Bonterra Transitional Care & Rehabilitation
2801 Felton Drive, East Point, GA 30344 · Fulton County · 118 certified beds · avg 111 residents/day · certified since Jul 1, 1993
Part of chain: WELLINGTON HEALTH CARE SERVICES (14 facilities, chain avg rating 1.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Mar 19, 2025 · F-0656 · triggered by a complaint
The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 29, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Mar 19, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 29, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Mar 19, 2025 · F-0835 · triggered by a complaint
The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents.
Why it matters: Poor administration often shows up as understaffing, supply shortages, and care problems across the whole facility.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 29, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Mar 19, 2025 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 29, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 19, 2025 · F-0774 · triggered by a complaint
The facility did not help residents with transportation to and from laboratory services outside the facility.
Why it matters: Without transportation help, residents can miss important tests their doctors ordered.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 29, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 16, 2023 · F-0656 · triggered by a complaint
The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 16, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 16, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 16, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (37)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 30, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Mar 19, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Mar 19, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 19, 2025 | ▲ J · Immediate jeopardy, one-off | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint |
| Mar 19, 2025 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Mar 19, 2025 | ▲ G · Actual harm, one-off | The facility did not help residents with transportation to and from laboratory services outside the facility. · from a complaint |
| Mar 19, 2025 | F · Potential for harm, facility-wide | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. · from a complaint |
| Mar 19, 2025 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 19, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Mar 19, 2025 | E · Potential for harm, repeated | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. · from a complaint |
| Mar 19, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Mar 19, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Mar 19, 2025 | E · Potential for harm, repeated | The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. · from a complaint |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. · from a complaint |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. · from a complaint |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Feb 22, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Feb 22, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Feb 22, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Feb 22, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 16, 2023 | ▲ G · Actual harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Aug 16, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 16, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Aug 16, 2023 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint |
| Jan 5, 2023 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Jan 5, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jan 5, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jan 5, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jan 5, 2023 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jan 5, 2023 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Jan 5, 2023 | D · Potential for harm, one-off | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (21 → 1).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 11 | 2 | G ▲ |
| 2024 | 4 | 0 | F |
| 2025 | 21 | 5 | J ▲ |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
4 fines totaling $40,596, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Mar 19, 2025 | Fine | $17,660 |
| Mar 19, 2025 | Payment Denial | 16 days from May 13, 2025 |
| Nov 20, 2023 | Fine | $4,587 |
| Nov 13, 2023 | Fine | $4,587 |
| Oct 23, 2023 | Fine | $13,762 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Georgia avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.83 | 3.54 | 3.95 | bottom 11% in Georgia; bottom 9% in the U.S. |
| Registered Nurse hours | 0.17 | 0.50 | 0.69 | bottom 3% in Georgia; bottom 1% in the U.S. |
| Weekend total nurse staffing | 2.58 | 3.09 | 3.50 | bottom 21% in Georgia; bottom 12% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.15 | 0.35 | 0.48 | bottom 11% in Georgia; bottom 5% in the U.S. |
| Total nursing staff turnover (%) | 60.0 | 46.0 | 45.8 | bottom 15% in Georgia; bottom 17% in the U.S. |
| RN turnover (%) | 70.0 | 44.5 | 42.9 | bottom 15% in Georgia; bottom 12% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.96, RN 0.17, weekend 2.70. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: 1/5
Who owns this facility
For profit - Partnership
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Andrews, James | Individual | 5% or Greater Indirect Ownership Interest | — | 09/01/2015 |
| Andwell Investments, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 09/01/2015 |
| Rees, Heather | Individual | 5% or Greater Indirect Ownership Interest | — | 01/28/2017 |
| Rewell Investments, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 09/01/2015 |
| Wellington Healthcare Services III, LP | Organization | 5% or Greater Direct Ownership Interest | 100% | 09/01/2015 |
| Wellington Healthcare, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 09/01/2015 |
| Andrews, James | Individual | Corporate Director | NOT APPLICABLE | 09/01/2015 |
| Andrews, James | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2015 |
| Andrews, James | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2015 |
| Shuler, Valeria | Individual | W-2 Managing Employee | NOT APPLICABLE | 02/07/2021 |
| Wellington Healthcare Services III, LP | Organization | Limited Partnership Interest | NOT APPLICABLE | 09/01/2015 |
| Wiii GP, LLC | Organization | General Partnership Interest | NOT APPLICABLE | 09/01/2015 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What were the findings behind this administration citation, and what has leadership changed since?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How do you arrange transportation when a resident needs tests or appointments outside the facility?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who oversees antibiotic use here, and how do you decide when an antibiotic is really needed?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Crestview Health & Rehab Ctr | 0.6 mi | Atlanta, GA | ★☆☆☆☆ | 1/5 | abuseSFF |
| Fulton Center for Rehabilitation LLC | 0.6 mi | Atlanta, GA | ★☆☆☆☆ | 1/5 | |
| Reliable Health & Rehab at Lakewood | 1.5 mi | Atlanta, GA | ★★☆☆☆ | 2/5 | |
| Healthcare at College Park, LLC | 2.0 mi | College Park, GA | ★☆☆☆☆ | 2/5 | |
| A.g. Rhodes Home, INC, the | 5.2 mi | Atlanta, GA | ★★★☆☆ | 3/5 | |
| Legacy Transitional Care & Rehabilitation | 5.2 mi | Atlanta, GA | ★☆☆☆☆ | 1/5 | |
| Sadie G. Mays Health & Rehabilitation Center | 6.0 mi | Atlanta, GA | ★☆☆☆☆ | 1/5 | |
| Fountainview Ctr for Alzheimer | 7.2 mi | Atlanta, GA | ★☆☆☆☆ | 1/5 | abuse |
| Westminster Commons | 7.4 mi | Atlanta, GA | ★★☆☆☆ | 2/5 | abuse |
| Arrowhead Post Acute LLC | 7.4 mi | Jonesboro, GA | ★☆☆☆☆ | 2/5 | |
| Riverdale Center for Nursing and Healing | 7.4 mi | Riverdale, GA | ★★☆☆☆ | 2/5 | |
| Pruitthealth - West Atlanta | 7.5 mi | Atlanta, GA | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 115555.