All citations for Bonterra Transitional Care & Rehabilitation

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

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Last standard health inspection on record

April 30, 2026

Showing 1 to 25 of 25 citations

  1. Immediate jeopardy to resident health or safety

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Isolated (one or a few residents). CMS level J.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    Past non-compliance: already corrected by the time of the inspection (July 29, 2024).

  2. Immediate jeopardy to resident health or safety

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Isolated (one or a few residents). CMS level J.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    Past non-compliance: already corrected by the time of the inspection (July 29, 2024).

  3. Immediate jeopardy to resident health or safety

    Administer the facility in a manner that enables it to use its resources effectively and efficiently.

    Isolated (one or a few residents). CMS level J.

    Health citation F-0835, Administration Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    Past non-compliance: already corrected by the time of the inspection (July 29, 2024).

  4. Harm to a resident

    Provide safe, appropriate pain management for a resident who requires such services.

    Isolated (one or a few residents). CMS level G.

    Health citation F-0697, Quality of Life and Care Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  5. Harm to a resident

    Help the resident with transportation to and from laboratory services outside of the facility.

    Isolated (one or a few residents). CMS level G.

    Health citation F-0774, Administration Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  6. No harm, with potential for more than minimal harm

    Implement a program that monitors antibiotic use.

    Widespread (many residents). CMS level F.

    Health citation F-0881, Infection Control Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  7. No harm, with potential for more than minimal harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  8. No harm, with potential for more than minimal harm

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  9. No harm, with potential for more than minimal harm

    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0800, Nutrition and Dietary Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  10. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  11. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  12. No harm, with potential for more than minimal harm

    Provide behavior health training consistent with the requirements and as determined by a facility assessment.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0949, Administration Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  13. No harm, with potential for more than minimal harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0550, Resident Rights Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  14. No harm, with potential for more than minimal harm

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  15. No harm, with potential for more than minimal harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  16. No harm, with potential for more than minimal harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0609, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  17. No harm, with potential for more than minimal harm

    PASARR screening for Mental disorders or Intellectual Disabilities

    Isolated (one or a few residents). CMS level D.

    Health citation F-0645, Resident Assessment and Care Planning Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  18. No harm, with potential for more than minimal harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  19. No harm, with potential for more than minimal harm

    Provide safe and appropriate respiratory care for a resident when needed.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0695, Quality of Life and Care Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  20. No harm, with potential for more than minimal harm

    Provide or obtain dental services for each resident.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0791, Quality of Life and Care Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  21. No harm, with potential for more than minimal harm

    Make sure that a working call system is available in each resident's bathroom and bathing area.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0919, Environmental Deficiencies. Inspection of March 19, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 29, 2025).

  22. No harm, with potential for more than minimal harm

    Construct fire resistant interior walls.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0331, Smoke Deficiencies. Inspection of March 19, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 13, 2025).

  23. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of March 19, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 13, 2025).

  24. No harm, with potential for more than minimal harm

    Have properly installed electrical wiring and gas equipment.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0511, Services Deficiencies. Inspection of March 19, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 13, 2025).

  25. No harm, with potential for more than minimal harm

    Have proper medical gas storage and administration areas.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 19, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 13, 2025).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.