Inspection Reports for Bonterra Transitional Care and Rehabilitation
2801 Felton Dr, Atlanta, GA 30344, GA, 30344
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 2, 2025, found no deficiencies during a follow-up survey verifying correction of prior issues. Earlier inspections showed a mixed pattern, with a significant number of deficiencies cited in March 2025 related to medication security, dental services, antibiotic stewardship, nursing care, and food safety, as well as life safety code violations. Complaint investigations from 2023 and 2024 identified substantiated issues including falls with injury, behavioral health care gaps, infection control problems, and environmental sanitation concerns, though many complaints were unsubstantiated or substantiated without deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The trend indicates improvement over time, with recent surveys showing correction of previously cited deficiencies and no new citations in the latest follow-up.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
15.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
210% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
114 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 2, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Deficiencies: 0
Date: May 29, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Bonterra Transitional Care & Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies.
Inspection Report
Re-Inspection
Census: 114
Deficiencies: 0
Date: May 29, 2025
Visit Reason
A revisit survey was conducted from 5/27/2025 through 5/29/2025 in conjunction with a complaint investigation based on Complaint Intake Numbers GA00254773, GA00255070, and GA00255068.
Complaint Details
Complaint investigation was conducted with intake numbers GA00254773, GA00255070, and GA00255068; no deficiencies were found.
Findings
No deficient practices were identified during the revisit survey, and all deficiencies cited in the 3/19/2025 Annual Survey were found to be corrected.
Report Facts
Complaint Intake Numbers: GA00254773, GA00255070, GA00255068
Inspection Report
Re-Inspection
Census: 114
Deficiencies: 0
Date: May 29, 2025
Visit Reason
A revisit survey was conducted from 5/27/2025 through 5/29/2025 in conjunction with a complaint investigation based on Complaint Intake Numbers GA00254773, GA00255070, and GA00255068.
Complaint Details
Complaint investigation was conducted with intake numbers GA00254773, GA00255070, and GA00255068; no deficiencies were found.
Findings
No deficient practices were identified during the revisit survey, and all deficiencies cited in the 3/19/2025 Annual Survey were found to be corrected.
Report Facts
Complaint Intake Numbers: GA00254773, GA00255070, GA00255068
Inspection Report
Routine
Deficiencies: 5
Date: Mar 19, 2025
Visit Reason
A State Licensure survey was conducted at Bonterra Transitional Care & Rehabilitation from 3/10/2025 through 3/19/2025 to assess compliance with state health regulations and facility policies.
Findings
The survey revealed multiple deficiencies including failure to secure medication carts, failure to provide dental services to a resident with documented dental needs, lack of an effective antibiotic stewardship program, inadequate nursing care related to activities of daily living and pain management for sampled residents, and physical plant issues such as improper food labeling and an unclean ice machine.
Deficiencies (5)
The facility failed to properly lock and secure three of four medication carts, leaving medications accessible to residents.
The facility failed to provide dental services for one resident with documented loose teeth and oral pain, and failed to make timely dental referrals.
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 for residents returning from hospital.
The facility failed to provide adequate nursing care for two residents: one with long, untrimmed fingernails despite expressing desire for nail care, and another with unmanaged pain related to surgical staples and missed appointments.
The facility failed to properly label food items with expiration dates, properly cover opened food items, and keep the ice machine free of debris.
Report Facts
Sampled residents: 36
Residents affected: 114
Residents affected: 112
Staples removed: 28
Staples remaining: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Observed leaving medication cart unlocked and confirmed medication types on cart |
| CMA CC | Certified Medical Assistant | Observed leaving medication cart unlocked and confirmed training on medication storage |
| LPN FF | Licensed Practical Nurse | Observed leaving medication cart unlocked |
| LPN EE | Unit Manager / Licensed Practical Nurse | Observed locking medication cart and confirmed dental referral procedures |
| LPN GG | Licensed Practical Nurse | Observed medication cart unlocked and confirmed in-service training |
| RN DD | Registered Nurse Supervisor | Confirmed medication cart locking procedures and in-service training |
| DON | Director of Nursing | Provided expectations on medication cart security, oral assessments, pain management, and infection control |
| SSD | Social Services Director | Confirmed dental referral process and Medicaid dental program eligibility |
| CNA BBB | Certified Nursing Assistant | Reported on oral care assistance and resident nail care observations |
| LPN DDDD | Licensed Practical Nurse | Conducted oral assessments and confirmed resident dental pain |
| Wound Care Nurse | Alerted to missed appointment and removed staples from resident R71 | |
| Medical Director | MD | Unaware of missed post-op appointment and resident pain |
| CNA MM | Certified Nurse Assistant | Reported resident R71's pain related to staples |
| CNA XX | Certified Nurse Assistant | Reported resident R71's leg pain |
| DM | Dietary Manager | Reported on food labeling expectations and ice machine cleaning |
| Maintenance Director | Responsible for ice machine cleaning and confirmed debris presence | |
| Administrator | Confirmed expectations for food labeling and ice machine cleaning |
Inspection Report
Routine
Census: 114
Deficiencies: 17
Date: Mar 19, 2025
Visit Reason
A standard survey was conducted at Bonterra Transitional Care & Rehabilitation from 3/10/2025 through 3/19/2025, including investigation of multiple complaint intake numbers.
Complaint Details
Complaint Intake Numbers GA00248925, GA00249920, GA00248977, GA00253223, GA00253553, GA00253845, and GA00253859 were substantiated deficiencies; GA00252555 and GA00253232 were substantiated with no deficiencies; GA00251980 and GA00253847 were unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including immediate jeopardy related to care planning, quality of care, and administration. Additional deficiencies involved resident dignity, cleanliness, medication misappropriation, PASARR screening, ADL care, oxygen therapy, pain management, medication cart security, missed transportation for medical appointments, dental services, food preparation and storage, infection control, call light system, and behavioral health training.
Deficiencies (17)
Immediate Jeopardy related to failure to provide care and services in accordance with professional standards, including a choking incident due to dietary noncompliance and failure to provide transportation for post-op appointments resulting in embedded staples.
Failure to maintain resident dignity during personal care with door left open.
Failure to maintain clean home-like environment with feces stains on walls in resident room.
Failure to ensure one resident was free from misappropriation of prescribed narcotics.
Failure to report misappropriation of narcotics to State Survey Agency.
Failure to obtain Level II PASARR screening for two residents with mental disorders.
Failure to provide adequate ADL care related to nail care for one resident.
Failure to administer oxygen therapy according to physician's orders for two residents.
Failure to ensure pain management consistent with professional standards and care plan for one resident, resulting in embedded staples and unmanaged pain.
Failure to properly lock and secure medication carts on multiple wings.
Failure to schedule transportation for medical appointment resulting in missed post-op appointment for one resident.
Failure to provide dental services for one resident with loose teeth and oral pain.
Failure to use recipe when preparing pureed food, resulting in inconsistent food preparation.
Failure to properly label food items with expiration dates, cover opened food items, and keep ice machine clean.
Failure to provide proper infection surveillance and monitoring, including missing infection criteria, incomplete tracking, and failure to remove personal clothing from linen cart or cover clean clothing during transport.
Failure to ensure nursing call light was answered and accessible; resident was told not to push call light and call cord was disconnected.
Failure to provide effective behavioral health training consistent with facility assessment and person-centered care for residents with mental disorders.
