Bonterra Transitional Care & Rehabilitation

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Enhanced Barrier Precautions Policy, the facility failed to ensure nursing staff used appropriate personal protective equipment (PPE) during catheter care and a bed bath for one of 20 residents (R) (R90) on EBP (enhanced barrier precautions). R90 had a suprapubic catheter, colostomy, and sacral wound, placing them at increased risk for infection.

Inspectors wroteBased on record reviews, staff interviews, and a review of the facility's policy titled Care Plan Policy, the facility failed to implement the care plan for one of 26 sampled residents (R) (R165) related to nutrition. Specifically, the facility provided R165 a sandwich which resulted in him being sent out to the local emergency room (ER) and admitted to a hospice facility where he expired on 8/31/2024. On 3/13/2025 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) for F656, F684, and F835 on 3/13/2025 at 12:48 pm. The noncompliance related to the IJ was identified to have existed on 7/23/2024. [...]

Inspectors wroteBased on observations, record reviews, staff interviews, and review of the facility's policies Modified Texture of Food and Resident Food Preferences, the facility failed to provide a pureed snack to one of 26 sampled residents (R) (R165) ordered to receive a mechanically altered diet. Specifically, the facility provided R165 a sandwich which resulted in him being sent out to the local emergency room (ER) and admitted to a hospice facility where he expired on 8/31/2024. On 3/13/2025 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) for F656, F684, and F835 on 3/13/2025 at 12:48 pm. [...]

Inspectors wroteBased on interviews, record reviews, and a review of the documents Administrator and Director of Nursing, the Administration failed to effectively and efficiently manage facility compliance with federal regulatory requirements related to Quality of Care for one of 26 sampled residents (R) (R165) receiving an altered diet. Specifically, the facility provided R165 a sandwich, which resulted in him being sent out to the local emergency room (ER) and admitted to a hospice facility where he expired on 8/31/2024. On 3/13/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review, and the facility's policy titled Pain Management - Acute, Chronic, and Subacute, the facility failed to ensure that pain management was provided for one of 36 sampled residents (R) (R71) who require such services consistent with professional standards of practice and the comprehensive person-centered care plan. Actual Harm was identified on 3/13/2025, when staples became embedded in R71's amputation surgical site after the facility failed to provide transportation for post-operation (post-op) appointments.

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

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policy titled, Antibiotic Stewardship, the facility failed to establish and maintain an Antibiotic Stewardship program related to clinical signs and symptoms, laboratory reports, stop dates on antibiotics, and monitoring systems in place for residents returning to the hospital. This had the potential to affect all 114 residents residing in the facility.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to make handrails accessible on two of two wings (East Wing and [NAME] Wing); and failed to adequately assess one of 36 sampled residents (R) (R20) for self-administration of medication.

Inspectors wroteBased on observations, staff interviews, and a review of the facility policy titled Administration of Medications, the facility failed to properly lock and secure three of four medication carts (Medication Carts A and B on the East Wing and Medication Cart C on the [NAME] Wing).

Inspectors wroteBased on observation, record review, staff interviews, and review of facilities policy titled Therapeutic Diets, the facility failed to use a recipe when preparing pureed food. This deficient practice has the potential to affect six residents on a pureed diet.

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

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policy titled Infection Prevention and Control Program Overview, the facility failed to provide proper surveillance and monitoring for infections and communicable diseases for 114 out of 114 residents residing in the facility. Furthermore, the facility failed to remove personal clothing items from the unit linen cart and failed to cover the resident's clean clothing while transporting the laundry cart.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled Education and Training Requirements, the facility failed to provide an effective behavioral health training program consistent with the facility assessment and person-centered care for three of 36 samples residents (R) (R55, R66, and R76).

Inspectors wroteBased on observations, staff interviews, record reviews, and the review of the facility's policy titled Resident's Rights, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity for one of 36 sampled residents (R) (R6).

Inspectors wroteBased on observations, record review, interviews, and review of the facility's policies titled Cleaning and Disinfecting Residents' Rooms and 5-Steps to Room Cleaning, the facility failed to maintain a clean home-like environment for one of 24 rooms (room [ROOM NUMBER]) located on the East Wing.

Inspectors wroteBased on observations, interviews, record review, and review of the facility's policies titled Abuse Prevention Policy and Drug Diversion Policy, the facility failed to ensure one of 36 sampled residents (R) (R71) was free from misappropriation of prescribed narcotics.

