Brunswick Rehab: Shower Temps, Incontinence Failures - NC
Not one shower room. All three.
The facility's administrator acknowledged the gap to inspectors during a March 2025 recertification survey. When the old paper logs were replaced with a new electronic tracking system, the three shower rooms, designated shower room No. 1, No. 2, and No. 3, were simply left off the new form. A new Maintenance Director came on board and had no record of needing to track shower water temperatures at all. The paper logs stopped. The electronic logs never started. Nobody noticed.
The administrator told inspectors he believed the facility's own plan of correction from a prior inspection was not working. He was right. The plan had been written to address water temperature problems found during an earlier survey. Inspectors had come back to check whether those fixes held. They had not.
He said staff were unaware of any cold-water concerns in the showers during the period the monitoring had lapsed. That is, in part, because nobody was measuring anything. Once inspectors flagged the problem during the recertification visit, staff added the three shower rooms to the electronic form. The temperatures had gone untracked for an undetermined stretch of time before that.
The shower monitoring failure was not the only problem inspectors documented.
During the same survey, inspectors found the facility had failed to provide incontinence care to a resident who needed staff assistance with basic daily activities. The resident could not manage personal hygiene without help. Help did not come.
That finding was not new either. During a separate complaint investigation survey, inspectors had documented the same failure for four residents, all of them unable to carry out activities of daily living on their own. All four had needed assistance. All four had not received it.
The administrator, reached by phone, said the Director of Nursing had been made responsible for ensuring that rounds were completed and that incontinent residents were being changed. That was the plan of correction written after the earlier complaint investigation. Inspectors returned and found a resident still waiting.
The pattern here is specific and worth stating plainly. Inspectors identified a problem. The facility wrote a plan to fix it. Inspectors came back. The problem remained. That cycle, repeated across both the shower temperature monitoring and the incontinence care failures, is what the March 2025 survey captured.
Incontinence care is not a peripheral concern in a nursing facility. Residents who are left in soiled conditions are at risk for skin breakdown, pressure injuries, and infections. They are also, in the plainest sense, not being cared for. For residents who cannot reposition themselves, cannot call for help effectively, or cannot communicate their discomfort, the failure to make rounds is not a paperwork problem. It is the difference between dignity and its absence.
The facility's administrator did not dispute the findings. He described the shower monitoring lapse as inadvertent, a word that appears reasonable until you consider that the oversight persisted through a staffing transition, a software migration, and at least one prior inspection cycle without anyone catching it.
Brunswick Rehabilitation and Healthcare Center is located at 1070 Old Ocean Highway in Bolivia, in Brunswick County. The recertification survey was completed March 5, 2025. Inspectors rated the incontinence care deficiency as causing minimal harm or potential for actual harm, and noted it affected some residents.
The four residents who went without incontinence care during the complaint investigation survey are not named in the inspection report. Neither is the resident found during the recertification visit. The report does not say how long any of them waited.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brunswick Rehabilitation and Healthcare Center from 2025-03-05 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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Brunswick Rehabilitation and Healthcare Center in Bolivia, NC was cited for violations during a health inspection on March 5, 2025.
The facility's administrator acknowledged the gap to inspectors during a March 2025 recertification survey.
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.