Inspection Reports for Bonterra Transitional Care and Rehabilitation

A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.

All previously cited survey tags have been corrected as noted during the follow-up survey.

The document is a Statement of Deficiencies and Plan of Correction for Bonterra Transitional Care & Rehabilitation, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide specific findings or deficiencies.

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.

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.

Complaint investigation was conducted with intake numbers GA00254773, GA00255070, and GA00255068; no deficiencies were found.

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.

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.

Complaint investigation was conducted with intake numbers GA00254773, GA00255070, and GA00255068; no deficiencies were found.

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.

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.

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.

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.

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.

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.

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.

An abbreviated/partial extended survey was conducted to investigate Complaint Intake Number GA00250523 at Bonterra Transitional Care and Rehabilitation.

The complaint was found substantiated, but no deficiencies were cited during the investigation.

Complaint Intake Number GA00250523 was found substantiated.

An abbreviated/partial extended survey was conducted to investigate multiple complaints against the facility.

Several complaints were investigated; four complaints were unsubstantiated, and two complaints were substantiated without deficiency.

Complaints GA00245565 and GA00246425 were substantiated without deficiency. Complaints GA00246459, GA00246577, GA00247171, and GA00248381 were unsubstantiated.

The document is a Statement of Deficiencies and Plan of Correction for Bonterra Transitional Care & Rehabilitation, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide specific details on deficiencies or findings.

A revisit survey was conducted to verify correction of deficiencies cited during the 2/22/2024 Recertification Survey.

All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.

A Complaint Investigation survey was conducted at Bonterra Transitional Care and Rehabilitation from February 12, 2024 through February 22, 2024 to investigate alleged deficiencies.

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.

The survey was complaint-driven, investigating infection control and environmental sanitation concerns. The complaint was substantiated with multiple deficiencies cited.

An Abbreviated Survey was conducted to investigate multiple complaint intake numbers related to Bonterra Transitional Care & Rehabilitation.

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.

The survey was initiated to investigate multiple complaint intake numbers. Several complaints were substantiated with federal deficiencies cited, while others were unsubstantiated.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The document is a statement of deficiencies and plan of correction for Bonterra Transitional Care & Rehabilitation, indicating a regulatory inspection was conducted.

No specific deficiencies or findings are detailed in the provided report page.

A revisit survey was conducted to verify correction of deficiencies cited during the complaint-only survey on 2023-08-16.

All deficiencies cited as a result of the 8/16/2023 complaint-only survey were found to be corrected.

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.

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.

An Abbreviated/Partial Extended Survey was conducted from August 14 to August 16, 2023, investigating complaint numbers GA00237908, GA00237912, and GA00237983.

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.

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.

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.

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.

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.

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.

The document is a statement of deficiencies and plan of correction for Bonterra Transitional Care & Rehabilitation following a regulatory inspection.

The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.

A revisit survey was conducted to verify correction of deficiencies cited during the 01/05/2023 Annual Survey.

All deficiencies cited as a result of the 01/05/2023 Annual Survey were found to be corrected.

A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.

All previously cited survey tags have been corrected as noted by the surveyor during the follow-up visit.

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.

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.

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.

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.

Complaint Intake number GA00230085 was unsubstantiated. Complaint Intake number GA00227361 was substantiated with deficiencies cited.

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.

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.

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).

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.

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).

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.

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).

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.

An abbreviated survey was conducted to investigate complaint #GA00226007.

The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.

Complaint #GA00226007 was unsubstantiated with no deficiencies cited.

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).

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.

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).

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.

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).

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.

An abbreviated survey was conducted to investigate complaints #GA00223251 and #GA00224644.

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).

Complaints #GA00224644 and #GA00223251 were investigated and found to be unsubstantiated without deficiencies cited.

An abbreviated survey was conducted to investigate complaints #GA00223251 and #GA00224644.

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).

Complaints #GA00224644 and #GA00223251 were investigated and found to be unsubstantiated without deficiencies cited.

An abbreviated survey was conducted to investigate complaints #GA00223251 and #GA00224644.

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).

Complaints #GA00224644 and #GA00223251 were investigated and found to be unsubstantiated without deficiencies cited.

An abbreviated survey was conducted to investigate complaints #GA00223251 and #GA00224644.

The complaints were unsubstantiated and no deficiencies were cited. The facility was found to be in compliance with vaccination requirements for facility staff.

Complaints #GA00224644 and #GA00223251 were investigated and found to be unsubstantiated without deficiencies cited.

An abbreviated survey was conducted to investigate complaints #GA00223251 and #GA00224644.

The complaints were unsubstantiated and no deficiencies were cited. The facility was found to be in compliance with vaccination requirements for facility staff.

