Blumenthal Health and Rehab: Pain Left Untreated - NC
Inspectors visiting Blumenthal Health and Rehabilitation Center on September 13, 2025, watched as Resident #136, who had an open heel wound on his left leg, grimaced, closed his eyes tightly, and began taking rapid, shallow breaths while staff removed the outer wrap and gauze from his foot. The unit manager conducting the dressing change sat on the bare floor, supplies laid out on a clean gauze pad set directly on the floor beside her. The nurse stood at the resident's side, holding his elevated leg.
When the resident said the pain really hurt, the surveyor asked Nurse #3 whether she would consider getting him pain medication. Nurse #3 said she probably would, but did not stop.
The dressing change continued. The unit manager moistened gauze with a clear solution and began cleaning the exposed heel wound. Resident #136 groaned. "Oh my goodness that really hurts," he said, grimacing, his breathing fast and deep.
At that point, the surveyor intervened directly and asked Nurse #3 to get the resident pain medication before continuing. The unit manager agreed: "Yes, he needs some pain medication."
Nurse #3 lowered the resident's leg to the bare floor, said she would get the medication, and left the room. The unit manager, rather than waiting, placed another piece of moistened gauze on the wound and finished rewrapping the foot before Nurse #3 returned.
When Nurse #3 came back and asked the resident to rate his pain, he said it had been an 8 out of 10 during the dressing change. He was then given the medication he had an order for.
In a follow-up interview on September 10, Nurse #3 said she had been so focused on the wound and the procedure that she didn't think to stop. "In hindsight, it would have been better to have stopped," she said. "I'm sorry."
The unit manager told inspectors she had never performed wound care before, was not familiar with the resident's orders, and had been pulled to cover wound rounds for the shift because the regular wound nurse was out on a family emergency. She said she had been assigned to assist with dressing changes despite having no experience with the procedure.
Every supervisor interviewed afterward said what happened should not have happened. The Director of Nursing said that not assessing for pain or giving pain medication when a resident was in pain during a dressing change was not the expected practice. The administrator said she would expect that a resident not be in pain during a dressing change and that any resident who was in pain should be treated. The nurse practitioner said all residents in pain during dressing changes should be treated.
The wound care nurse practitioner added a layer of context that made the lapse harder to explain away. She told inspectors that Resident #136 experienced significant pain during many of his dressing changes, particularly during any attempts to debride the wound, removing dead tissue. She said she would give him pain medication before those procedures, and at times would simply stop the debridement if his pain became too severe.
His pain during dressing changes was not a surprise. It was documented, anticipated, and had a prescribed response.
The inspection report classified the violation as causing actual harm to the resident, the agency's designation for deficiencies where a resident suffered real injury, not merely risk of injury.
On the day the surveyor watched Resident #136 groan and grip the arms of his wheelchair, a unit manager who had never done wound care before was running his dressing change, and the nurse holding his leg knew he needed pain medication and kept holding it anyway. Nobody had thought to give him anything before they started.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Blumenthal Health and Rehabilitation Center from 2025-09-13 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 20, 2026 · Our methodology
Blumenthal Health and Rehabilitation Center in Greensboro, NC was cited for violations during a health inspection on September 13, 2025.
The unit manager conducting the dressing change sat on the bare floor, supplies laid out on a clean gauze pad set directly on the floor beside her.
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.