Bonterra Transitional Care: Pain Management Failures - GA
The resident, identified in inspection records only as Resident 71, had staples in her leg following surgery. Staff knew she was in pain. A certified nursing assistant told inspectors that R71 regularly complained about her leg hurting. The pain was not a surprise to anyone working there.
What inspectors found was a gap between what staff knew and what got done about it.
The Director of Nursing told inspectors that the facility assesses residents for pain every shift using a pain scale, and that any change in condition triggers a follow-up assessment. She said R71 had medications and interventions in place for post-surgical pain. She said if pain becomes unmanageable, the resident gets sent to the emergency department.
The Administrator said much the same thing. She told inspectors she expects staff to conduct pain assessments, notify the physician, follow the physician's recommendations, talk to the resident, and then monitor whether any of it is working.
Those are the right steps. The inspection record suggests they weren't being followed for R71.
The deficiency was cited at the level of actual harm, not a technical paperwork failure or a near-miss. That classification means inspectors determined the resident was hurt because her pain wasn't properly addressed. She was a post-surgical patient with staples in her leg, telling staff shift after shift that she was hurting, and the systems the facility's own leadership described as standard practice were not being applied to her.
There is a specific cruelty in that kind of gap. Post-surgical pain is not ambiguous. Staples in a limb are not a subtle symptom. A resident who tells her caregivers she is hurting and cannot wait to have the hardware removed from her body is not presenting a diagnostic puzzle. She is asking for help.
The Director of Nursing acknowledged that unmanaged pain can result in harm. The Administrator acknowledged the same. Both described protocols that, on paper, should have caught this. Neither offered an explanation for why R71 fell through them.
The inspection cross-references a related deficiency under F774, which covers the facility's obligations around physician services and follow-through on medical orders, suggesting the pain management failure may have extended beyond documentation into whether the right people were notified and whether their instructions were carried out.
Bonterra Transitional Care & Rehabilitation operates at 2801 Felton Drive in East Point, a suburb southwest of Atlanta. The March 19 inspection was a standard health survey.
R71 told a nursing assistant her leg hurt. She said it more than once. She said she couldn't wait to get the staples out. At some point, someone wrote it down. What the inspection record does not show is anyone doing enough about it while she was still there, still waiting, still in pain.
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.
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Last verified: November 4, 2026 · Our methodology
BONTERRA TRANSITIONAL CARE & REHABILITATION in EAST POINT, GA was cited for violations during a health inspection on March 19, 2025.
The resident, identified in inspection records only as Resident 71, had staples in her leg following surgery.
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.