Report Facts
Facility census: 114
Staples removed: 28
Staples remaining: 6
Medication tablets dispensed: 15
Medication tablets administered: 3
Medication carts unlocked: 3
Residents affected by pureed diet: 6
Residents in facility: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in medication misappropriation and medication cart unlocked findings |
| LPN AAA | Licensed Practical Nurse | Named in medication misappropriation findings |
| LPN HH | Licensed Practical Nurse | Named in medication misappropriation findings |
| DON | Director of Nursing | Named in multiple findings including medication misappropriation, infection control, and pain management |
| Administrator | Named in multiple findings including medication misappropriation, infection control, and pain management | |
| CNA CCC | Certified Nurse Assistant | Named in resident dignity finding |
| CNA DDD | Certified Nurse Assistant | Named in resident dignity finding |
| Housekeeping Aide EEE | Named in cleanliness finding | |
| Wound Care Nurse | Named in pain management finding | |
| Maintenance Director | Named in handrails and ice machine cleaning findings | |
| Dietary Kitchen Manager | Named in pureed food preparation finding | |
| Medication Technician SS | Named in medication cart security finding | |
| CMA CC | Certified Medical Assistant | Named in medication cart security finding |
| LPN FF | Licensed Practical Nurse | Named in medication cart security finding |
| LPN GG | Licensed Practical Nurse | Named in medication cart security finding |
| RN DD | Registered Nurse | Named in medication cart security finding |
| RN LLLL | Registered Nurse | Named in call light system finding |
| CNA ZZZ | Certified Nurse Assistant | Named in behavioral health training finding |
| CNA AAAA | Certified Nurse Assistant | Named in behavioral health training finding |
| CNA BBBB | Certified Nurse Assistant | Named in behavioral health training finding |
| RN CCCC | Registered Nurse | Named in behavioral health training finding |
| Housekeeping WWW | Named in behavioral health training finding | |
| Dietary Aide LLL | Named in behavioral health training finding | |
| CNA VVV | Certified Nurse Assistant | Named in behavioral health training finding |
| CNA QQQ | Certified Nurse Assistant | Named in behavioral health training finding |
| Activities Director | Named in behavioral health training finding | |
| Staff Development Coordinator | Named in behavioral health training finding | |
| Social Services Director | Named in behavioral health training finding | |
| CNA RRR | Certified Nurse Assistant | Named in behavioral health training finding |
| Physical Therapy Assistant TTT | Named in behavioral health training finding | |
| LPN UUU | Licensed Practical Nurse | Named in behavioral health training finding |
| Laundry Aide XXX | Named in behavioral health training finding |
Inspection Report
Life Safety
Census: 116
Capacity: 118
Deficiencies: 4
Date: Mar 12, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, with deficiencies noted in smoke compartment integrity, sprinkler system maintenance, electrical safety, and gas equipment storage and signage.
Deficiencies (4)
Failed to ensure resistance to the passage of smoke into ceiling spaces; missing ceiling tiles or metal partitions in laundry and MDS office.
Failed to maintain sprinkler system to highest preparedness; sprinkler head in laundry found loaded.
Failed to take all precautions against possible electrical shock; Multi-Outlet Power Supply found on floor in Director of Nursing office.
Failed to ensure proper signage for gas equipment storage; Oxygen signage not visible to identify 'Full' vs 'Empty' in East Wing storage area.
Report Facts
Smoke compartments affected: 1
Certified beds: 118
Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations. |
Inspection Report
Complaint Investigation
Deficiencies: 20
Date: Mar 10, 2025
Visit Reason
The inspection was conducted based on complaints and allegations regarding resident rights, cleanliness, abuse prevention, medication misappropriation, care planning, and other regulatory compliance issues at Bonterra Transitional Care & Rehabilitation.
Complaint Details
The complaint investigation focused on multiple allegations including failure to maintain resident dignity and privacy, misappropriation of narcotics, failure to provide appropriate care and services, failure to maintain a safe environment, failure to provide adequate behavioral health training, and failure to manage facility compliance effectively. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, failure to maintain a clean environment, misappropriation of narcotics, failure to obtain required PASARR screenings, failure to implement care plans resulting in resident harm, inadequate assistance with activities of daily living, failure to ensure safe environment and medication self-administration assessment, failure to provide appropriate pain management, failure to schedule transportation for medical appointments, failure to provide dental services, failure to properly secure medication carts, failure to maintain infection prevention and control program, failure to provide adequate behavioral health training, failure to maintain call light system, failure to follow therapeutic diet recipes, and failure to effectively manage facility compliance.
Deficiencies (20)
Failure to maintain resident dignity and privacy during personal care.
Failure to maintain a clean and homelike environment including unclean walls with feces stains.
Failure to protect resident from misappropriation of prescribed narcotics.
Failure to timely report suspected abuse, neglect, or theft related to narcotics misappropriation.
Failure to obtain required PASARR Level II screening for residents with mental disorders or intellectual disabilities.
Failure to develop and implement a complete care plan related to nutrition, resulting in resident choking on inappropriate food and subsequent death.
Failure to provide adequate assistance with activities of daily living, specifically nail care.
Failure to provide appropriate treatment and care according to orders, including providing a pureed snack as ordered.
Failure to ensure nursing home area is free from accident hazards due to blocked handrails and failure to adequately assess resident for medication self-administration.
Failure to provide safe and appropriate respiratory care by not administering oxygen therapy according to physician's orders.
Failure to provide safe, appropriate pain management for a resident, resulting in embedded staples and pain due to missed post-op appointments.
Failure to help the resident with transportation to and from laboratory services outside of the facility, resulting in missed post-op appointment.
Failure to provide or obtain dental services for a resident with oral pain and loose teeth.
Failure to administer the facility in a manner that enables it to use its resources effectively and efficiently, including failure to implement care plan and provide appropriate diet.
Failure to ensure drugs and biologicals are labeled and stored in locked compartments; medication carts left unlocked and unattended.
Failure to provide and implement an infection prevention and control program, including failure to monitor infections, remove personal clothing from linen carts, and cover clean clothing during transport.
Failure to implement a program that monitors antibiotic use, including missing lab orders, no resolved dates for antibiotics, and lack of monitoring for residents returning from hospital.
Failure to make sure a working call system is available and accessible in resident's bathroom and bathing area, and failure to respond appropriately to call light use.
Failure to provide behavior health training consistent with facility assessment for residents with mental disorders including schizophrenia and PTSD.
Failure to provide each resident with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, including failure to use recipes for pureed food preparation.
