024. She further stated this was the only time this company had provided the in-service to staff. The SDC stated that Resident Rights online training mentions schizophrenia. A transcript of this training was requested but not provided. The SDC stated that non-direct staff, such as dietary and housekeeping staff, are in-service with other staff. The SDC further stated that staff competencies are conducted annually or initiated when staff are lacking in something. To train agency staff, the SDC stated she puts in-service training in the agency training binder for agency staff regarding behavioral issues. The agency staff are expected to read the book, and the SDC takes their word for it. The SDC further stated there is no competency test for agency staff. She confirmed she did not see any behavior-related training in the agency training binder. The SDC stated that competency exams are conducted annually for staff but not agency staff. The SDC further stated that the Social Services Director(SSD) provides in-service training on behaviors.

During an interview on 3/18/2025 at 3:44 pm, the SSD revealed that sometimes she conducts training on behaviors. She stated that she introduces the behavior program during new hire orientation, which is education on a behavior book kept on the unit that staff members will write in to document behaviors for discussion during the management's weekly meetings. The SSD clarified that this is mostly on-the-spot training specific to current events of what is going on with a specific resident at the time. The SSD further stated that her in-service training is in the in-service binder. When asked for training specific to schizophrenia, mental disorders, and PTSD, the SSD stated it has been about three years since this training was conducted.

During an interview on 3/19/2025 at 1:40 pm, CNA RRR, an agency CNA, revealed that it is her second day working at this facility. She stated that she has not had training on behavioral health, schizophrenia, mental disorders, or PTSD.

During an interview on 3/19/2025 at 1:56 pm, Physical Therapy Assistant (PTA) TTT revealed that he has worked at the facility for about three years. When asked about his behavioral health training, he stated that it was very dementia-focused and tied mental disorders in with dementia, but he did not recall any mention of PTSD.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 57 115555 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0949 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 Level of Harm - Minimal harm or further stated that for agency staff, the facility asks to read the information in the agency training binder. She potential for actual harm 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 Residents Affected - Some 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.

50803

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 57 115555