Brunswick Health & Rehab Center
Brunswick Health & Rehab Center in Ash, NC — inspection on April 9, 2026.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident #7 ' s current care plan revealed that the resident was not care planned for self-administration of his medications. A review of Resident #7 ' s electronic medical record revealed no assessments were completed for the self-administration of his medications. A review of Resident #7's current physician's orders revealed no order for naproxen sodium (nonsteroidal anti-inflammatory drug) as needed for a headache and no order for lidocaine-prilocaine cream (prescription only topical anesthetic) to be applied to the fistula site prior to dialysis.
The physician orders did not include an order for the resident to self-administer any of his medications.An observation was conducted on 4/7/26 at 9:10 AM as Resident #7 was sitting on the side of his bed in his room. An observation and interview conducted on 4/7/26 at 9:10 AM revealed an opened bottle of naproxen sodium 500 milligrams and 4 opened tubes of lidocaine-prilocaine cream on his overbed tray table. An interview was conducted on 4/7/26 at 9:15 AM with Medication Aide #1. At that time, Medication Aide #1 was outside of the Resident #7's room standing at the medication cart (not within view of the resident).
Medication Aide #1 was assigned to Resident #7 on 4/7/26 from 7:00 AM to 11:00 AM.
Medication Aide #1 stated that she was unaware that Resident #7 had medications in his room including the tubes of lidocaine cream and a bottle of naproxen observed on the overbed tray table. An interview conducted on 4/7/26 at 9:20 AM with Resident #7 revealed that he had naproxen in his room in case he had a headache and that he took the medication on occasion. Resident #7 indicated that he applied the lidocaine cream to his fistula prior to dialysis. Resident #7 stated that the medications were obtained from an outside pharmacy and his responsible party brought them into the facility. An interview was conducted with the Physician on 4/8/26 at 12:40 PM.
The Physician explained that naproxen is a nonˆsteroidal antiˆinflammatory drug (NSAID) that Resident #7 should not selfˆadminister and that unsupervised use could lead to complications.
The Physician indicated that the prescription lidocaine cream was an anesthetic and that unsupervised use of the lidocaine cream could cause complications.
The Physician further stated that residents were to be assessed for the ability to safely self-administer medications. An interview with Unit Manager #1 on 4/8/26 at 12:00 PM confirmed that medications should not be kept at the bedside, as there were confused residents on the unit who sometimes entered other residents' rooms.
Unit Manager #1 explained that residents must be assessed for their ability to self-administer medications, the medications must be secured, a physician's order must be obtained, and the care plan must be updated accordingly.
Unit Manager #1 stated that she was unaware that Resident #7 was self-administering naproxen and lidocaine cream and that the medications were kept unsecured in his room.An interview was conducted on 4/9/26 at 4:43 PM with the Director of Nursing (DON).
During the interview, concerns identified regarding a resident's self-administration of medications and the safe and secure storage of the medications were discussed.
The DON stated that she was not aware that Resident #7 had medications in his room that he was self-administering.
The DON stated that for a resident to self-administer medications, the resident had to be assessed for safety and if determined to be appropriate, a physician order was required specifying which medications were to be self-administered, the medications were to be stored properly, and the care plan was to be updated to reflect this.
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Brunswick Health & Rehab Center 9600 No 5 School Road Ash, NC 28420
occupational therapy and was able to bear weight as tolerated. An interview was conducted with the
no longer employed at the facility but was in the position during July 2025.
The Medical Director
several days by the resident being moved, transferred and ambulated.
The Medical Director stated that there was the potential for worsening of the fracture. An interview with the Director of Nursing (DON) on 4/9/26 at 1:25 PM revealed that she expected all unwitnessed falls, as well as falls reported by a resident, family member, or visitor, to be reported immediately and for the resident to be thoroughly assessed for injuries.
The DON further stated that her expectation was for the nursing staff to monitor residents for pain, assess the resident, and report increased pain or any changes in condition to the physician for further evaluation.
The Director of Nursing stated that the xˆray results were faxed to the facility and were also available in the computer system, and that all nurses had access to the log in information needed to obtain the results electronically.
The Director of Nursing stated that she expected the nurse on the shift following the completion of the xˆrays to check both the fax machine and the computer system for the results.
The DON was unable to confirm when Resident #61's x-ray results were received at the facility.
The DON confirmed that the facility conducted an investigation when Resident #61 was diagnosed with an acute femoral fracture.
The investigation determined that Nurse #12 was informed of an unwitnessed fall and failed to report the incident resulting in a delay in treatment.
The DON indicated that it was important to complete and document all assessments thoroughly.
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Brunswick Health & Rehab Center 9600 No 5 School Road Ash, NC 28420
educated all staff on how to review the resident profile to determine the transfer status, ensuring gait
of Nursing prior to their next scheduled shift. 4.
Indicate how the facility plans to monitor its
completed.