Report Facts
Residents sampled: 36
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication carts: 3
Residents: 114
Residents: 114
Residents affected: 1
Residents affected: 3
Residents affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) CCC | Certified Nurse Assistant | Confirmed peri-care privacy door policy |
| Certified Nurse Assistant (CNA) DDD | Certified Nurse Assistant | Observed leaving door open during care |
| Housekeeping Aide EEE | Housekeeping Aide | Admitted not cleaning feces stains on wall |
| Housekeeping Director | Housekeeping Director | Expected cleaning of spots on walls |
| Administrator | Administrator | Stated expectations for privacy, cleanliness, narcotics management, pain management, and training |
| Director of Nursing (DON) | Director of Nursing | Stated expectations for privacy, narcotics management, pain management, infection control, and training |
| Licensed Practical Nurse (LPN) BB | Licensed Practical Nurse | Provided written statement on narcotics administration |
| Licensed Practical Nurse (LPN) AAA | Licensed Practical Nurse | Provided written statement on narcotics administration |
| Licensed Practical Nurse (LPN) HH | Licensed Practical Nurse | Provided written statement on narcotics administration |
| Licensed Practical Nurse (LPN) DD | Licensed Practical Nurse | Last nurse to administer narcotics |
| Wound Care Nurse | Wound Care Nurse | Alerted to missed staple removal appointment |
| Vascular Clinic Representative | Clinic Representative | Confirmed appointment cancellations and rescheduling |
| Certified Medical Assistant (CMA) CC | Certified Medical Assistant | Observed medication cart unlocked |
| Licensed Practical Nurse (LPN) FF | Licensed Practical Nurse | Left medication cart unlocked |
| Registered Nurse (RN) DD | Registered Nurse | Confirmed medication cart locking procedures |
| Licensed Practical Nurse (LPN) GG | Licensed Practical Nurse | Left medication cart unlocked |
| Dietary Manager (DM) | Dietary Manager | Observed unlabeled food items and unclean ice machine |
| Laundry Aide (LA) WW | Laundry Aide | Observed uncovered laundry cart with clothing items exposed |
| Registered Nurse (RN) LLLL | Registered Nurse | Observed telling resident not to push call light |
| Certified Nursing Assistant (CNA) BBB | Certified Nursing Assistant | Reported resident nail care status and oral assessments |
| Licensed Practical Nurse (LPN) DDDD | Licensed Practical Nurse | Reported oral assessments and behavioral health training |
| Unit Manager Licensed Practical Nurse (LPN) EE | Unit Manager Licensed Practical Nurse | Confirmed oral assessment and dental referral responsibilities |
| Social Services Director (SSD) | Social Services Director | Reported dental referral process and behavioral health training |
| Certified Nursing Assistant (CNA) ZZZ | Certified Nursing Assistant | Reported lack of behavioral health training |
| Certified Nursing Assistant (CNA) AAAA | Certified Nursing Assistant | Reported lack of behavioral health training |
| Certified Nursing Assistant (CNA) BBBB | Certified Nursing Assistant | Reported lack of behavioral health training |
| Registered Nurse (RN) CCCC | Registered Nurse | Reported lack of behavioral health training |
| Housekeeping WWW | Housekeeping | Reported lack of behavioral health training |
| Dietary Aide (DA) LLL | Dietary Aide | Reported lack of behavioral health training |
| Certified Nursing Assistant (CNA) BBB | Certified Nursing Assistant | Reported lack of behavioral health training |
| Certified Nursing Assistant (CNA) RRR | Certified Nursing Assistant | Reported lack of behavioral health training |
| Physical Therapy Assistant (PTA) TTT | Physical Therapy Assistant | Reported lack of behavioral health training |
| Licensed Practical Nurse (LPN) UUU | Licensed Practical Nurse | Reported lack of behavioral health training |
| Laundry Aide (LA) XXX | Laundry Aide | Reported lack of behavioral health training |
| Staff Development Coordinator (SDC) | Staff Development Coordinator | Reported behavioral health training practices and limitations |
| Activities Assistant | Activities Assistant | Reported lack of behavioral health training |
| Certified Nursing Assistant (CNA) VVV | Certified Nursing Assistant | Reported lack of behavioral health training |
| Certified Nursing Assistant (CNA) QQQ | Certified Nursing Assistant | Reported lack of behavioral health training |
| Activities Director (AD) | Activities Director | Reported lack of behavioral health training |
Inspection Report
Abbreviated Survey
Census: 112
Deficiencies: 0
Date: Sep 12, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate Complaint Intake Number GA00250523 at Bonterra Transitional Care and Rehabilitation.
Complaint Details
Complaint Intake Number GA00250523 was found substantiated.
Findings
The complaint was found substantiated, but no deficiencies were cited during the investigation.
Inspection Report
Abbreviated Survey
Census: 107
Deficiencies: 0
Date: Jul 16, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints against the facility.
Complaint Details
Complaints GA00245565 and GA00246425 were substantiated without deficiency. Complaints GA00246459, GA00246577, GA00247171, and GA00248381 were unsubstantiated.
Findings
Several complaints were investigated; four complaints were unsubstantiated, and two complaints were substantiated without deficiency.
Report Facts
Complaints investigated: 6
Inspection Report
Deficiencies: 0
Date: Apr 12, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Bonterra Transitional Care & Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 108
Deficiencies: 0
Date: Apr 12, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 2/22/2024 Recertification Survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 4
Date: Feb 22, 2024
Visit Reason
A Complaint Investigation survey was conducted at Bonterra Transitional Care and Rehabilitation from February 12, 2024 through February 22, 2024 to investigate alleged deficiencies.
Complaint Details
The survey was complaint-driven, investigating infection control and environmental sanitation concerns. The complaint was substantiated with multiple deficiencies cited.
Findings
The facility failed to maintain infection control due to a non-functioning washing machine chemical mixer, resulting in the use of household detergent pods for laundry, potentially affecting 108 residents. Additionally, safety hazards were found in the West Wing shower room with a sharp jagged edge, and environmental sanitation issues were noted in multiple bathrooms with strong odors, unclean conditions, and structural damage.
Deficiencies (4)
Washing machine chemical mixer was not working, leading to use of household detergent pods for resident laundry.
Sharp, jagged edge on divider wall in West Wing shower room posed injury risk to residents.
Black/grey/orange substance growth on walls of West Wing shower stalls and stained ceiling tile above shower head.
Strong urine and feces odors and unclean conditions in multiple bathrooms on East Wing with broken tiles and exposed brown-yellowish substances.
Report Facts
Residents potentially affected: 108
Residents affected: 54
Bathrooms affected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laundry Aide DD | Laundry Aide | Interviewed regarding laundry practices and detergent use |
| Laundry Aide CC | Laundry Aide | Interviewed regarding non-working washer chemicals and use of household detergent pods |
| Environmental Services Supervisor | Interviewed about washing machine chemical mixer servicing and facility conditions | |
| Administrator | Interviewed about awareness and plans regarding washing machine mixer and facility repairs | |
| Infection Prevention Registered Nurse | Registered Nurse | Interviewed about infection control concerns related to laundry detergent use |
| Certified Nursing Assistant BB | Certified Nursing Assistant | Reported on shower room hazards and resident care observations |
| Maintenance Manager | Interviewed about shower room hazards and maintenance plans | |
| Environmental Director | Provided observations on bathroom sanitation and odors | |
| Maintenance Director | Provided observations on bathroom conditions and plumbing issues |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 4
Date: Feb 22, 2024
Visit Reason
An Abbreviated Survey was conducted to investigate multiple complaint intake numbers related to Bonterra Transitional Care & Rehabilitation.
Complaint Details
The survey was initiated to investigate multiple complaint intake numbers. Several complaints were substantiated with federal deficiencies cited, while others were unsubstantiated.
Findings
The facility was found deficient in several areas including failure to promote resident dignity by serving meals on Styrofoam containers, unsafe and unsanitary bathroom and shower conditions with mold and urine odors, accident hazards due to a broken shower wall, and infection control issues related to malfunctioning laundry chemical mixers leading to use of household detergent pods.
Deficiencies (4)
Failure to promote dignity by serving meals on Styrofoam containers and plastic cutlery to 107 of 108 residents on two wings.
Failure to provide a safe, clean, comfortable, homelike environment in the West Wing shower room and seven bathrooms on the East Wing with mold growth and strong urine odors.
Failure to ensure environment free of accident hazards due to a sharp, jagged edge on a divider wall in the West Wing shower room.
Failure to provide infection prevention and control due to malfunctioning washing machine chemical mixer and use of household detergent pods for laundry affecting 108 residents.
