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Nursing HomeMedicaid Investigative

Bonterra Transitional Care & Rehabilitation

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

2801 Felton Drive, River Park · East Point, GA 30344118 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
2.9/5

based on 29 Google reviews

5
4
3
2
1
Bonterra Transitional Care & Rehabilitation Nursing Home in East Point, GA — Street View
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4/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (2/5 stars)
  • Above-median deficiencies (21 vs median 5.0)

Bottom 25% in GA · Critically understaffed (RN) · Worst in WELLINGTON HEALTH CARE SERVICES chain · $57,064 in fines

Source: Medicare data

What this means for your family

While some families report positive experiences with rehab and specific staff members, the facility has a recurring history of serious medical and hygiene-related complaints. If you consider this facility, we strongly recommend conducting unannounced visits and asking specifically about their medication administration protocols and how they handle patient hygiene requests.

Google Reviews

Google Reviews

29 reviews on Google
Bonterra Transitional Care & Rehabilitation receives highly polarized feedback, with significant concerns regarding basic hygiene, medication safety, and responsiveness. While some families praise specific staff members for their compassion, others report severe neglect, including patients left soiled for hours, medication errors, and poor communication from administration.

Quality Themes

Tap a score for details
Food1.0Staff4.0Clean2.0Activities8.0Meds1.0MemoryN/AComms2.0ValueN/A

Strengths

  • Select compassionate and dedicated nursing staff
  • Effective rehab therapy for some patients
  • Responsive unit management in specific cases

Concerns

  • Neglect regarding hygiene and toileting (patients left soiled) (mentioned by 3 reviewers)
  • Poor communication and long wait times for visitors (mentioned by 2 reviewers)
  • Medication management errors (mentioned by 2 reviewers)
  • Poor food quality and lack of variety (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2343.0'13(1)1.01.0'17(3)5.05.0'19(2)3.41.0'22(2)2.3'25(4)

Distribution · 20 analyzed

5
6
4
1
3
1
2
2
1
10

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1I've heard wonderful things about the compassion of your nursing staff; how do you ensure that level of care is maintained during shift changes?
  • 2What specific protocols do you have in place to ensure medication administration is always accurate and timely for every resident?
  • 3How does the team manage routine hygiene and personal care needs to ensure residents are always comfortable and clean throughout the day?
  • 4Could you tell me more about the dining experience, specifically regarding how you plan menus to ensure variety and nutritional quality?
  • 5How does the facility handle communication with families, and what is the best way for us to get quick updates on our loved one's status?
  • 6In the event of a medical emergency during the night, what is the immediate process for notifying both the medical team and the family?

Personalized based on this facility's data


Key Review Excerpts

They gave my dad chemo pills for prostate cancer. He doesn't have prostate cancer. Could have killed him.

Family member · 2017☆☆☆☆

My father (Mr. Lynch) lived there for 2 years and 5 months and I was very pleased with the staff and care given to him. They made sure that he was clean, shaved, fed, clothed and comfortable.

Long-term resident's family · 2019★★★★★

My brother was at Bonterra for rehab and it was a great experience for him. We were very pleased with the care he received, the unit Manager Adrienne Jenkins, was a pleasure and she always returned my calls when we had questions.

Rehab patient's family · 2025★★★★
Source: 29 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.18hrs
24%
Registered nurses for medical care
Total Nursing
3.12hrs
76%
All nurses + aides combined
Staff Turnover
62%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

