Bonterra Transitional Care & Rehabilitation
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 29 Google reviews

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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
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 detailsStrengths
- 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
Distribution · 20 analyzed
How They Respond to Reviews
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.”
“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.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both 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
9
measures
7
measures
1
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 whose bladder or bowel control got worse
Residents on antipsychotic medication
Residents vaccinated for the flu
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
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
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, 2025Complaint21
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.
Mar 19, 2025Routine4
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.
Feb 22, 2024Complaint4
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.
Aug 16, 2023Complaint4
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.
Jan 5, 2023Routine13
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Miscellaneous Deficiencies
Have restrictions on the use of portable space heaters.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
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.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
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.
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.
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.
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
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, 2021Routine7
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
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
Resident Assessment and Care Planning Deficiencies
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
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
Bonterra Transitional Care & Rehabilitation
for profit
Chain Affiliation
Wellington Health Care Services
14 facilities nationwide
Chain avg rating: 1.7/5 · Rank 9 of 13 (Worst)
Ownership & Management
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
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
29 reviews from families & visitors
Official Website
Visit bonterratc.com
Medicare data downloads
Original nursing home datasets
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