Report Facts
Resident census: 108
Number of residents affected by meal service deficiency: 107
Number of bathrooms with deficiencies: 7
Number of residents potentially affected by bathroom deficiencies: 54
Number of shower stalls with mold growth: 2
Number of industrial washing machines affected: 2
Date washing machine mixer refurbished: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Certified Nursing Assistant | Reported mold in shower stalls and broken shower wall hazard |
| DD | Laundry Aide | Reported use of household detergent pods due to malfunctioning washing machine mixer |
| CC | Laundry Aide | Reported ongoing washing machine chemical mixer issues and use of household detergent pods |
| R15 | Resident | Reported lack of dignity with Styrofoam meal service and unsanitary bathroom conditions |
| R20 | Resident | Reported dissatisfaction with Styrofoam meal service |
| Environmental Services Supervisor | Aware of washing machine mixer issues and shower room deficiencies | |
| Maintenance Manager | Aware of shower room hazards and remodeling plans | |
| Administrator | Provided information on shower room repairs and laundry mixer refurbishment | |
| Infection Prevention Registered Nurse | Aware of laundry detergent pod use and researching infection control implications |
Inspection Report
Routine
Census: 108
Deficiencies: 4
Date: Feb 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, safety, environmental cleanliness, accident hazards, and infection prevention and control at Bonterra Transitional Care & Rehabilitation.
Findings
The facility failed to promote resident dignity by serving meals on Styrofoam containers due to staffing shortages, had unsafe and unsanitary conditions in shower rooms and bathrooms including mold growth and strong odors, had accident hazards such as a sharp jagged edge in a shower room, and failed to maintain proper infection control due to a malfunctioning washing machine chemical mixer, resulting in the use of household detergent pods for laundry.
Deficiencies (4)
Serving meals on Styrofoam containers and plastic cutlery on two separate days, affecting 107 of 108 residents.
Failure to provide a safe, clean, comfortable, homelike environment due to black/grey/orange growth in shower stalls and unsanitary bathroom conditions in multiple rooms affecting 54 residents.
Presence of a sharp, jagged edge in the shower room divider wall posing a risk of injury to residents.
Failure to provide an infection prevention and control program due to malfunctioning washing machine chemical mixer and use of household detergent pods for laundry, potentially affecting all 108 residents.
Report Facts
Residents affected: 107
Residents affected: 108
Residents affected: 54
Bathrooms affected: 7
Shower stalls affected: 2
Washing machines: 2
Laundry operation: 24
Date of service: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laundry Aide DD | Laundry Aide | Reported use of household detergent pods due to malfunctioning washing machine mixer |
| Laundry Aide CC | Laundry Aide | Reported ongoing malfunction of washing machine chemicals and use of household detergent pods |
| Infection Prevention Registered Nurse | Infection Prevention Registered Nurse | Reported awareness of laundry detergent issue and concerns about infection risk |
| Maintenance Manager | Maintenance Manager | Reported awareness of shower room hazards and plans for remodeling |
| Environmental Services Supervisor | Environmental Services Supervisor | Reported knowledge of washing machine issues and shower room conditions |
| Administrator | Administrator | Provided information on laundry dispenser service and shower room repair plans |
Inspection Report
Deficiencies: 1
Date: Nov 20, 2023
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 11/13/2023 and 11/19/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Nov 13, 2023
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 11/06/2023 and 11/12/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Date range: Between 11/06/2023 and 11/12/2023
Inspection Report
Routine
Deficiencies: 1
Date: Nov 6, 2023
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 10/30/2023 and 11/05/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Oct 30, 2023
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 10/23/2023 and 10/29/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Oct 23, 2023
Visit Reason
The inspection was conducted to review the facility's compliance with reporting requirements to the CDC's National Healthcare Safety Network (NHSN) regarding COVID-19 data during a required seven-day reporting period.
Findings
The facility failed to report complete COVID-19 information to the NHSN between 10/16/2023 and 10/22/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 0
Date: Sep 29, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Bonterra Transitional Care & Rehabilitation, indicating a regulatory inspection was conducted.
Findings
No specific deficiencies or findings are detailed in the provided report page.
Inspection Report
Re-Inspection
Census: 110
Deficiencies: 0
Date: Sep 29, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint-only survey on 2023-08-16.
Findings
All deficiencies cited as a result of the 8/16/2023 complaint-only survey were found to be corrected.
Inspection Report
Deficiencies: 1
Date: Aug 21, 2023
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 08/14/2023 and 08/20/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 4
Date: Aug 16, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from August 14 to August 16, 2023, investigating complaint numbers GA00237908, GA00237912, and GA00237983.
Complaint Details
The investigation was initiated due to complaints GA00237908, GA00237912, and GA00237983. The facility failed to report a serious incident involving a resident with a cord around her neck and failed to provide appropriate care and behavioral health services to residents as required.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to report an incident involving a resident with a cord around her neck, failure to develop and implement a comprehensive care plan specifying two-person assistance for a resident resulting in a fall with major injury, failure to protect a resident from a fall causing bilateral femur fractures, and failure to provide behavioral health services to a resident displaying suicidal ideations.
Deficiencies (4)
Failed to report to the State Survey Agency an incident involving a resident having a wrapped cord around her neck.
Failed to develop and implement a comprehensive care plan specifying the need for two-person assistance with Activities of Daily Living (ADL) care, resulting in a resident falling and sustaining bilateral lower extremity fractures.
Failed to protect a resident from a fall with major injury during ADL care, resulting in bilateral femur fractures.
Failed to provide behavioral health services to a resident who displayed suicidal ideations after an incident.
Report Facts
Resident Census: 116
Deficiencies cited: 4
BIMS score: 14
BIMS score: 15
BIMS score: 12
Date of fall: May 26, 2023
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 16, 2023
Visit Reason
The inspection was conducted due to complaints involving failure to timely report an incident of a resident with a wrapped cord around her neck, failure to develop and implement a comprehensive care plan specifying two-person assistance for a resident, failure to protect a resident from a fall with major injury, and failure to provide necessary behavioral health services to a resident displaying suicidal ideations.
Complaint Details
The complaint investigation revealed failure to report an incident involving resident #1 with a wrapped cord around her neck, failure to update care plan and provide adequate assistance leading to resident #2's fall and fractures, and failure to provide behavioral health services to resident #1 after suicidal ideations. The Director of Nursing and Administrator acknowledged the failures during interviews.
Findings
The facility failed to report a critical incident involving resident #1, failed to develop and implement a care plan for resident #2 requiring two-person assistance leading to a fall with bilateral femur fractures, failed to protect resident #2 from a fall during ADL care, and failed to provide behavioral health services to resident #1 after a suicidal incident.
Deficiencies (4)
Failed to timely report suspected abuse, neglect, or theft related to resident having a wrapped cord around her neck.
Failed to develop and implement a complete care plan specifying two-person assistance with ADL care for resident #2, resulting in fall and bilateral femur fractures.
Failed to protect resident #2 from a fall with major injury during ADL care resulting in bilateral femur fractures.
Failed to provide necessary behavioral health care and services to resident #1 who displayed suicidal ideations.