9

measures

Worse Than Avg

7

measures

Mixed Results

1

measures

Long-Stay Residents
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility50.8%
Worse than Avg
Here
50.8%
US
93.4%
GA
91.2%
Fulton
91.3%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
12.1%
GA
10.6%
Fulton
14.9%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility9.9%
Better than Avg
Here
9.9%
US
19.5%
GA
20.5%
Fulton
19.7%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility14.2%
Better than Avg
Here
14.2%
US
19.4%
GA
16.0%
Fulton
20.9%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility14.2%
Better than Avg
Here
14.2%
US
15.4%
GA
20.1%
Fulton
14.2%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility91.8%
Mixed vs Avgs
Here
91.8%
US
95.5%
GA
95.0%
Fulton
87.7%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility13.0%
Worse than Avg
Here
13.0%
US
81.8%
GA
80.4%
Fulton
78.2%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility51.4%
Worse than Avg
Here
51.4%
US
79.7%
GA
78.4%
Fulton
68.8%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.5%
Worse than Avg
Here
2.5%
US
1.6%
GA
2.4%
Fulton
1.9%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

21deficiencies
6penalties
Well above state avg (6.1)
29 complaint-triggered
$57,064 in fines

This facility has significant concerns with 29 complaint-triggered deficiencies from family reports, indicating serious problems with care planning, resident protection from abuse and neglect, and safety hazards. The most recurring issues involve inadequate care planning, repeated safety violations that risk resident harm, and failures in protecting residents from abuse. While the facility reports correcting these deficiencies, the persistent pattern of serious complaints across multiple surveys suggests ongoing care quality concerns that families should carefully evaluate.

Mar 19, 2025Complaint
21
0656Immediate jeopardy · IsolatedResolved (past non-compliance)

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0684Immediate jeopardy · IsolatedResolved (past non-compliance)

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0835Immediate jeopardy · IsolatedResolved (past non-compliance)

Administration Deficiencies

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

0697Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

0774Actual harm · IsolatedCorrected

Administration Deficiencies

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

0881Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0689Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0800Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0949Potential for harm · PatternCorrected

Administration Deficiencies

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

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0584Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0645Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0791Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

0919Potential for harm · IsolatedCorrected

Environmental Deficiencies

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

Mar 19, 2025Routine
4
0331Potential for harm · IsolatedCorrected

Smoke Deficiencies

Construct fire resistant interior walls.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0511Potential for harm · IsolatedCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

0923Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Feb 22, 2024Complaint
4
0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0550Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

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.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Aug 16, 2023Complaint
4
0656Actual harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0740Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Jan 5, 2023Routine
13
0006Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Conduct risk assessment and an All-Hazards approach.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0363Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0372Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0781Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Have restrictions on the use of portable space heaters.

0918Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0623Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0919Potential for harm · IsolatedCorrected

Environmental Deficiencies

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

0921Potential for harm · IsolatedCorrected

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

May 27, 2021Routine
7
0291Potential for harm · PatternCorrected

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

0321Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0645Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

0646Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

0867Potential for harm · IsolatedCorrected

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Federal Penalties

Fine

Mar 19, 2025

$17,345

Payment Denial

Mar 19, 2025

16-day denial

Fine

Nov 20, 2023

$4,587

Fine

Nov 13, 2023

$4,587

Fine

Oct 23, 2023

$13,762

Fine

Aug 16, 2023

$7,443

Ownership & Operations

Who Operates This Facility

Owner / Operator

Bonterra Transitional Care & Rehabilitation

Organization Type

for profit

Chain Affiliation

Chain Name

Wellington Health Care Services

Chain Size

14 facilities nationwide

Chain avg rating: 1.7/5 · Rank 9 of 13 (Worst)

Ownership & Management

Owners

Wellington Healthcare Services III, Lp

Owner · Organization

100%

Andwell Investments, LLC

Owner (parent company) · Organization

Rewell Investments, LLC

Owner (parent company) · Organization

Wellington Healthcare, LLC

Owner (parent company) · Organization

Andrews, James

Owner (parent company)

Rees, Heather

Owner (parent company)

Key personnel

Shuler, ValeriaW-2 Managing EmployeeAndrews, JamesOfficer / DirectorAndrews, JamesOfficer / DirectorAndrews, JamesManagerWiii Gp, LLCGeneral Partnership Interest
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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