Universal Health Care/Brunswick: Wound Care Failures, NC
BOLIVIA, NC - Bolivia Rehabilitation and Healthcare Center was cited for multiple violations during a March 5, 2025 inspection, including failure to provide proper wound care for serious pressure injuries and inadequate staffing that left residents without basic hygiene care.
Critical Wound Care Lapses Documented
Inspectors found the facility failed to provide ordered wound care treatments for a resident with severe pressure injuries, including a Stage IV pressure ulcer on the left heel and an unstageable deep tissue injury on the right heel. The resident, who had dementia and was at nutritional risk, did not receive critical wound-healing supplements despite repeated recommendations from the facility's registered dietitian.
The dietitian recommended Arginaid, an amino acid supplement essential for wound healing, twice daily for 30 days in December 2024. However, medication records showed the supplement was never administered to the resident during December 2024 or January 2025. When the dietitian made a second recommendation in February 2025 for Arginaid twice daily for 90 days, the supplement again was not provided.
The resident's condition deteriorated during this period, with the left heel injury progressing from a deep tissue injury to a full Stage IV pressure ulcer - the most severe category of pressure wound that extends through skin and tissue to underlying muscle or bone.
The breakdown in the supplement ordering process involved multiple staff levels. The facility's unit manager acknowledged that the December 2024 recommendation "was missed and was never implemented." The supplement was not ordered until after the inspection began, arriving at the facility on March 3, 2025.
Widespread Bathing and Hygiene Neglect
The inspection revealed systematic failures in basic personal care, with three residents in the facility's locked dementia unit not receiving scheduled showers and one resident remaining in a saturated brief for over four hours.
On February 15, 2025, three residents with severe cognitive impairments missed their scheduled Saturday night showers. When questioned, the agency nurse aide assigned to the locked unit stated he "was busy during the shift and just didn't get the showers done on any of the three residents."
The bathing failures extended into the following day, with staff reporting residents still had not received baths by Sunday evening. A nurse aide working alone on the locked unit during the day shift stated there was "no time to give baths" due to being the only aide assigned to the unit.
The facility's Director of Nursing confirmed the shower neglect, stating the nurse aides "chose not to do the showers" and received disciplinary action as a result.
Inadequate Incontinence Care Due to Staffing Shortages
A cognitively intact resident with full incontinence experienced prolonged neglect when a nurse aide failed to change her saturated brief for over four hours. The resident reported her brief had not been changed since early morning and that she had requested assistance but the aide said she would "be right back" and never returned.
When inspectors observed the resident at 1:15 PM, her brief was "saturated with a significant amount of urine." The assigned nurse aide acknowledged the resident "had gone over 4 hours before she was changed again" and said she was responsible for 16 residents, stating it was "difficult to do it alone and provide the care needed."
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 dietitian recommended **Arginaid, an amino acid supplement essential for wound healing**, twice daily for 30 days in December 2024.
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.