Complaints #GA00223251 and #GA00224644 were investigated and found to be unsubstantiated without deficiencies cited.

An abbreviated survey was conducted to investigate complaint #GA00221979.

The complaint was found to be unsubstantiated and no deficiencies were identified during the survey.

Complaint #GA00221979 was investigated and found to be unsubstantiated with no deficiencies.

A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.

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.

An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00217999 and #GA00218372.

The complaints #GA00217999 and #GA00218372 were unsubstantiated and no regulatory violations were cited.

Complaints #GA00217999 and #GA00218372 were investigated and found to be unsubstantiated.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited survey tags have been corrected during this follow-up visit.

The document is a statement of deficiencies and plan of correction for Bonterra Transitional Care & Rehabilitation, indicating a regulatory inspection was conducted.

The report contains a summary statement of deficiencies identified during the inspection; however, no specific deficiencies or findings are detailed in the provided page.

A revisit survey was conducted to verify correction of previously cited deficiencies from the Standard survey.

All deficiencies cited as a result of the Standard survey were found to be corrected at the time of the revisit.

The inspection was conducted as a licensure survey for Bonterra Transitional Care & Rehabilitation.

No deficiencies were identified during the licensure survey.

A standard survey was conducted to assess compliance with Medicare/Medicaid regulations related to long term care facilities.

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.

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.

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.

An abbreviated/partial extended survey was conducted to investigate complaints #GA00205398, #GA00208481, and #GA00203582.

The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.

Complaints #GA00205398, #GA00208481, and #GA00203582 were investigated and found to be unsubstantiated.

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.

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.

An unannounced, abbreviated survey was conducted to investigate Complaint Number GA00202571 at Bonterra Transitional Care and Rehabilitation.

The complaint was substantiated but no citation was issued.

Complaint Number GA00202571 was investigated and substantiated without citation.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The survey noted that all previously cited deficiencies had been corrected.

An abbreviated survey was conducted to investigate complaint GA002023466.

The complaint GA002023466 was found to be unsubstantiated during the abbreviated survey.

Complaint GA002023466 was investigated and found to be unsubstantiated.

A revisit survey was conducted to verify correction of deficiencies cited during the Standard Survey from 12/2/19 to 12/5/19.

All deficiencies cited in the prior Standard Survey were found to be corrected during this revisit survey.

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.

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.

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.

The complaint was unsubstantiated and no citation was cited.

Complaint was unsubstantiated and no citation was cited.

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.

No deficiencies were cited during the complaint survey.

Complaint GA00194607 was investigated and found to have no deficiencies.

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.

No deficiencies were cited during the complaint survey.

Complaint GA001192199 was investigated and found to have no deficiencies.

A revisit survey was conducted to verify correction of deficiencies cited in the August 2, 2018 Standard Survey.

All deficiencies cited in the prior August 2, 2018 Standard Survey were found to be corrected during this revisit survey.

An abbreviated/partial extended survey was conducted to investigate complaint GA 00191781.

The complaint was unsubstantiated and no deficiencies were identified during the survey.

Complaint GA 00191781 was investigated and found to be unsubstantiated with no deficiencies.

A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.

The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.

A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations related to long term care facilities.

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.

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.

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.

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.

A Life Safety Code Survey was conducted to assess compliance with fire safety and related regulations for participation in Medicare/Medicaid.

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.

An Abbreviated/Partial Extended Survey was conducted to determine compliance with Federal and State Long Term Care Requirements, investigating GA 00188280.

The survey was unsubstantiated with no deficiencies found.

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.

No deficiency was cited; the facility was found to be in compliance with the applicable Federal and State Long Term Care Requirements.

The complaint investigation was conducted for complaints GA00183220 and GA00183974 and resulted in no deficiencies cited.

A revisit survey was conducted to verify correction of deficiencies cited during the 8/31/17 Standard Survey.

All deficiencies cited as a result of the 8/31/17 Standard Survey were found to be corrected.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.

The inspection was conducted as a complaint survey to investigate complaint numbers GA00179435 and GA00180265.

No health care deficiencies were cited during the complaint survey.

Complaint numbers GA00179435 and GA00180265 were investigated and found to have no health care deficiencies.

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.

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.

The inspection was conducted to investigate complaints #GA00176859 and determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey at Bonterra Transitional Care & Rehabilitation.

Complaint survey conducted to investigate complaints #GA00176859; no deficiencies were found.

An Abbreviated Survey was conducted to investigate complaints GA00165753, GA00163934, and GA00163773.

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.

Complaints GA00165753, GA00163934, and GA00163773 were investigated and found to be not substantiated.