Report Facts
Deficiencies cited: 4
Resident admission date: Dec 2, 2021
Resident admission date: Feb 19, 2019
BIMS score: 14
BIMS score: 12
Fall date: May 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding failure to report incident and care plan deficiencies | |
| Administrator | Interviewed regarding awareness of incident and reporting requirements | |
| Licensed Practical Nurse Unit Manager | Interviewed regarding fall incident and care assistance | |
| Social Services Director | Interviewed regarding behavioral health services for resident #1 |
Inspection Report
Renewal
Deficiencies: 1
Date: Aug 16, 2023
Visit Reason
The inspection was a Licensure Survey conducted from August 14, 2023 through August 16, 2023 to assess compliance with licensure requirements for Bonterra Transitional Care & Rehabilitation.
Findings
The facility failed to develop and implement a comprehensive care plan for one of three sampled residents (R#2) that specified the need for two-person assistance with Activities of Daily Living (ADL) care. This failure resulted in harm when the resident fell from the bed and sustained bilateral lower extremity fractures.
Deficiencies (1)
Failure to develop and implement a comprehensive care plan specifying the need for two-person assistance with ADL care for resident R#2.
Report Facts
Dates of survey: 3
Brief Interview for Mental Status (BIMS) score: 12
Resident admission date: Feb 19, 2019
Care plan problem start date: Mar 10, 2019
Date of fall incident: May 26, 2023
Date of facility investigation: Jun 1, 2023
Date of care plan review: Jun 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager | Interviewed regarding the fall incident and care plan update | |
| Director of Nursing | Interviewed and confirmed care plan did not reflect number of staff needed during ADL care |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 12, 2023
Visit Reason
The facility was reviewed due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 06/05/2023 and 06/11/2023 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 0
Date: Feb 22, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Bonterra Transitional Care & Rehabilitation following a regulatory inspection.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.
Inspection Report
Re-Inspection
Census: 111
Deficiencies: 0
Date: Feb 22, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 01/05/2023 Annual Survey.
Findings
All deficiencies cited as a result of the 01/05/2023 Annual Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 22, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor during the follow-up visit.
Inspection Report
Routine
Deficiencies: 7
Date: Jan 5, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident transfer notifications, resident assessments, care planning, medication management, call light availability, and facility safety.
Findings
The facility failed to provide timely written transfer/discharge notices to residents and their representatives, failed to provide accurate resident assessments and care plans, did not complete required Abnormal Involuntary Movement Scale (AIMS) assessments timely, failed to ensure daily skilled nursing assessments were conducted as ordered, failed to provide working call lights for two residents, and failed to maintain an air gap between drainpipes and floor drains in the kitchen.
Deficiencies (7)
Failed to provide timely written transfer/discharge notice including appeal rights to residents and their representatives for emergent hospital transfers.
Failed to provide timely and accurate resident assessments, including accurate discharge coding and weight loss identification.
Failed to develop and implement comprehensive person-centered care plans for residents, including care plans for wander guard use, cognitive deficits, depression, and antipsychotic medication use.
Failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments timely for a resident on antipsychotic medication.
Failed to provide accurate daily skilled nursing assessments for a resident, with repeated unchanged assessments raising concerns about monitoring for daily changes.
Failed to ensure two residents had working call lights available in their rooms for assistance.
Failed to ensure an air gap between the drainpipe and floor drain for the ice machine and prep sink in the kitchen, risking contamination of water supply.
Report Facts
Residents reviewed for transfer notice: 33
Residents affected by transfer notice deficiency: 2
Residents reviewed for assessments: 31
Residents affected by assessment deficiencies: 2
Residents reviewed for care plans: 32
Residents affected by care plan deficiencies: 3
Residents reviewed for unnecessary medications: 5
Residents affected by AIMS assessment deficiency: 1
Residents reviewed for skilled assessments: 4
Residents affected by skilled assessment deficiency: 1
Residents reviewed for call light availability: 33
Residents affected by call light deficiency: 2
Facility census: 107
Residents receiving oral diet: 102
Days call lights were out: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided transfer form, confirmed lack of appeal rights info, confirmed care plan update policies, and acknowledged AIMS assessment timing |
| Licensed Practical Nurse 2 | LPN | Described transfer paperwork process and confirmed no paperwork given to residents |
| Dietary Manager | Dietary Manager (DM) | Reviewed resident weights and confirmed weight loss coding error |
| Unit Manager | Unit Manager (UM) | Confirmed wander guard use and AIMS assessment frequency |
| MDS Coordinator 1 | MDS Coordinator (MDSC 1) | Confirmed care plan update process and deficiencies |
| MDS Coordinator 2 | MDS Coordinator (MDSC 2) | Confirmed care plan update process and deficiencies |
| Social Services Director | Social Services Director (SSD) | Confirmed care plan deficiencies and responsibilities |
| Administrator | Facility Administrator | Confirmed call light repair status and lack of drain air gap policy |
| Maintenance Director | Maintenance Director | Confirmed lack of drain air gap policy |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jan 5, 2023
Visit Reason
A State Licensure survey was conducted at Bonterra Transitional Care and Rehabilitation from January 2, 2023 through January 5, 2023 to assess compliance with state health regulations and identify any deficiencies.
Findings
The survey revealed multiple deficiencies including failure to provide accurate daily skilled resident assessments, failure to provide required written transfer/discharge notices to residents and their representatives, failure to complete timely assessments for unnecessary medications, failure to develop comprehensive person-centered care plans for certain residents, and failure to provide call lights to residents potentially affecting timely care.
Deficiencies (5)
Failure to provide accurate daily skilled resident assessments for one resident, raising concern that assessments were not conducted as ordered to monitor daily changes.
Failure to provide written transfer/discharge notices with required information to two residents transferred emergently to hospital.
Failure to ensure one resident had an Abnormal Involuntary Movement Scale (AIMS) assessment completed timely.
Failure to develop and implement comprehensive person-centered care plans for three residents, missing care plans for wander guard use, cognitive deficits, and depression with antipsychotic medication.
Failure to provide call lights to two residents, potentially affecting timeliness of care or response in urgent situations.
Report Facts
Residents reviewed for assessment accuracy: 4
Residents reviewed for facility initiated emergent hospital transfer: 33
Residents reviewed for unnecessary medications: 5
Residents sampled for care plan review: 32
Residents sampled for call light availability: 33
Dates skilled assessments were unchanged: 13
Days call lights were out of service: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding assessment anomalies, transfer notices, and care plan requirements. | |
| Licensed Practical Nurse (LPN) 2 | Interviewed about emergent transfer process and paperwork given to residents. | |
| Unit Manager (UM) | Interviewed about AIMS assessments and care plan for wander guard. | |
| MDS Coordinator (MDSC) 1 and 2 | Interviewed about care plan updates and deficiencies. | |
| Social Services Director (SSD) | Interviewed about care plan creation based on MDS assessments. | |
| Administrator | Interviewed about call light availability and repair status. |
Inspection Report
Annual Inspection
Census: 107
Deficiencies: 7
Date: Jan 5, 2023
Visit Reason
A standard annual survey was conducted from January 2 through January 5, 2023, including investigation of two complaint intake numbers, one substantiated and one unsubstantiated.
Complaint Details
Complaint Intake number GA00230085 was unsubstantiated. Complaint Intake number GA00227361 was substantiated with deficiencies cited.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide written transfer/discharge notices, inaccurate resident assessments, incomplete care plans, untimely Abnormal Involuntary Movement Scale assessments, inaccurate daily skilled resident assessments, lack of call lights for residents, and plumbing issues with drain air gaps in the kitchen.
Deficiencies (7)
Failure to provide written transfer/discharge notice to residents R#79 and R#92 including reason, place of transfer, and appeal information.
Failure to provide timely and accurate resident assessments for R#107 and R#79, including inaccurate discharge coding and weight loss coding.
