Bonterra Transitional Care: Nail Care Neglect Cited - GA
Those two things cannot both be true. Federal inspectors who visited the facility in March found no evidence anyone had tried to reconcile them.
The resident, identified in inspection records only as R47, was admitted to Bonterra following a heart attack and a condition that impaired his brain function. A cognitive assessment rated him with moderate impairment. His care plan, dated January 19, 2025, listed a series of refusals: bathing, changing clothes, shaving, podiatry care. Under that same entry, the plan noted he had long fingernails and toenails.
What the care plan did not capture was what R47 told inspectors directly.
When an inspector observed him in his room on March 10, his fingernails were long and curled, with a dark substance visible underneath. R47 said his nails had been that way for a while. He said he had told staff he wanted them cut. "The staff would tell him, 'Oh, your nails are really long,'" the inspection report states, "but they do not do anything about it."
The inspector returned the next morning. The nails were still long. The dark substance was still there. R47 said someone had come in that morning and attempted to trim the tips, but had not cut them all the way down and had not cleaned underneath. The inspector confirmed it: still long, still dirty.
A certified nursing assistant who knew R47 told inspectors that nails should be cut every two weeks and that she had noticed his were long with dark substance underneath. She said she was not sure what the substance was. "It could possibly be food," she said. She confirmed the nails did not look like they had been cut within the past two weeks.
The Director of Nursing, interviewed on the last day of the inspection, said R47 had been care planned for refusals and that "he won't allow the staff to get them down." She acknowledged that staff should attempt nail care if the resident allows, and that ADL care should happen daily.
The gap between those two positions is where R47 spent those weeks. His care plan said he refused. He said he asked. Staff noticed the problem out loud and left the room. Someone came in the morning of March 11 and clipped a few tips without finishing the job or cleaning beneath the nails. By the time inspectors wrapped their visit on March 19, the nails were still long.
The facility's own hygiene policy, revised in April 2024, instructs staff to clean and trim nails as needed.
Inspectors cited the deficiency at a level of minimal harm, affecting a small number of residents. The finding covered one of 36 residents reviewed during the inspection.
What the record does not show is how long R47 sat in that room with curled fingernails and a dark substance underneath them, telling staff what he needed, watching them acknowledge it, and waiting for someone to come back.
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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Last verified: November 6, 2026 · Our methodology
BONTERRA TRANSITIONAL CARE & REHABILITATION in EAST POINT, GA was cited for neglect violations during a health inspection on March 19, 2025.
Those two things cannot both be true.
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.