BOLIVIA, NC - Federal inspectors documented multiple care violations at Bolivia Rehabilitation and Healthcare Center during a March 2025 inspection, including failures in wound care management, medication administration, and basic hygiene assistance.
Critical Wound Care Deficiencies Found
Inspectors identified significant problems with wound care protocols affecting a resident with severe pressure ulcers. The resident had a Stage IV pressure ulcer on the left heel and an unstageable wound on the right heel, both requiring daily specialized treatment with Santyl ointment and protective dressings.
Records showed that wound care was missed for over 48 hours during a February weekend. The resident's dressings, which were supposed to be changed daily, remained in place from Friday February 14 until late Sunday February 16. When inspectors observed the resident on Sunday, the dressings on both heels were soiled, falling off, and dated February 14.
The attending nurse explained she had planned to have the night shift nurse change the dressing during the resident's scheduled shower on Saturday night, but the shower was never provided. When she returned Sunday morning, she discovered the wound care had not been completed but failed to prioritize the overdue treatment.
Medical protocols require consistent daily wound care to prevent infection and promote healing. Stage IV pressure ulcers extend through all layers of skin into underlying tissue, making them particularly vulnerable to complications. The resident was already receiving antibiotics for wound infection at the time of the missed treatments.
Medication Administration Errors Identified
The inspection revealed a 12% medication error rate, significantly exceeding the federal limit of 5%. Inspectors observed multiple medication administration failures during routine observations.
In one case, a nurse administered blood pressure medication without first checking the resident's blood pressure, despite physician orders requiring the medication be withheld if blood pressure readings fell below specific parameters. When questioned, the nurse acknowledged overlooking this requirement.
Another medication error involved a different resident whose blood pressure medication Carvedilol was held 17 times during December 2024 alone, despite having no written parameters authorizing staff to withhold the medication. Nurses made independent decisions to hold the medication based on blood pressure readings they considered too low, without notifying the prescribing physician.
Conversely, inspectors found that another resident received blood pressure medication Midodrine 27 times when it should have been withheld according to physician orders. The medication was prescribed to raise blood pressure but included specific instructions to hold it when blood pressure exceeded 130 mmHg. Staff administered the medication despite blood pressure readings consistently above this threshold.
Proper medication administration requires strict adherence to physician orders and parameters. When medications affect vital signs like blood pressure, following hold parameters prevents potentially dangerous fluctuations that could lead to strokes, falls, or other complications.
Basic Hygiene Care Neglected
Multiple residents experienced delays in basic hygiene care due to staffing issues. Three residents on the dementia unit missed their scheduled showers on the same night when two nurse aides working the overnight shift chose not to complete the bathing routine.
One resident with severe cognitive impairment went over four hours without an incontinence brief change despite being always incontinent of bowel and bladder. The resident was found sitting in a saturated brief and reported asking for assistance hours earlier. The assigned nurse aide stated she was "too busy with 18 residents" to maintain the facility's 2-3 hour checking schedule.
This resident had a Stage IV pressure ulcer on her tailbone, making prompt incontinence care crucial for preventing further skin breakdown. Prolonged exposure to moisture and waste significantly increases infection risk and can worsen existing wounds.
Nutritional Support System Failures
A resident with bilateral heel wounds requiring enhanced nutrition for healing was ordered a specialized supplement called Arginaid twice daily for wound recovery. Despite this order being in place for over three months, records showed the supplement was never administered.
Arginaid contains arginine, an amino acid essential for wound healing that stimulates growth hormone release. The resident's wounds progressed from deep tissue injuries to a Stage IV pressure ulcer during this period without receiving the prescribed nutritional support.
The breakdown occurred in the facility's order processing system. The registered dietitian made the recommendation, which was supposed to be forwarded to physicians for approval and then entered into the medication administration system. However, the recommendation was lost in this multi-step process and never implemented.
Staffing and Quality Oversight Concerns
The facility operated with insufficient registered nurse coverage on 13 days during the reviewed period, failing to meet federal requirements for eight hours of RN supervision daily. On the day of inspection, six nurse aides were responsible for 81 residents, creating assignments of 16-17 residents per aide.
Multiple staff members reported being unable to complete required care tasks due to heavy workloads. One nurse aide stated it was "difficult to do it alone and provide the care needed" when managing 18 residents during a 12-hour shift.
The quality assurance program failed to identify and correct these recurring issues. Despite previous violations and corrective action plans, the facility continued experiencing similar problems with wound care, medication administration, and basic hygiene assistance.
Industry Standards and Medical Consequences
Federal nursing home regulations require facilities to provide care that maintains or improves each resident's physical and mental well-being. This includes following physician orders precisely, maintaining skin integrity through proper wound care and incontinence management, and ensuring adequate nutrition.
Pressure ulcers represent a significant quality indicator in long-term care. Stage IV ulcers can take months to heal under optimal conditions and may never fully close when care is inconsistent. Each missed wound treatment increases infection risk and delays healing progress.
Medication errors involving blood pressure medications can have serious consequences. Withholding prescribed antihypertensive medications may lead to dangerous blood pressure spikes, while giving medications outside prescribed parameters can cause excessive blood pressure changes resulting in falls or cardiac events.
Additional Issues Identified
Food safety violations were documented in kitchen storage areas, where multiple items lacked proper labeling or expiration dates. Inspectors found expired apple juice, unlabeled ground meat, and various partially used containers without dates in both refrigerated and dry storage areas.
The facility also failed to implement a physician-ordered occupational therapy evaluation for a resident experiencing difficulty with eating. The order was written in January but not carried out until inspectors brought it to attention during their February visit.
These violations demonstrate systemic issues with care coordination, staff communication, and quality oversight that extended beyond individual incidents to affect multiple aspects of resident care 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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