BOLIVIA, NC - Federal inspectors identified multiple serious violations at Bolivia Rehabilitation and Healthcare Center in March 2025, including registered nurse staffing deficiencies and failures to follow infection control protocols for residents with chronic wounds.
Critical Nursing Shortages Compromise Patient Care
Bolivia Rehabilitation and Healthcare Center experienced significant registered nurse (RN) staffing shortages during the inspection period, failing to provide required eight-hour RN coverage on 13 of 275 days reviewed during the current survey. This represented a continuation of previous staffing problems, as the facility had failed to provide adequate RN coverage on 28 of 45 days during an earlier inspection.
The Administrator acknowledged the facility's ongoing struggles with RN recruitment and retention during interviews with inspectors. "The facility had a hard time hiring full and part time RN's and the Agency they used also had trouble providing licensed RNs for the facility," the Administrator stated. Despite having several PRN (as-needed) registered nurses on staff, these nurses were not scheduling any days to work.
The staffing shortages occurred despite the facility's implementation of corrective measures, including daily schedule reviews during morning staff meetings and weekly weekend schedule assessments. The Administrator expressed confusion about the continued coverage gaps, noting that schedules were scrutinized daily for budget compliance and that a weekend RN supervisor had been hired to help address the problem.
Federal regulations require nursing homes to have a registered nurse on duty for at least eight consecutive hours every day, seven days a week. This requirement exists because RNs possess advanced training in clinical assessment, medication management, and emergency response that is essential for resident safety. When facilities lack adequate RN coverage, residents face increased risks of medication errors, delayed recognition of health deterioration, and inadequate response to medical emergencies.
Infection Control Breaches Put Vulnerable Residents at Risk
Inspectors documented serious infection control violations involving staff who failed to use proper personal protective equipment (PPE) when caring for residents with chronic wounds and medical devices. The facility's Enhanced Barrier Precautions policy requires staff to wear both gowns and gloves when providing high-contact care to residents with certain conditions, including wound care and device management.
During observations, a registered nurse was seen providing wound care to a resident with Stage IV and unstageable chronic foot wounds without wearing gloves or a gown. The nurse removed soiled dressings from bilateral heel wounds with her bare hands before being stopped by inspectors. When questioned, the nurse stated "she thought that she was only going to look at the wounds and not complete the dressing change and that was why she did not apply gloves or a gown prior to handling the wounds."
Additionally, two nurse aides were observed providing incontinence care to a resident with a Stage IV pressure ulcer and feeding tube while wearing only gloves, despite clear signage on the resident's door indicating Enhanced Barrier Precautions were required. When interviewed, one aide stated "I thought I was only suppose to wear gloves" despite being aware the resident had wounds and medical devices requiring enhanced precautions.
Enhanced Barrier Precautions represent a critical infection prevention strategy designed to prevent the transmission of multidrug-resistant organisms and other infections in nursing home settings. These precautions are particularly important for residents with chronic wounds, as these areas provide entry points for bacteria and other pathogens. Stage IV pressure ulcers extend through the skin and subcutaneous tissue into muscle, tendon, or bone, creating significant infection risks that can lead to sepsis and life-threatening complications.
Administrative Oversight Deficiencies
The inspection revealed systematic failures in administrative oversight across multiple operational areas. The Administrator acknowledged he had stopped reviewing daily nursing hour postings after three to four months following the previous inspection, resulting in inaccurate documentation on multiple days. "The Administrator stated he had not done his due diligence as the reviewer and needed to do better to fix the problem," according to inspection records.
The facility also failed to maintain proper oversight of incontinence care auditing systems. Despite implementing corrective measures for previous violations, the Administrator admitted that after initial audits were completed, no further assessment was conducted to determine whether the plan of correction was effective. This lack of follow-through resulted in continued delays in incontinence care for residents.
These administrative failures reflect broader challenges in maintaining consistent quality oversight in nursing home operations. Effective nursing home administration requires continuous monitoring of clinical outcomes, staffing adequacy, and regulatory compliance. When administrators fail to maintain these oversight functions, multiple care areas can deteriorate simultaneously, creating compounding risks for resident safety and wellbeing.
Food Safety and Storage Violations
Inspectors identified additional violations related to food safety and storage practices in the facility's kitchen operations. Food items in walk-in refrigerators, reach-in refrigerators, and dry goods storage areas were found to be unlabeled, undated, or expired. The Administrator attributed these problems to poor leadership in the kitchen following the abrupt departure of the Dietary Manager, who left with less than a week's notice.
Proper food labeling and dating systems prevent foodborne illness outbreaks, which can be particularly dangerous for elderly nursing home residents who may have compromised immune systems. Expired or improperly stored food can harbor harmful bacteria that cause serious gastrointestinal infections, potentially leading to dehydration, malnutrition, and other complications in vulnerable populations.
Additional Issues Identified
Beyond the major violations, inspectors documented ongoing challenges with incontinence care procedures, including previous failures to provide timely assistance to residents. The facility had implemented corrective measures for these issues, but the Administrator acknowledged that additional assessment was needed to ensure the effectiveness of these interventions.
The inspection findings represent a pattern of regulatory non-compliance affecting multiple aspects of resident care and facility operations. Federal regulations exist to protect nursing home residents who often cannot advocate for themselves and rely entirely on staff for their daily care needs, medical management, and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Universal Health Care / Brunswick from 2025-03-05 including all violations, facility responses, and corrective action plans.
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