Failure to develop and implement comprehensive person-centered care plans for residents R#19, R#97, and R#30, missing care plans for wander guard, cognitive deficits, depression, and antipsychotic use.
Failure to ensure timely completion of Abnormal Involuntary Movement Scale (AIMS) for resident R#19 prescribed antipsychotic medication.
Failure to provide accurate daily skilled resident assessments for resident R#104, with repeated unchanged nursing progress notes raising concern assessments were not conducted daily as ordered.
Failure to ensure residents R#78 and R#89 were provided with call lights for assistance, with call light cords missing from wall outlets.
Failure to ensure an air gap between drainpipe and floor drain for ice machine and prep sink in kitchen, risking contamination of water system.
Report Facts
Resident census: 107
Sample size: 33
Weight loss percentage: 16
BIMS score: 2
BIMS score: 14
BIMS score: 99
BIMS score: 4
BIMS score: 13
BIMS score: 12
Admission date: Sep 28, 2022
Discharge date: Oct 11, 2022
Admission date: Nov 15, 2022
Dates with unchanged assessments: 13
Days call lights out: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided transfer forms and confirmed lack of appeal information on transfer notices |
| Dietary Manager | Dietary Manager (DM) | Confirmed incorrect MDS coding for weight loss for resident R#79 |
| Licensed Practical Nurse 2 | Licensed Practical Nurse (LPN) 2 | Described process for emergent transfer paperwork and confirmed no paperwork given to resident |
| Unit Manager | Unit Manager (UM) | Confirmed resident R#19 had a wander guard that should be on care plan |
| MDS Coordinator 1 | MDS Coordinator (MDSC) 1 | Confirmed care plans should include wander guard, cognitive deficits, depression, and antipsychotic use |
| MDS Coordinator 2 | MDS Coordinator (MDSC) 2 | Confirmed care plans should include wander guard, cognitive deficits, depression, and antipsychotic use |
| Social Services Director | Social Services Director (SSD) | Agreed care plans should be created based on MDS findings for cognition and depression |
| Administrator | Facility Administrator | Confirmed call lights for residents R#78 and R#89 were being repaired |
| Maintenance Director | Maintenance Director | Confirmed no policy regarding drain air gaps |
Inspection Report
Life Safety
Census: 111
Capacity: 118
Deficiencies: 6
Date: Jan 4, 2023
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Program and Life Safety Code compliance, including sprinkler system maintenance, corridor doors, smoke barriers, portable space heaters, and essential electrical systems.
Findings
The facility was found not in substantial compliance with emergency preparedness and life safety requirements. Deficiencies included an outdated emergency preparedness plan, sprinkler system issues (corrosion, loaded and painted heads), resident doors that did not resist smoke spread, smoke barrier penetrations allowing smoke passage, presence of an unauthorized portable space heater, and lack of a documented 2-hour or 4-hour generator load test within the last 12 months.
Deficiencies (6)
Emergency preparedness plan was not updated or approved in the last year.
Fire sprinkler system had deficiencies related to corrosion, loaded heads, and painted heads.
Resident doors failed to resist the spread of smoke; door #107 had a visual gap at the top and door #112 would not latch.
Smoke barrier penetrations could allow smoke passage at the east wing entrance door.
Portable space heater found in kitchen manager's office without manufacturer instructions indicating thermostat rating below 212°F.
Facility generator lacked a record of a 2-hour or 4-hour load test within the last 12 months.
Report Facts
Census: 111
Total Capacity: 118
Smoke Compartments affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during the inspection | |
| Staff A | Confirmed emergency preparedness plan findings |
Inspection Report
Deficiencies: 1
Date: Aug 16, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period between 08/08/2022 and 08/14/2022, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Aug 8, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Aug 2, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 07/25/2022 and 07/31/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 27, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00226007.
Complaint Details
Complaint #GA00226007 was unsubstantiated with no deficiencies cited.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Deficiencies: 1
Date: Jul 25, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period between 07/18/2022 and 07/24/2022, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Jul 18, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period between 07/11/2022 and 07/17/2022, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Jul 11, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period between 07/04/2022 and 07/10/2022, as determined by CMS based on CDC data.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Reporting period: 7
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 6, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00223251 and #GA00224644.
Complaint Details
Complaints #GA00224644 and #GA00223251 were investigated and found to be unsubstantiated without deficiencies cited.
Findings
The complaints were unsubstantiated and no deficiencies were cited. The facility was found to be in compliance with vaccination requirements for facility staff under CFR 483.80 (i) (1) - (3) (i) - (x).
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 6, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00223251 and #GA00224644.
Complaint Details
Complaints #GA00224644 and #GA00223251 were investigated and found to be unsubstantiated without deficiencies cited.
Findings
The complaints were unsubstantiated and no deficiencies were cited. The facility was found to be in compliance with vaccination requirements for facility staff under CFR 483.80 (i) (1) - (3) (i) - (x).
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 6, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00223251 and #GA00224644.
Complaint Details
Complaints #GA00224644 and #GA00223251 were investigated and found to be unsubstantiated without deficiencies cited.
Findings
The complaints were unsubstantiated and no deficiencies were cited. The facility was found to be in compliance with vaccination requirements for facility staff under CFR 483.80 (i) (1) - (3) (i) - (x).
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 6, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00223251 and #GA00224644.
Complaint Details
Complaints #GA00224644 and #GA00223251 were investigated and found to be unsubstantiated without deficiencies cited.
Findings
The complaints were unsubstantiated and no deficiencies were cited. The facility was found to be in compliance with vaccination requirements for facility staff.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 6, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00223251 and #GA00224644.
Complaint Details
Complaints #GA00223251 and #GA00224644 were investigated and found to be unsubstantiated without deficiencies cited.
Findings
The complaints were unsubstantiated and no deficiencies were cited. The facility was found to be in compliance with vaccination requirements for facility staff.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 8, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00221979.
Complaint Details
Complaint #GA00221979 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was found to be unsubstantiated and no deficiencies were identified during the survey.
Inspection Report
Routine
Census: 108
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in substantial compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 2, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00217999 and #GA00218372.
Complaint Details
Complaints #GA00217999 and #GA00218372 were investigated and found to be unsubstantiated.
Findings
The complaints #GA00217999 and #GA00218372 were unsubstantiated and no regulatory violations were cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 15, 2021
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during this follow-up visit.
Inspection Report
Deficiencies: 0
Date: Jul 13, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Bonterra Transitional Care & Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains a summary statement of deficiencies identified during the inspection; however, no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 12, 2021
Visit Reason
A revisit survey was conducted to verify correction of previously cited deficiencies from the Standard survey.
Findings
All deficiencies cited as a result of the Standard survey were found to be corrected at the time of the revisit.
Inspection Report
Original Licensing
Deficiencies: 0
Date: May 27, 2021
Visit Reason
The inspection was conducted as a licensure survey for Bonterra Transitional Care & Rehabilitation.
Findings
No deficiencies were identified during the licensure survey.
Inspection Report
Routine
Census: 109
Deficiencies: 5
Date: May 27, 2021
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations related to long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to protect a resident from sexual abuse by a roommate, failure to report alleged abuse to the State Survey Agency, failure to complete a PASARR Level II for a resident with cognitive impairment, failure to notify psychiatric services of significant behavioral changes, and failure to maintain an effective quality assessment and assurance program addressing behavioral issues.