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

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled Preadmission Screening and Annual Resident Review (PASARR) Policy, the facility failed to obtain a level II PASARR screening for two of 36 sampled residents (R) (R55 and R76).

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled ADL Care-Bath (Shower) Hygiene Care, the facility failed to ensure Activities of Daily Living (ADL) care was provided for one of 36 sampled residents (R) (R47) relating to nail care.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy Oxygen Therapy Policy, the facility failed to administer oxygen therapy according to the physician's orders for two of 13 residents (R) (R75 and R99) receiving oxygen therapy.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled Dental Services Policy, the facility failed to provide dental services for one of 36 sampled residents (R) (R77).

Inspectors wroteBased on observations, interviews, record reviews, and review of the facility's policy titled Call System/Light Policy, the facility failed to ensure that the nursing call light was answered and accessible for one of 36 sampled residents (R) (R33).

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to provide an environment that was free from potential infections. Specifically, the washing machine mixer machine that adds detergent and chlorine bleach to the two industrial sized washing machines was not working and the facility was using household detergent pods to wash personal clothing, linen, and towels. The deficient practice had the potential to affect 108 out of 108 residents.

Inspectors wroteBased on observations and resident and staff interviews, the facility failed to promote dignity by serving two meals on two separate days out of a four-day period on Styrofoam containers and with plastic cutlery to 107 of 108 residents on two of two wings (the East Wing and [NAME] Wing) who get their meals from the facility kitchen.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to provide a safe, clean, comfortable, homelike environment in the [NAME] Wing shower room and in seven of 17 bathrooms (Rooms 107, 111, 126, 127, 129, 133, and 139) on the East wing. The deficient practice had the potential to affect 54 out of 54 residents on the [NAME] Wing and seven of 17 bathrooms on the East Wing.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure the environment remained free of accident hazards in one of one shower room on the [NAME] Wing. Specifically, the [NAME] Wing shower room had a divider wall with a sharp, jagged edge hanging away from the wall where residents could get cut and/or injured.

Inspectors wroteBased on record review, resident, family and staff interviews, and review of the facility policy titled, Transfer or Discharge, Emergency Policy, the facility failed to ensure two of two residents (R)(R#79 and R#92) that were reviewed for facility initiated emergent hospital transfer from a total sample of 33 residents, were provided with written transfer/discharge notice that stated the reason for the transfer, the place of the transfer, and other information regarding the transfer. This failure has the potential to affect R#79 and R#92 and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to provide timely and accurate resident assessments. These failures effected two of 31 residents (R) (R#107 and R#79) sampled. Specifically, the facility failed to provide accurate discharge coding in the electronic medical record (EMR) for R#107 and failed to accurately identify and code weight loss in an assessment for R#79. Findings Include: 1. Review of the admission Record from the EMR Profile tab for R#79 showed an admission date of 12/02/2021 with medical diagnoses that included traumatic subdural hemorrhage, heart failure, traumatic brain injury (TBI), hypertension, convulsions, and cardiac arrythmia. [...]

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Care Plan Policy, the facility failed to develop and implement a comprehensive person-centered care plan for three of 32 sampled residents (R) (R#19, R#97 and R#30) whose care plans were reviewed. Specifically, R#19 did not have a care plan for use of the wander guard, R#97 did not have a care plan for cognitive deficits, and #R30 did not have a care plan for depression and the use of an antipsychotic medication.

Inspectors wroteBased on record review, staff interviews and review of the facility policy titled, Resident Assessments, the facility failed to ensure one resident (R)#19 of five residents reviewed for unnecessary medications, had an assessment that accurately reflected the resident's status. Specifically, the facility failed to ensure the Abnormal Involuntary Movement Scale (AIMS) for R#19 was completed timely.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to provide accurate daily skilled resident assessments for one resident (R)#104 of four residents reviewed for assessment accuracy. Specifically, this failure has the potential for assessments not being conducted as ordered to monitor for daily changes in condition and/or baseline changes.

Inspectors wroteBased on observations, record review, staff interviews and review of the facility policy titled, Call Light Policy, the facility failed to ensure two (R) (R#78 and R#89) of 33 residents sampled were provided with a call light for use when assistance could possibly be needed. This failure had the potential to adversely affect the timeliness of care or response time in case of an urgent or emergent need.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure there was an air gap between the drainpipe and the floor drain for the ice machine and the prep sink in the kitchen. In the event of a sewer line back-up, this failure could cause contamination to the facility water system affecting the ice used for beverages and/or water used in food preparation. The facility census was 107 with 102 residents receiving an oral diet.