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Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 32 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
1 finding in latest survey
This facility has areas of concern that warrant careful consideration. Registered Nurse hours are 23% of the EveryPlace reference benchmark; ask how RN coverage is allocated across shifts. We recommend asking the administrator directly: "How are you addressing recent staffing shortfalls?" These are not reasons to panic, but they are reasons to ask tough questions and visit in person.
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
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Concerns
Rating Trends
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Distribution · 32 analyzed
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.”
“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.”
“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.”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
6
measures
8
measures
3
measures
Residents vaccinated for pneumonia
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on anti-anxiety or sleep medication
Residents vaccinated for the flu
Residents whose bladder or bowel control got worse
Residents on antipsychotic medication
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
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.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Administration Deficiencies
Help the resident with transportation to and from laboratory services outside of the facility.
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
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.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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.
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Smoke Deficiencies
Construct fire resistant interior walls.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Federal Penalties
Fine
Mar 19, 2025
$17,660
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
Bonterra Transitional Care & Rehabilitation
for profit
Wellington Health Care Services
14 facilities nationwide
Chain avg rating: 1.7/5 · Rank 9 of 13 (Lowest rating)
Owners
Wellington Healthcare Services III, Lp
Owner · Organization
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
Contact this facility directly and verify the details that matter most to your family.
Medicare Care Compare
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Google Reviews
32 reviews from families & visitors
Official Website
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Medicare data downloads
Original nursing home datasets
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. Some summaries, interpretations, suggested questions, and pricing research are AI-generated or AI-assisted and may contain errors or omit important context. 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.
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