Bonterra Transitional Care: Laundry Cart Violation - GA
The finding was documented during an inspection completed March 19, 2025. The violation was rated at the lower end of the harm scale, with inspectors noting minimal harm or potential for actual harm and listing some residents as affected.
When inspectors interviewed the housekeeper, identified in the report as LA WW, she acknowledged the problem herself. She pointed to a white folded sheet sitting on top of the cart and said that sheet was supposed to be covering the clean clothes. It wasn't. The clothes were exposed. She knew the protocol. She just wasn't following it.
She also told inspectors that the standard process was to transport the clothing back to residents' rooms, suggesting the cart was in transit when they found it, moving through shared hallways with laundry sitting open to the air.
The facility's infection preventionist nurse was interviewed separately, the following afternoon. She said the expectation was clear: laundry carts hauling clean resident clothing should be covered. She said she expected housekeeping to comply with infection control practices.
That gap, between what the nurse expected and what the housekeeper was actually doing in the hallway, is what inspectors documented.
The violation itself is narrow. There is no allegation in this inspection report of residents becoming ill, no claim that contaminated laundry caused harm. The rating reflects that. But infection control protocols in nursing homes exist precisely because the population living in them is vulnerable in ways that most people are not. Residents in transitional care and rehabilitation settings are often recovering from surgery, illness, or injury. Their immune systems are frequently compromised. Clean clothing that passes through a hallway uncovered picks up whatever is in that hallway, and in a healthcare facility, what's in the hallway is not nothing.
The sheet was folded on top of the cart. It was there. It just wasn't being used.
Bonterra Transitional Care & Rehabilitation operates at 2801 Felton Drive in East Point, a suburb southwest of Atlanta. The facility's CMS identification number is 115555.
The inspection report does not describe how long the practice had been occurring, whether this was the first time inspectors observed it, or whether other housekeeping staff had been observed doing the same. It does not say whether the facility had previously been cited for infection control lapses. What it captures is a single observation, a single interview, and a confirmation from the housekeeper herself that she knew what the sheet was for.
The infection preventionist's comment carries its own weight. Her job is to set expectations for infection control compliance across the facility. When inspectors asked her about it, she described what should be happening, not what she had verified was happening. The expectation and the practice were not the same thing, and she learned that from a federal inspection rather than her own oversight.
For the residents whose clothing was on that cart, the immediate consequence was laundry returned to their rooms after a trip through an uncovered hallway. Whether any of them knew, or were told, the report does not say.
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 6, 2026 · Our methodology
BONTERRA TRANSITIONAL CARE & REHABILITATION in EAST POINT, GA was cited for violations during a health inspection on March 19, 2025.
The finding was documented during an inspection completed March 19, 2025.
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.