Bonterra Transitional Care: Dental Care Neglect - GA
The resident, identified in federal inspection records only as R77, was at Bonterra Transitional Care and Rehabilitation on Felton Drive when inspectors arrived in March 2025. What they found was not a complicated system failure. It was a gap between a documented problem and a phone call that never got made.
A nurse had already charted it. Sometime before the inspection, a staff nurse completed a dental assessment for R77 and marked yes, indicating a loose tooth. The Unit Manager, LPN EE, confirmed that finding during an interview on March 18. She also confirmed that a yes answer on that assessment was supposed to trigger the next step: hand the form to the Social Services Director so a dental referral could be placed. That step did not happen.
"This should have been completed fully, indicating if a referral is needed," LPN EE told inspectors.
It wasn't.
The Social Services Director told inspectors she had no idea R77 had a loose tooth. She had never received a referral for him. She also confirmed, when asked, that R77 qualifies for Medicaid dental benefits, meaning the facility's in-house dentist, who comes on-site quarterly, could have seen him. The mechanism existed. The referral did not.
On the morning of March 18, inspectors watched LPN DDDD conduct an oral assessment of R77 in real time. She confirmed what she saw: one loose tooth, all upper teeth missing. R77 told her directly that he was experiencing pain. LPN DDDD told inspectors that findings like those, oral pain, loose teeth, missing teeth, should be charted and referred to a dentist. She confirmed that what she was looking at met that standard.
A certified nursing assistant, identified as CNA BBB, told inspectors she was not aware R77 had any loose teeth. CNAs at the facility help residents brush their teeth and are supposed to flag problems to nurses. She said she had seen nothing to flag.
The Director of Nursing told inspectors on March 19 that oral assessments at the facility are done at least annually, often more frequently, and that nurses look for new missing teeth, oral pain, and loose teeth during those assessments. She described what can happen when a referral is not made in time: pain, weight loss.
The Administrator said the same thing. "Potential weight loss, pain, or not being able to eat or chew," he told inspectors, describing the consequences of a delayed referral.
R77 has a physician order on file directing dental consultation and treatment as indicated. LPN EE confirmed that order exists and that the indications listed include oral pain, cavities, and loose teeth. R77 had at least two of the three.
The inspection report does not say how long R77 had been experiencing pain, or how long the loose tooth had been documented before inspectors arrived and a nurse finally looked at his mouth. It does not say whether he had lost weight or was having difficulty eating. What the report says is that on March 18, 2025, a resident told a nurse he was hurting, a nurse confirmed his mouth showed exactly the kind of problems that require a dentist, and the Unit Manager confirmed no referral had ever been placed.
CMS cited the deficiency at a scope and severity level indicating minimal harm or potential for actual harm, affecting a small number of residents.
R77 qualifies for the Medicaid dental program. The dentist comes quarterly. Whether he had been seen by the time inspectors left the building on March 19, the report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bonterra Transitional Care & Rehabilitation from 2025-03-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
BONTERRA TRANSITIONAL CARE & REHABILITATION in EAST POINT, GA was cited for neglect violations during a health inspection on March 19, 2025.
What they found was not a complicated system failure.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.