Deficiencies (5)
Failure to protect one resident (R#48) from sexual abuse by his roommate (R#87) who exhibited inappropriate sexual behavior.
Failure to report an allegation of sexual abuse to the State Survey Agency as required.
Failure to ensure a PASARR Level II screening was completed for resident R#87 with cognitive impairment and behavioral issues.
Failure to notify psychiatric services and the physician of significant behavioral changes and increased behaviors of resident R#87.
Failure to maintain a quality assessment and assurance committee that effectively identified and addressed behavioral management concerns.
Report Facts
Resident census: 109
Sample size: 42
Psychotropic medication dosage: 40
Psychotropic medication dosage: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Witnessed sexual abuse incident involving resident R#87 and reported to nurse |
| LPN CC | Licensed Practical Nurse | Documented behavior notes and incidents involving resident R#87 |
| UM BB | Unit Manager | Observed and redirected resident R#87 during behavioral episodes |
| DON | Director of Nursing | Interviewed regarding awareness and management of resident R#87's behaviors and failure to report |
| Medical Director | Interviewed regarding lack of notification about resident R#87's behaviors and gave order for ER transfer | |
| NP | Nurse Practitioner | Psychiatric services provider who saw resident R#87 on limited occasions and was unaware of behavioral escalation |
| SSD | Social Services Director | Discussed PASARR process and behavioral referrals for resident R#87 |
| Administrator | Interviewed regarding facility QAPI process and behavioral management issues |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 5
Date: May 27, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to protect a resident from sexual abuse by his roommate and failure to report the abuse to the State Survey Agency.
Complaint Details
The complaint investigation was triggered by allegations of sexual abuse of resident R#48 by his roommate R#87, who had a history of physical aggression and inappropriate behaviors. The facility failed to protect the resident and failed to report the abuse to the State Survey Agency. The investigation included interviews with staff, review of clinical records, behavior notes, and facility policies.
Findings
The facility failed to protect one resident (R#48) from sexual abuse by his roommate (R#87), who exhibited aggressive and inappropriate behaviors. The facility also failed to timely report the suspected abuse to the State Survey Agency and failed to notify the physician and psychiatric services of the resident's increased and hazardous behaviors. Additionally, the facility did not ensure proper PASARR Level II screening for the resident and failed to maintain an effective quality assessment and assurance program addressing behavioral issues.
Deficiencies (5)
Failed to protect resident from sexual abuse by roommate exhibiting aggressive and inappropriate behaviors.
Failed to timely report suspected abuse to the State Survey Agency.
Failed to ensure PASARR Level II screening for resident with severe cognitive impairment and behavioral issues.
Failed to notify physician and psychiatric services of significant changes and increased behaviors in resident.
Failed to maintain an ongoing quality assessment and assurance program that effectively addressed behavioral concerns.
Report Facts
Sample size: 42
Census: 106
Dates of behavior notes: Behavior notes dated 1/25/2021, 2/13/2021, 3/23/2021, 4/14/2021, 4/28/2021
Psychiatric visits: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN DD | Licensed Practical Nurse | Documented behavior notes regarding resident R#87 |
| DON | Director of Nursing | Interviewed regarding awareness of resident behaviors and failure to report abuse |
| UM BB | Unit Manager | Interviewed and observed resident behavior, attempted redirection |
| CNA AA | Certified Nursing Assistant | Witnessed sexual abuse incident and reported to nurse |
| LPN CC | Licensed Practical Nurse | Documented progress notes and interviewed about behavior documentation |
| SSD | Social Services Director | Discussed referral process and behavioral challenges |
| Medical Director | Medical Director | Interviewed about notification of resident behaviors and gave verbal order for ER transfer |
| NP | Nurse Practitioner | Psychiatry services provider, interviewed about resident evaluations and awareness of behaviors |
| Administrator | Facility Administrator | Interviewed about quality assessment and assurance processes |
Inspection Report
Life Safety
Census: 108
Capacity: 118
Deficiencies: 2
Date: May 24, 2021
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.90(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with Life Safety Code requirements, specifically regarding emergency lighting records and hazardous area enclosure. Deficiencies included missing hard copies of monthly emergency lighting inspection records for at least two months and a janitorial supply closet door closer not properly connected to keep the door closed, affecting one of three smoke compartments.
Deficiencies (2)
Failed to provide and keep hard copies of records on the monthly emergency lighting inspections; at least 2 months of records unavailable.
Failed to assure compartmentation of hazardous chemicals and materials exposure to residents; janitorial supply closet door closer not properly connected to keep the door closed.
Report Facts
Census: 108
Total Capacity: 118
Months of missing emergency lighting inspection records: 2
Number of smoke compartments affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding emergency lighting records and door closer deficiency during facility tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 18, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00205398, #GA00208481, and #GA00203582.
Complaint Details
Complaints #GA00205398, #GA00208481, and #GA00203582 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Census: 86
Deficiencies: 0
Date: Jun 30, 2020
Visit Reason
A Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted at Bonterra Transitional Care and Rehabilitation on June 30, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19 preparation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 20, 2020
Visit Reason
An unannounced, abbreviated survey was conducted to investigate Complaint Number GA00202571 at Bonterra Transitional Care and Rehabilitation.
Complaint Details
Complaint Number GA00202571 was investigated and substantiated without citation.
Findings
The complaint was substantiated but no citation was issued.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 23, 2020
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Abbreviated Survey
Census: 111
Deficiencies: 0
Date: Jan 23, 2020
Visit Reason
An abbreviated survey was conducted to investigate complaint GA002023466.
Complaint Details
Complaint GA002023466 was investigated and found to be unsubstantiated.
Findings
The complaint GA002023466 was found to be unsubstantiated during the abbreviated survey.
Inspection Report
Re-Inspection
Census: 110
Deficiencies: 0
Date: Jan 22, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Standard Survey from 12/2/19 to 12/5/19.
Findings
All deficiencies cited in the prior Standard Survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 108
Capacity: 118
Deficiencies: 4
Date: Dec 3, 2019
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety and life safety requirements under 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including failures to prevent smoke spread through ceiling penetrations, improper maintenance of fire alarm system batteries, incomplete closure of resident doors to resist smoke spread, and unsealed smoke barrier penetrations. These deficiencies placed residents and staff at risk in the event of fire.
Deficiencies (4)
Facility failed to assure prevention of smoke spread from fire due to several ceiling penetrations in Kitchen, Laundry, and east electrical closet.
Fire alarm batteries did not have manufacturer date labeled, indicating failure to maintain notification system properly.
Resident room door to room #120 would not close to latch, failing to resist smoke spread.
Smoke barrier penetration altered and unsealed in west wing doorway, allowing smoke spread.
Report Facts
Census: 108
Total Capacity: 118
Residents at risk: 6
Residents at risk: 30
Residents at risk: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 9, 2019
Visit Reason
A complaint survey was conducted to investigate a complaint by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint was unsubstantiated and no citation was cited.
Findings
The complaint was unsubstantiated and no citation was cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 25, 2019
Visit Reason
A complaint survey was conducted to investigate complaint GA00194607 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00194607 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 22, 2018
Visit Reason
A complaint survey was conducted to investigate complaint GA001192199 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA001192199 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Re-Inspection
Census: 107
Deficiencies: 0
Date: Oct 3, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the August 2, 2018 Standard Survey.
Findings
All deficiencies cited in the prior August 2, 2018 Standard Survey were found to be corrected during this revisit survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 3, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA 00191781.