The Director of Nursing or designee will observe transfers 3 times a week for 4 weeks on all halls on various shifts to ensure residents are being transferred according to their plan of care. In addition, the Director of Nursing will assess 3 cognitively impaired residents weekly for 4 weeks to ensure there are no signs of mistreatment or psychosocial distress and interview 3 cognitively intact residents weekly for 4 weeks to ensure the residents feel safe in the facility.
The audits will be reviewed by the QA committee at the end of the monitoring period to ensure the plan is effective.
The QAPI committee will determine the need for further intervention and auditing beyond 4 weeks to assure compliance is sustained.
The facility alleged compliance of the corrective action plan on 5/27/25.
Validation of the corrective action plan was completed on 4/9/26.
This included staff interviews regarding the incident and in-service training that was received to ensure understanding and knowledge of the training provided.
Inservice training records were verified and included staff signatures.
The initial audits including the weekly audits were reviewed to verify all residents on all halls across various shifts were included.
Staff providing a safe transfer of a resident was observed during the validation.
There were no concerns identified.
The plan of correction with a completion date of 5/27/25 was validated.
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Brunswick Health & Rehab Center 9600 No 5 School Road Ash, NC 28420
verbalized hip pain but was unable to provide details due to resident's dementia.
Mobile x-rays were
lower extremity. An interview was conducted with the Unit Manager #1 on 4/9/26 at 11:00 AM.
Unit
Resident #61 on 7/18/25 from 11:00 AM to 3:00 PM.
Unit Manager #1 stated that Resident #61 was not scheduled for any medication during the time she was assigned to her, so she did not go into Resident #61's room and did not assess the resident.
Unit Manager #1 stated that she did not recall if she was informed of Resident #61 having pain or any changes in mobility.
Unit Manager #1 stated that she had not assessed Resident #61's pain but she did not think that Resident #61 was able to rate her pain on a 0 to 10 scale or request pain medication due to her dementia with impaired cognition. Resident #61's x-ray report of the mobile X-ray of the left hip dated 7/18/25 at 11:31 PM indicated an acute left femoral neck fracture with displacement. Resident #61's electronic MAR indicated that acetaminophen was administered by Nurse #5 on 7/19/25 at 10:36 AM and was documented as effective.
The MAR did not have numerical pain monitoring documented with the administration of the as needed medication for pain. A nursing progress note in Resident #61's electronic health record dated 7/19/25 at 11:52 AM written by Nurse #5 stated that results of the x-ray completed on 7/18/25 indicated an acute left femoral neck fracture with displacement. A nursing progress note dated 7/19/25 at 12:45 PM written by Nurse #5 stated that Resident #61 was transferred to the emergency department for evaluation. A follow up interview with Nurse #5 on 4/9/26 at 4:15 PM revealed that he was assigned to Resident #61 on 7/19/25 from 11:00 AM to 11:00 PM.
Nurse #5 stated that he came in early for his 11:00 AM to 11:00 PM shift on 7/19/25 and when he came on for his shift, he found the x-ray results for Resident #61 dated 7/18/25 on the fax machine.
Nurse #5 did not recall if Resident #61 was able to indicate a pain level or request pain medication or if he administered the acetaminophen on 7/19/25 after seeing the x-ray result that indicated a fracture.
Upon noting that the x-ray report indicated a fracture, he reported the results to the on-call provider and received an order to send Resident #61 to the hospital for evaluation.
The hospital history and physical report dated 7/19/25 indicated that Resident #61 was sent to the emergency department for evaluation of a left femoral neck fracture.
The report indicated that Resident #61 stated upon arrival to the emergency department that she had hip pain and orders were written on presentation for hydromorphone (a potent narcotic medication use to treat moderate to severe pain) 0.2 milligrams intravenous every 3 hours as needed and cyclobenzaprine (a muscle relaxant) 5 milligrams every 8 hours as needed for pain.
The hospital medication administration record revealed that Resident #61 received acetaminophen 650 milligrams every 6 hours as needed for pain on 7/19/25 at 8:28 PM. Resident #61 received hydromorphone 0.2 milligrams intravenous on 7/20/25 at 9:37 AM.
The hospital Discharge summary dated [DATE] indicated that Resident #61 underwent a left hip hemiarthroplasty on 7/20/25 without complications and was stable to return to the facility. An interview with the Director of Nursing (DON) on 4/9/26 at 1:25 PM revealed that she expected residents with pain would be thoroughly assessed regardless of the residents' cognitive status.
The DON further stated that her expectation was for the nursing staff to monitor residents for pain, assess the resident, and report increased pain or any changes in condition to the physician for further evaluation.
The DON stated that Resident #61 was unable to rate her pain on a scale of 0 to 10 and was unable to request pain medication but that the resident should have been assessed for pain using non-verbal indicators and provided with pain medication as needed.
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Brunswick Health & Rehab Center 9600 No 5 School Road Ash, NC 28420
consuming large servings of fluid and could not have a large cup of orange juice. An interview with the
trays, she checked the meal tray ticket for allergies and the diet.
The Medical Records Manager
under his ordered fluid restriction and that he did not receive a double portion of protein.
The Medical Records Manager stated that she was not sure what a renal diet consisted of.An interview with the Dietary Manager was conducted on 4/7/26 at 3:15 PM.
