Bonterra Transitional Care: Privacy Violations Found - GA
Inspectors documented two separate incidents on the morning of March 10, 2025, both involving the same resident, identified in inspection records only as R6. She had hemiplegia, with impaired movement on one side of both her upper and lower extremities, and her care plan described her as requiring extensive to maximal assistance for most daily care tasks. She had a roommate. The door to her room opened onto a shared space.
At 11:17 a.m., an inspector walked past R6's room and found the door standing open. The privacy curtain had been pulled, but staff inside could be heard actively providing care. Two minutes later, the certified nursing assistant inside, identified in records as CNA CCC, confirmed she was performing peri-care — intimate hygiene involving the genital area. She also confirmed, without apparent hesitation, that the door should always be closed during personal care.
Thirteen minutes later, a second certified nursing assistant, CNA DDD, was observed entering R6's room and again leaving the door open. She walked out carrying a bag of soiled linen. She told the inspector that R6 had been receiving help getting changed. She said R6 usually manages on her own but needs assistance sometimes. Then she explained the facility's own procedure: the door stays closed at all times, with the privacy curtain pulled, because R6 has a roommate who could walk in at any moment.
She knew the procedure. She left the door open anyway.
The next morning, R6 spoke for herself. During an interview at 9:43 a.m. on March 11, she told the inspector that staff had been in her room the previous morning giving her a bed bath when they left the door open.
The Director of Nursing, interviewed seventeen minutes later, said the expectation was clear: privacy curtain pulled, door closed, every time, for every personal care interaction. She said she expected staff to respect residents' right to privacy. She offered no explanation for why it had happened twice in the same morning to the same resident.
The facility's own written policy, dated May 30, 2024, states that all activities and interactions with residents must focus on maintaining and enhancing each resident's self-esteem and self-worth. It guarantees the right to be treated with dignity and respect.
Inspectors cited the deficiency as causing minimal harm or potential for actual harm, the lowest tier on the federal scale. One resident was affected out of 36 sampled during the inspection.
The clinical picture of what that means in practice: a woman who cannot move one side of her body, who depends on staff to bathe and change her, who shares a room with another person, was left exposed during the most private moments of her care. Not once. Twice. On the same morning. And she remembered it the next day.
Both CNAs knew what the procedure required. The Director of Nursing knew. The written policy had been in place for nearly a year. None of that stopped it from happening, and nothing in the inspection record suggests anyone had addressed it with staff before a federal inspector walked past an open door.
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 3, 2026 · Our methodology
BONTERRA TRANSITIONAL CARE & REHABILITATION in EAST POINT, GA was cited for violations during a health inspection on March 19, 2025.
Inspectors documented two separate incidents on the morning of March 10, 2025, both involving the same resident, identified in inspection records only as R6.
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.