BOLIVIA, NC - State health inspectors documented multiple violations at Bolivia Rehabilitation and Healthcare Center during a March 2025 survey, including failures in medication administration affecting residents with cardiovascular conditions and widespread environmental safety issues including inadequate water temperatures and deteriorating bathroom facilities throughout the facility.
Critical Medication Administration Failures Impact Cardiac Patients
The facility's medication administration protocols broke down for two residents with serious cardiovascular conditions, creating potentially dangerous situations that could have resulted in severe health consequences. In one case, a resident prescribed Carvedilol, a beta-blocker critical for managing hypertension and heart failure, failed to receive their prescribed twice-daily doses. In another incident, staff continued administering Midodrine, a medication designed to raise blood pressure, even when a resident's blood pressure readings exceeded safe thresholds.
Resident #54's missed doses of Carvedilol represent a significant departure from cardiac care standards. Carvedilol works by blocking the effects of certain natural substances in the body, such as epinephrine, on the heart and blood vessels. This medication reduces heart rate, blood pressure, and strain on the heart. When doses are missed, patients can experience rebound hypertension, where blood pressure spikes above previous levels. Additionally, inconsistent administration can lead to destabilization of heart rhythm, increased risk of heart failure exacerbation, and potential for cardiovascular events.
The medication administration failures extended to Resident #43, who continued receiving Midodrine despite systolic blood pressure readings exceeding 130 mmHg. Midodrine is specifically prescribed for patients with orthostatic hypotension - a condition where blood pressure drops significantly when standing. The medication works by constricting blood vessels to increase blood pressure. Standard protocols require holding this medication when systolic pressure exceeds 130 mmHg because administering it under these conditions can push blood pressure to dangerously high levels, potentially causing hypertensive crisis, stroke, or cardiac complications.
These medication errors occurred despite multiple safeguards that should have prevented them. Nursing homes typically employ electronic medication administration records, barcode scanning systems, and multiple verification steps. The failures suggest systemic breakdowns in the facility's medication management protocols, potentially affecting more residents than just the two identified during the inspection.
Shower Room Temperature Failures Create Safety Hazards
The facility's hot water system failures created unsafe conditions in critical resident care areas. During the February 17, 2025 inspection, water temperatures in both 300-hall shower rooms fell dangerously below acceptable standards. Spa #1 registered temperatures fluctuating between 85 and 89 degrees Fahrenheit, while Spa #2 ranged from 83 to 101 degrees - all significantly below the facility's target of 114 degrees Fahrenheit.
These temperature variations present multiple risks for elderly residents. Water below 100 degrees Fahrenheit is inadequate for proper hygiene and infection control. Elderly skin requires warmer water temperatures for effective cleansing due to reduced oil production and slower cellular turnover. Additionally, cooler water temperatures increase the risk of hypothermia in elderly residents, who often have compromised thermoregulation. The fluctuating temperatures in Spa #2, ranging from 83 to 101 degrees, create unpredictable conditions that could startle residents and increase fall risks.
The Administrator revealed during the inspection that "as of September 2024, their paper water temperature logs were no longer being used" after transitioning to an electronic maintenance system. However, the new system failed to include shower rooms in its monitoring protocols. This oversight meant shower water temperatures went unmonitored for approximately five months, during which residents potentially experienced hundreds of uncomfortable or unsafe bathing experiences.
The Maintenance Director's explanation that "hot water having to travel all the way from the boiler to the shower rooms" contributed to the problem indicates fundamental infrastructure issues. Properly designed healthcare facilities incorporate recirculation systems, point-of-use water heaters, or other solutions to ensure consistent water temperatures. The suggestion that staff should wait 3-5 minutes for water to heat up is impractical during busy morning routines when multiple residents require assistance with bathing.
Widespread Environmental Deterioration Affects Multiple Units
Environmental observations revealed systematic maintenance failures affecting at least eight resident rooms across three hallways. Black-greenish substance covered the caulking around toilet bases in rooms 200, 201, 205, 207, 208, 209, 305, and 411. This contamination likely represents mold or mildew growth, which thrives in moist bathroom environments when proper maintenance is neglected.
Mold exposure in healthcare settings is particularly concerning for elderly residents with compromised immune systems. Exposure can trigger respiratory problems, allergic reactions, and infections. For residents with chronic obstructive pulmonary disease, asthma, or other respiratory conditions, mold exposure can cause severe exacerbations requiring hospitalization. The widespread nature of this problem - affecting rooms across multiple hallways - suggests long-term neglect of basic maintenance protocols.
The facility also failed to maintain basic lighting in resident rooms. Rooms 202 and 411 had non-functioning overhead lights, forcing residents to rely on natural light from windows and keeping hallway doors open for illumination. All four alert residents in these rooms reported notifying nursing staff about the lighting problems without receiving repairs.
Adequate lighting is essential for preventing falls, maintaining circadian rhythms, and enabling residents to perform daily activities safely. Elderly individuals require approximately three times more light than younger adults to achieve the same visual acuity. Non-functioning overhead lights force residents to navigate in dim conditions, significantly increasing fall risks. Falls remain the leading cause of injury-related deaths among adults aged 65 and older, with environmental hazards like poor lighting being major contributing factors.
Systemic Maintenance Failures Indicate Broader Issues
The Maintenance Director acknowledged being "new to the building" with no assistant while "slowly keeping up with facility repairs." This staffing situation appears inadequate for a facility of this size. Industry standards typically recommend one maintenance worker per 30-40 beds, with additional support for specialized systems. Operating with a single, newly hired maintenance director without support staff virtually guarantees deferred maintenance and accumulating problems.
The Administrator's statement that "they were making progress and were improving residents' living environment to make it more home-like, and that it would take time" acknowledges awareness of the problems but fails to address the immediate safety concerns. While long-term improvement plans are important, residents deserve safe, clean, and properly maintained living conditions immediately, not at some undefined future date.
Additional Issues Identified
Beyond the major violations detailed above, inspectors documented concerning patterns in the facility's wound care protocols. A nurse failed to perform daily wound care for a resident with an infected Stage IV left heel pressure wound and an unstageable right heel pressure wound, both acquired within the facility. Stage IV pressure wounds involve full-thickness tissue loss with exposed bone, tendon, or muscle, requiring intensive daily care to prevent life-threatening infections. The failure to provide this care constitutes neglect under federal regulations.
The inspection also revealed the facility had discontinued paper documentation for water temperature monitoring without ensuring the electronic replacement system captured all necessary data points. This transition failure left critical safety monitoring gaps for months.
Medical Standards and Regulatory Requirements
Federal regulations require nursing homes to maintain medication administration accuracy rates above 95%. The errors documented at Bolivia Rehabilitation and Healthcare Center fell below this threshold. Similarly, Centers for Medicare & Medicaid Services guidelines specify that hot water in resident care areas must be maintained between 105 and 120 degrees Fahrenheit to ensure both safety and comfort.
Environmental standards mandate that facilities maintain all areas in good repair, free from accident hazards, and adequately lit. The widespread caulking deterioration, non-functioning lights, and inadequate water temperatures violate these fundamental requirements. These are not merely cosmetic issues but safety hazards that directly impact resident health and quality of life.
The documented violations at Bolivia Rehabilitation and Healthcare Center reveal systemic failures in medication management, environmental safety, and basic maintenance protocols. While facility leadership acknowledged these problems and expressed intentions to improve, the immediate risks to resident safety require urgent corrective action beyond promises of gradual improvement.
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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