Bonterra Transitional Care: Food Safety Failures - GA
Federal inspectors who visited Bonterra Transitional Care & Rehabilitation in March 2025 documented food safety failures in the facility's kitchen, including an ice machine with visible debris and food items in the pantry, cooler, and freezer that hadn't been properly labeled with open or expiration dates.
The ice machine problem surfaced first. On the morning of March 11, an inspector observed debris inside the machine. The dietary manager said she didn't know how it had been missed. She said the machine is normally cleaned once a month.
That answer created a problem for the maintenance director, who said something different when inspectors interviewed him a week later. He told them he's responsible for cleaning the ice machine twice a month, and that the facility's policy sets a minimum of once a month. After inspectors showed him a photograph of what they'd found, he confirmed it was debris.
The machine had apparently gone uncleaned long enough for debris to accumulate, even though two different staff members described a cleaning schedule that should have caught it.
The unlabeled food was a separate thread. Inspectors found items in the pantry, cooler, and freezer that hadn't been dated or labeled. One bag of Sysco green peas in the freezer wasn't properly sealed.
The dietary manager explained the expectation during an interview on March 18: staff are supposed to date and label everything with an open date and an expiration date. She described what happens when they don't. Staff members, she said, don't know when to use a product or how long it's been in the facility.
That's not a hypothetical concern in a nursing home kitchen. Residents receiving meals from that kitchen are often elderly, medically fragile, or immunocompromised, and the consequences of consuming spoiled or improperly stored food can be more serious for them than for a healthy adult.
The administrator addressed both issues when inspectors spoke with her on the final day of the survey, March 19. She said staff should be labeling food items with open and expiration dates according to policy. She also said she expected the ice machine to be cleaned according to the cleaning schedule, at least monthly or as needed.
The gap between what the administrator expected and what inspectors actually found in the kitchen is the core of what the inspection documented.
CMS rated the violations at the lowest level of harm, minimal harm or potential for actual harm, and noted that some residents were affected. The rating reflects the agency's assessment that no resident had been demonstrably hurt by the time inspectors arrived. It does not resolve the question of how long the ice machine had gone without cleaning, or how many unlabeled items had cycled through the kitchen before the inspection.
The dietary manager said the ice machine is cleaned once a month. The maintenance director said he cleans it twice a month and confirmed the debris when shown the photo. The administrator said she expected it to be cleaned on schedule.
None of them said it had been.
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 violations during a health inspection on March 19, 2025.
The ice machine problem surfaced first.
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.