East Carolina Health and Rehab: Wound Care Failures - NC
The wound the physician found that morning was deep. It measured 2.3 centimeters by 2 centimeters by 1 centimeter, with 90 percent of the wound bed covered in slough, the dead tissue that accumulates when wounds are left to deteriorate. Only 10 percent showed granulation, the tissue that signals healing. The physician also found a deep tissue injury to the resident's right heel measuring more than 5 centimeters across. She had not known either wound existed.
The physician, interviewed by inspectors on September 10, said she was available at any time for the facility to contact her with questions or to obtain orders. She said she had not been notified about the sacral wound until August 20, and that when she arrived she found the dressing dated eight days prior.
How the wound was discovered on August 11 and then disappeared from the chain of communication is something the inspection report traces carefully, and the answer involves a series of handoffs where nobody stepped up.
A nurse who received information about the wound during shift change report on August 11 told inspectors on September 11 that she could not recall specifically what she had done with it. She said she believed she would have passed the information to the wound care nurse. But the wound care nurse was on vacation from August 11 through August 15. She told inspectors she did not know about the pressure sore until August 20, and she did not recall seeing an old dressing on the wound when she did.
Between August 11 and August 20, the inspection report found no documentation that any physician had been notified about the sacral wound.
The Director of Nursing, interviewed September 11, said nurses are supposed to contact the physician when a new pressure sore is found and obtain orders to treat it. That did not happen here.
By the time inspectors conducted their review, Resident 8's condition had changed significantly. The DON described a woman who had recently stopped eating, stopped attending activities, and had underlying medical problems including undiagnosed gynecological bleeding. On September 8, a nurse practitioner entered an order for a hospice referral.
The medical director, who served as the resident's primary physician, told inspectors she had not been aware of any communication failures around wound care. She noted that if Resident 8 was both appropriate for hospice and diabetic, the wounds might not heal regardless of treatment.
On September 10, inspectors observed the wound care nurse treating Resident 8's wounds in person. The right heel showed both pink and black tissue, a wound bed roughly the size of a baby food jar lid. The sacral wound appeared pink and showed signs of healing.
The wound physician, in her September 10 interview, said she believed the sacral sore had improved and that she did not think the failure to notify her promptly had caused the resident a negative outcome. That may be true of the sacral wound. The heel wound, measuring more than five centimeters across with tissue that could not be fully measured in depth, remained open.
The inspection was conducted as a complaint investigation and completed September 11, 2025. CMS assigned the deficiency a harm level of minimal harm or potential for actual harm, affecting some residents.
What the record shows is a Stage 4 wound found on August 11, a dressing applied August 12, and a wound physician who walked in eight days later to find that dressing still in place, unchanged, unreported, the wound beneath it unseen by anyone with authority to order treatment. A woman who had once eaten in the dining room and gone to activities was, by the time inspectors arrived, being referred to hospice.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for East Carolina Health and Rehabilitation Center from 2025-09-11 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 22, 2026 · Our methodology
East Carolina Health and Rehabilitation Center in Greenville, NC was cited for violations during a health inspection on September 11, 2025.
The wound the physician found that morning was deep.
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.