Bonterra Transitional Care & Rehabilitation
2801 Felton Drive · East Point, GA · 30344 · 4047677591
118 certified beds For profit - Partnership Chain: Wellington Health Care Services
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (3 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $17,345 in fines in the last 24 months.
- Inspection results are getting worse cycle over cycle, not better.
Red flags
3 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
Cited under the freedom-from-abuse rule
Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
RN staffing in the bottom 10% nationally
0.18 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
62% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.12 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.18 | 0.55–0.75 |
| Weekend hours / resident-day | 2.74 | ≈ weekday level |
| Nursing turnover / year | 62% | median 45% |
| Fines (3-yr window) | 5 · $47,724 |
Inspection citations (42 in the current record)
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Potential for harm · D April 30, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Corrected June 5, 2026 · Infection Control
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Immediate jeopardy · J March 19, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 29, 2024 · Resident Assessment and Care Planning
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Immediate jeopardy · J March 19, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 29, 2024 · Quality of Life and Care
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Immediate jeopardy · J March 19, 2025 · found via complaint
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected July 29, 2024 · Administration
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Actual harm · G March 19, 2025 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected May 29, 2025 · Quality of Life and Care
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Actual harm · G March 19, 2025 · found via complaint
Help the resident with transportation to and from laboratory services outside of the facility.
Corrected May 29, 2025 · Administration
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Potential for harm · D March 19, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected May 29, 2025 · Resident Rights
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Potential for harm · D March 19, 2025 · found via complaint
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected May 29, 2025 · Resident Rights
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Potential for harm · D March 19, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected May 29, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D March 19, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected May 29, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D March 19, 2025 · found via complaint
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected May 29, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 19, 2025 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected May 29, 2025 · Quality of Life and Care
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Potential for harm · E March 19, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 29, 2025 · Quality of Life and Care
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Potential for harm · D March 19, 2025 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected May 29, 2025 · Quality of Life and Care
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Potential for harm · E March 19, 2025 · found via complaint
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected May 29, 2025 · Pharmacy Service
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Potential for harm · D March 19, 2025 · found via complaint
Provide or obtain dental services for each resident.
Corrected May 29, 2025 · Quality of Life and Care
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Potential for harm · E March 19, 2025 · found via complaint
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected May 29, 2025 · Nutrition and Dietary
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Potential for harm · E March 19, 2025 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected May 29, 2025 · Nutrition and Dietary
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Potential for harm · E March 19, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected May 29, 2025 · Infection Control
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Potential for harm · F March 19, 2025 · found via complaint
Implement a program that monitors antibiotic use.
Corrected May 29, 2025 · Infection Control
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Potential for harm · D March 19, 2025 · found via complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected May 29, 2025 · Environmental
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Potential for harm · E March 19, 2025 · found via complaint
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected May 29, 2025 · Administration
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Potential for harm · E February 22, 2024 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected April 7, 2024 · Resident Rights
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Potential for harm · E February 22, 2024 · found via complaint
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected April 7, 2024 · Resident Rights
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Potential for harm · D February 22, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 7, 2024 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 19, 2025 | Fine | $17,345 |
| March 19, 2025 | Payment Denial | 16 days |
| November 20, 2023 | Fine | $4,587 |
| November 13, 2023 | Fine | $4,587 |
| October 23, 2023 | Fine | $13,762 |
| August 16, 2023 | Fine | $7,443 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 115555 · certified since July 1, 1993. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.