Complaint Details
Complaint GA 00191781 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 18, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Routine
Census: 105
Deficiencies: 2
Date: Aug 2, 2018
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations related to long term care facilities.
Findings
The facility failed to maintain sanitary conditions in the kitchen and dining areas, including issues with handwashing facilities, food handling practices, and pest control. Additionally, the outdoor garbage refuse area was not properly maintained, with dumpsters missing lids and garbage scattered around, creating potential health hazards.
Deficiencies (2)
Failure to ensure the kitchen was maintained in a sanitary manner and meals were prepared and served according to sanitation standards, including non-functioning soap dispenser, contamination of clean dishes by staff with soiled gloves, and presence of cockroach in dining area.
Failure to properly dispose of garbage and refuse, including dumpsters missing lids, side doors left open, and garbage scattered around the dumpster area over multiple days.
Report Facts
Resident census: 105
Residents affected: 116
Cleaning frequency: 2
Cleaning frequency: 1
Garbage pickup frequency: 3
Performance improvement plan target completion date: Aug 31, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary DD | Dietary staff | Observed during kitchen inspection and noted soap dispenser issue |
| CNA AA | Certified Nurse Assistant | Observed handling food rolls with bare hands and chasing cockroach |
| LPN BB | Licensed Practical Nurse | Observed handling food rolls with bare hands |
| LPN HH | Licensed Practical Nurse | Observed cockroach incident while feeding residents |
| Director of Nursing | Director of Nursing | Interviewed about cockroach incident and staff food handling training |
| Dietary Manager | Dietary Manager | Interviewed about dishwashing practices and cleaning schedules |
| District Manager of Housekeeping | District Manager of Housekeeping | Interviewed about soap dispenser batteries and dumpster area cleanliness |
| Maintenance Director | Maintenance Director | Interviewed about dumpster lid replacement and area maintenance responsibilities |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Aug 2, 2018
Visit Reason
The inspection was conducted following observations and complaints related to kitchen sanitation, food handling practices, pest infestation, and dumpster area cleanliness at Bonterra Transitional Care & Rehabilitation.
Complaint Details
The visit was complaint-related due to reports of pest infestation (cockroaches), poor kitchen sanitation, and improper food handling practices. The complaint was substantiated based on observations during the inspection.
Findings
The inspection found multiple deficiencies including non-functional soap dispensers in the kitchen, staff contaminating clean dishes with soiled gloves, presence of cockroaches in the dining area, inadequate cleaning of the dish machine area, and poor maintenance of the dumpster area with garbage scattered around attracting pests.
Deficiencies (6)
Soap dispenser in the kitchen was non-functional due to dead batteries, preventing proper handwashing.
Staff member contaminated clean dishes by handling them with soiled gloves without handwashing or glove removal.
Cockroach observed crawling on the counter where residents' coffee cups were placed.
Black substance (mildew or mold) present on stainless-steel wall behind dish sprayer, not cleaned regularly.
Dish machine area cleaning was inadequate; deep cleaning scheduled twice monthly but only done once in July 2018.
Dumpster area had open lids, garbage scattered over approximately 50 feet diameter, attracting pests and rodents.
Report Facts
Inspection date: Jul 30, 2018
Inspection date: Aug 1, 2018
Inspection date: Aug 2, 2018
Garbage pickup frequency: 3
Dumpster garbage scatter area: 50
Cleaning frequency: 2
Cleaning frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary DD | Dietary Staff | Present during kitchen inspections and observations |
| Certified Nurse Assistant AA | CNA | Observed handling rolls with bare hands and identifying cockroach |
| Licensed Practical Nurse BB | LPN | Observed handling rolls with bare hands |
| Licensed Practical Nurse HH | LPN | Observed feeding residents and witnessing cockroach incident |
| Dietary Manager | Dietary Manager | Interviewed about cleaning practices and staff behavior |
| Director of Nursing | Director of Nursing | Interviewed about pest control and staff training |
| District Manager of Housekeeping | District Manager of Housekeeping | Interviewed about housekeeping responsibilities and pest sightings |
| Maintenance Director | Maintenance Director | Interviewed about dumpster area and maintenance responsibilities |
Inspection Report
Life Safety
Census: 106
Capacity: 118
Deficiencies: 6
Date: Jul 31, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety and related regulations for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance with fire safety requirements, including non-illuminated exit signs, unsynchronized fire alarm strobes, painted sprinkler heads, smoke barrier doors not closing properly, missing electrical outlet covers, and presence of prohibited portable space heaters.
Deficiencies (6)
Exit signs in the Laundry were not illuminated at all times as required.
Fire alarm strobes were flashing out of synchronization, potentially triggering seizures.
A sprinkler head in the dietary storage room was painted on the deflector and drop arm.
Smoke compartment doors at the fire separation did not close completely on the initial fire alarm test.
Missing electrical outlet cover in Room #144 exposed residents to potential electrical shock hazard.
Portable space heaters found in two locations without manufacturer documentation confirming safe heating elements.
Report Facts
Staff and Residents at risk: 36
Staff, Visitors, and Residents at risk: 10
Staff and Residents at risk: 60
Staff and Residents at risk: 4
Census: 106
Total licensed beds: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 3, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to determine compliance with Federal and State Long Term Care Requirements, investigating GA 00188280.
Findings
The survey was unsubstantiated with no deficiencies found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 23, 2018
Visit Reason
A complaint survey was conducted on 2/22-23/18 to investigate complaints GA00183220 and GA00183974 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The complaint investigation was conducted for complaints GA00183220 and GA00183974 and resulted in no deficiencies cited.
Findings
No deficiency was cited; the facility was found to be in compliance with the applicable Federal and State Long Term Care Requirements.
Inspection Report
Re-Inspection
Census: 111
Deficiencies: 0
Date: Oct 20, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 8/31/17 Standard Survey.
Findings
All deficiencies cited as a result of the 8/31/17 Standard Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 18, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 10, 2017
Visit Reason
The inspection was conducted as a complaint survey to investigate complaint numbers GA00179435 and GA00180265.
Complaint Details
Complaint numbers GA00179435 and GA00180265 were investigated and found to have no health care deficiencies.
Findings
No health care deficiencies were cited during the complaint survey.
Inspection Report
Life Safety
Census: 108
Capacity: 118
Deficiencies: 2
Date: Aug 29, 2017
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including issues with sprinkler system maintenance and corridor door safety. Specific deficiencies included loaded sprinkler heads that could delay activation and resident doors that did not properly resist smoke passage.
Deficiencies (2)
Loaded sprinkler heads within a specified area over the Physical Therapy Rehab and outside room #138 could delay initial sprinkler activation.
Several resident doors (Rooms 106, 107, 123, 124, and 129) would close to latch shut to resist or limit the passage of smoke to or from resident rooms, failing to assure residents were safe from smoke exposure.
Report Facts
Census: 108
Total Capacity: 118
Residents at risk: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to sprinkler heads and resident doors during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 6, 2017
Visit Reason
The inspection was conducted to investigate complaints #GA00176859 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint survey conducted to investigate complaints #GA00176859; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey at Bonterra Transitional Care & Rehabilitation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 27, 2017
Visit Reason
An Abbreviated Survey was conducted to investigate complaints GA00165753, GA00163934, and GA00163773.
Complaint Details
Complaints GA00165753, GA00163934, and GA00163773 were investigated and found to be not substantiated.
Findings
The complaints were not substantiated and the facility was found to be in compliance with Federal and State Long Term Care Requirements 42 CFR, Part 483, Subpart B.
Report
Mar 19, 2025
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