The Vardell Report.Bonterra Transitional Care & Rehabilitation

Across 4 inspections from January 2023 to April 2026, state surveyors documented 33 findings at Bonterra Transitional Care & Rehabilitation; 33 have a recorded correction; CMS lists 5 enforcement actions in the window.

Inspections

4

2023–2026, standard and complaint

Findings

33

Deficiencies cited by state inspectors

Corrected

33

Of 33 findings, with a recorded correction date

Penalties

5

4 fines; payment not published, 1 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Apr 302026

   Standard health inspection

   1 finding

   The same visit included a complaint investigation.

   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 5, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Mar 192025

   Standard health inspection

   21 findings

   The same visit included a complaint investigation.

   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level JImmediate jeopardyCorrected Jul 29, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Jul 29, 2024
   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level JImmediate jeopardyCorrected Jul 29, 2024
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level GActual harmCorrected May 29, 2025
   • F774Help the resident with transportation to and from laboratory services outside of the facility.Level GActual harmCorrected May 29, 2025
   • F881Implement a program that monitors antibiotic use.Level FNo actual harm, potential for moreCorrected May 29, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected May 29, 2025
   • F761Ensure 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.Level ENo actual harm, potential for moreCorrected May 29, 2025
   • F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Level ENo actual harm, potential for moreCorrected May 29, 2025
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected May 29, 2025
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected May 29, 2025
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level ENo actual harm, potential for moreCorrected May 29, 2025
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected May 29, 2025
   • F584Honor 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.Level DNo actual harm, potential for moreCorrected May 29, 2025
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected May 29, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected May 29, 2025
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected May 29, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected May 29, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected May 29, 2025
   • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected May 29, 2025
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected May 29, 2025

   Enforcement Action

   Civil money penalty, $17,660 imposed March 19, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 19, 2025, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed March 19, 2025. Status: Closed, May 29, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 19, 2025, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Feb 222024

   Complaint investigation

   4 findings

   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Apr 7, 2024
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Apr 7, 2024
   • F584Honor 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.Level ENo actual harm, potential for moreCorrected Apr 7, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 7, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Jan 52023

   Standard health inspection

   7 findings

   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Feb 15, 2023
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Feb 15, 2023
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Feb 15, 2023
   • F758Implement 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.Level DNo actual harm, potential for moreCorrected Feb 15, 2023
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Feb 15, 2023
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Feb 15, 2023
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Feb 15, 2023

   Enforcement Action

   Civil money penalty, $13,762 imposed October 23, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 5, 2023, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $4,587 imposed November 13, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 5, 2023, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $4,587 imposed November 20, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 5, 2023, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Infection Control, Cited in Three Inspections

   Inspectors cited F880 in February 2024, March 2025 and April 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242526F880 across all 4 inspections, oldest to newest
2. 2

   Dignity and Resident Rights, Cited in Two Inspections

   Inspectors cited F550 in February 2024 and March 2025. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242526F550 across all 4 inspections, oldest to newest
3. 3

   A Clean, Homelike Setting, Cited in Two Inspections

   Inspectors cited F584 in February 2024 and March 2025. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242526F584 across all 4 inspections, oldest to newest
4. 4

   Care Plans, Cited in Two Inspections

   Inspectors cited F656 in January 2023 and March 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242526F656 across all 4 inspections, oldest to newest
5. 5

   Accident Hazards and Supervision, Cited in Two Inspections

   Inspectors cited F689 in February 2024 and March 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242526F689 across all 4 inspections, oldest to newest
6. 6

   Citation F919, Cited in Two Inspections

   Inspectors cited F919 in January 2023 and March 2025. The agency describes it this way: Make sure that a working call system is available in each resident's bathroom and bathing area. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242526F919 across all 4 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in three inspections, most seriously at level F.

2. 02

   How do staff learn each resident’s preferences, and how is a complaint about dignity handled?

   Dignity and Resident Rights: cited in two inspections, most seriously at level E.

3. 03

   What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

   A Clean, Homelike Setting: cited in two inspections, most seriously at level E.

4. 04

   How is a care plan written and reviewed here, and how do families take part in it?

   Care Plans: cited in two inspections, most seriously at level J.

5. 05

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in two inspections, most seriously at level E.

6. 06

   What changed after F919 was cited, and how do you check it now?

   Citation F919: cited in two inspections, most seriously at level D.

7. 07

   How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

   No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

8. 08

   What led to the 2025 fine, and has it been paid?

   A $17,660 civil money penalty was imposed March 19, 2025. CMS publishes the fine, not whether it has been paid. The record holds five enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Georgia Department of Community Health, Healthcare Facility Regulation Division.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Georgia Department of Community Health, Healthcare Facility Regulation Division

  Inspection Jan 5, 2023 · Published Oct 1, 2026 · Retrieved Oct 31, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Georgia Department of Community Health, Healthcare Facility Regulation Division

  Inspection Feb 22, 2024 · Published Oct 1, 2026 · Retrieved Oct 31, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Georgia Department of Community Health, Healthcare Facility Regulation Division

  Inspection Mar 19, 2025 · Published Oct 1, 2026 · Retrieved Oct 31, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Georgia Department of Community Health, Healthcare Facility Regulation Division

  Inspection Apr 30, 2026 · Published Oct 1, 2026 · Retrieved Oct 31, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Oct 31, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 115555

  Published Oct 1, 2026 · Retrieved Oct 31, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.