The Dietary Manager stated that a renal diet included restrictions such as no tomatoes, tomato sauce or bananas and avoidance of other things that are high in potassium.
She reported that she maintained a posted list in the kitchen identifying foods to avoid on a renal diet and expected her staff to refer to the list when preparing Resident #7's meal trays.
The Dietary Manager stated that the small serving of ravioli provided to Resident #7 at lunch did not meet the requirement for a double protein portion and was served in error.
She also reported that the potatoes and carrots substituted for the Italian blend vegetables should not have been served due to the resident's renal diet restriction, which specifies avoiding potatoes.
The Dietary Manager added that she believed Resident #7 could have the roll, as he frequently received sandwiches in his bag lunch when going to dialysis.
Additionally, she confirmed that the meal tray ticket listing 8 ounces of water, 8 ounces of a beverage of choice, and 4 ounces of sherbet exceeded the resident's 240 mL fluid restriction and acknowledged this was an error for which she could not provide an explanation.
The Dietary Manager stated that there was no system in place to ensure that residents consistently received the correct diet or appropriate items on their meal trays. An interview with [NAME] #1 was conducted on 4/7/26 at 3:30 PM. [NAME] #1 stated that a renal diet meant the resident was not to receive tomatoes, potatoes and a few other certain things.
The [NAME] stated that there was a list posted in the kitchen that identified foods to avoid on a renal diet. [NAME] #1 stated that she did not check the list when she prepared Resident #7's lunch meal tray on 4/7/26. [NAME] #1 indicated she read the tray card when preparing the meals. An observation of Resident #7's breakfast tray on 4/8/26 at 8:30 AM revealed that the resident received 1 fried egg, 1 slice of toast and a 4-ounce (120 mL) cup of coffee.
The meal tray ticket indicated Resident #7 was to receive a renal diet with double portion of protein with an allergy listed as tea and a fluid restriction of 1000 mL per day with 240 mL provided at breakfast and lunch and 120 mL at dinner.
The ticket indicated that Resident #7 was to receive 4 ounces (120mL) coffee and did not list the food items that the resident received. An interview with the consultant Registered Dietitian (RD) on 4/8/26 at 1:40 PM revealed that Resident #7 was ordered a renal diet with double protein and a 1000 mL fluid restriction.
The RD stated that increased fluids can cause risks of poor volume management.
The RD indicated that increased protein was important for a resident receiving dialysis to counteract the protein losses during treatment, to prevent muscle wasting and combat chronic inflammation.
The RD stated that a small serving of ravioli was not a double portion of protein and further 1 fried egg was not a double portion of protein.
The RD indicated that 2 large fried eggs constituted a standard serving so a double serving was 3-4 eggs. An interview with the Director of Nursing on 4/9/26 at 4:43 PM revealed that she expected that fluid restrictions and diet restrictions would be followed as ordered by the physician.
The Director of Nursing stated that the dietary department was responsible for preparing meal trays according to the physician's orders, while the nursing staff was responsible for reviewing the meal tray ticket to ensure the diet was correct.
She further indicated that nursing staff should be knowledgeable about special diets, such as a renal diet, and any associated restrictions. If a resident received an item on their tray and the nursing staff were uncertain whether it was permitted, they were expected to consult the dietary department for clarification.
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Brunswick Health & Rehab Center 9600 No 5 School Road Ash, NC 28420
with Unit Manager #1 conducted on 4/8/26 at 12:00 PM revealed that medications were not to be left
not observed any medications left in Resident #7's room.An interview with the Director of Nursing
unsecured in a resident's room.
The DON stated that staff were expected to remain with the resident and observe the resident taking and swallowing the medications before leaving the room.
The DON further stated that medications were not to be left on the bedside table for the resident to take later and that residents were to be assessed for self-administration before they were allowed to have medications kept at the bedside.
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Brunswick Health & Rehab Center 9600 No 5 School Road Ash, NC 28420
received the diet order from the nursing department, that nursing entered the allergies in the clinical
system for the meal tray ticket.
The Dietary Manager stated that she did not know why she did not
someone at the corporate office to investigate this.
The Dietary Manager stated that she talked to residents regarding their likes and dislikes as needed but she did not have a form for this and did not document this information.
The Dietary Manager indicated that she did not have any documentation of the last time she spoke with Resident #7, did not recall the last time she talked to him about his diet, allergies, likes or dislikes and did not recall reviewing Resident #7's clinical record for allergies.
The Dietary Manager pulled up her meal tray ticket system and observed that tea was listed in the system as an allergy, but tomatoes were not and she again stated there was an error that it did not pull into the system from the clinical record. An interview with the Director of Nursing (DON) on 4/9/26 at 4:43 PM revealed that she expected that food allergies would be communicated from the nursing department to the dietary department and would be honored.
The DON stated that allergies were supposed to transfer from the clinical dashboard to the Dietary Manager's system but should also be included on the diet order slip that was provided to the dietary department.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Ash, NC, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Brunswick Health & Rehab Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.