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."
Medical Significance of Documented Violations
Proper wound care is critical for preventing complications that can be life-threatening in elderly residents. Stage IV pressure ulcers can lead to bone infections, sepsis, and death if not properly managed. Arginine supplements promote protein synthesis and collagen formation necessary for tissue repair.
Extended exposure to urine creates ideal conditions for skin breakdown and urinary tract infections, particularly dangerous for elderly residents with compromised immune systems. Professional standards require incontinence checks every 2-3 hours for dependent residents.
Regular bathing prevents skin infections, maintains dignity, and allows staff to monitor for developing health problems. For residents with dementia, consistent hygiene routines are especially important for psychological well-being.
Chronic Staffing Problems Identified
The facility operated with insufficient nursing aide coverage, forcing individual aides to care for up to 18 residents per shift. The normal staffing allocation called for seven nurse aides, but one was assigned to medication duties, leaving only six aides for 81 residents.
Multiple staff members reported the workload was unmanageable. One aide stated "18 residents on day shift was a lot of care to provide with one nurse aide." Another confirmed that "care to the residents was not always getting done such as incontinence care when there was not enough staff."
The administrator defended the staffing levels, calling the assignment of one aide to 16-17 residents "tough but doable," despite clear evidence that basic care needs were not being met.
Additional Issues Identified
The inspection documented additional concerns including failures to follow physician orders for wound treatments and breakdown in communication systems between dietary staff and nursing administration. The facility's wound care protocols were not consistently implemented, contributing to the deterioration of serious pressure injuries.
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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