Brunswick Rehabilitation And Healthcare Center
Brunswick Rehabilitation and Healthcare Center in Bolivia, NC — inspection on March 5, 2025.
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
During the complaint
potential for actual harm to carry out activities of daily living without staff assistance that were reviewed for needing assistance with ADLs.
An interview with the Administrator conducted via phone on [DATE] at 1:30 PM revealed the Director of Nursing was responsible for making sure rounds were being completed to ensure residents were being changed if they were incontinent as part of the plan of correction (POC) that was written for
During the recertification and complaint investigation survey of [DATE] the facility failed to provide 8 hours of Registered Nurse (RN) coverage for 28 of 45 days reviewed.
An interview with the Administrator on [DATE] at 9:56 AM revealed that the facility had a hard time hiring full and part time RN's and the Agency they used also had trouble providing licensed RNs for the facility.
Additionally, the Administrator stated that the facility had several as needed (PRN) RNs but those nurses were not scheduling any days to work.
The Administrator stated he was not sure why there were days in [DATE] that had no RN coverage because the new POC was in effect and the schedule was being reviewed every morning in the daily staff meeting.
The Administrator stated when it was discovered that there was no RN on the schedule, himself and the DON should have been notified immediately, but they were not.
The Administrator added, he and the DON even reviewed the weekend schedules every Friday in the morning meeting to ensure there was an RN on the schedule and discussed that in the event of a last minute call out, himself and the DON should have been notified immediately.
The Administrator stated he could not understand how this continued to happen because the schedule was also scrutinized daily to ensure they were within the budget and stated that a RN weekend supervisor was hired on [DATE] and this had helped.
d. On the current recertification and complaint investigation survey the facility failed to accurately document the Daily Nursing Hours postings on 4 of 324 days reviewed.
During the recertification and complaint investigation survey of [DATE] the facility failed to accurately document the Daily Nursing Hours staff postings for 2 days.
345549
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 345549 B.
Wing 03/05/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bolivia Rehabilitation and Healthcare Center 1070 Old Ocean Highway Bolivia, NC 28422
Findings included.
1a.) Resident #39 was admitted to the facility on [DATE] with diagnosis including Alzheimer's disease.
The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #39 was severely cognitively impaired.
She had no rejection of care.
She had impaired range of motion in her bilateral upper and lower extremities and was dependent on staff for activities of daily living (ADL).
A care plan dated 1/16/25 revealed Resident #39 had ADL self-care performance deficit related to her diagnosis of Alzheimer's disease, primary osteoarthritis, diabetes, and hypertension.
Interventions included to encourage participation in tasks.
During an interview on 2/16/25 at 5:00 PM Nurse #5 stated Resident #39 did not receive her scheduled shower last night on Saturday 2/15/25.
She stated it was reported to her this morning when she came on duty by the night nurse and Resident #39 still had not had a shower as of now.
She indicated she did not know why the showers weren't done by the Nurse Aides.
She stated Resident #39 was scheduled for showers to be given on night shift on Wednesday and Saturday nights.
During a phone interview on 3/4/25 at 8:30 PM Nurse Aide #9 stated he was the assigned Nurse Aide on 2/15/25 from 7:00 AM until 7:00 PM. He stated baths were not given to any residents during his shift on 2/15/25 because he was the only Nurse Aide assigned on the locked unit that day and there was no time to give baths.
During an interview on 2/18/24 at 3:00 PM Nurse Aide #7 stated he worked Saturday night 2/15/25 on the locked unit from 7:00 PM until 7:00 AM. He stated he was an agency nurse aide, and he was made aware of who needed showers when he came on shift. He stated three residents were supposed to get showered that night but stated he was busy during the shift and just didn't get the showers done on any of the three residents which included Resident #39. He stated there were two nurse aides on duty and assigned to the locked unit along with the nurse on Saturday night from 7:00 PM until 7:00 AM which was the usual number of staff on the locked unit.
During an interview on 2/16/25 at 2:51 PM Nurse Aide #5 stated she was the assigned Nurse Aide on the locked unit today and was scheduled to work from 7:00 AM until 7:00 PM.
She stated the second Nurse Aide who was scheduled this shift called out this morning, so it was just her and the nurse until approximately 10:00 AM.
She stated Resident #39 had not been given a bath today at this point because there was no time this morning to give baths.
b.) Resident #53 was admitted to the facility on [DATE] with diagnoses including dementia.
345549
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 345549 B.
Wing 03/05/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bolivia Rehabilitation and Healthcare Center 1070 Old Ocean Highway Bolivia, NC 28422
F-F727), accurately document the Daily Nursing Hours staff postings (
F-F732), and ensure that food items that were stored for use were labeled (
Findings included:
1. An observation of the two 300-hall shower rooms was completed during a round on 02/17/25 which started at 9:45 AM with the Maintenance Director.
The shower hot water temperature in Spa #1 fluctuated from 85 degrees Fahrenheit (F) to 89 degrees F, and the shower in Spa #2 hot water temperature fluctuated from 83 degrees F to 101 degrees F.
Both shower water temperatures were obtained using the calibrated thermometer provided by the Maintenance Director and the temperatures were obtained after 5-minutes of continuous hot water monitoring in both shower rooms.
The Maintenance Director stated during the observation the water was too cold for showers, which should have been around 114 degrees F.
The Maintenance Director said he would try to adjust the faucets and mixing valve to bring the hot water temperature up to around 114 degrees F.
An interview was conducted on 02/21/25 at 12:00 PM with the Administrator and he stated as of September 2024, their paper water temperature logs were no longer being used, since they updated to the electronic Maintenance TELS (The Equipment Lifecycle System) (an online system used to help manage maintenance in a facility).
The Administrator explained he had their new electronic TELS water testing log did not include testing water temperatures in the shower rooms.
The Administrator further explained he hired a new Maintenance Director and because the 3 shower rooms were inadvertently not added in the TELS water testing log, the Maintenance Director did not track the shower water temperatures which resulted in the 3 shower rooms water temperatures not being monitored.
The Maintenance Director said another reason the water in the shower rooms might be cold was due to the hot water having to travel all the way from the boiler to the shower rooms and staff were not waiting 3-5 minutes for the water to heat up.
2. An observation on 02/18/25 at 12:00 PM revealed resident commode base caulking in resident rooms (200, 201, 205, 207, 208, 209, 305, and 411), were noted to have black greenish substance located around the base of the commodes.
An interview and observation were conducted on 02/18/25 at 1:30 PM with the Maintenance Director. He stated there were areas on the 200, 300, and 400 halls that needed to be addressed, repaired, or replaced. He stated he was new to the building and had no assistant but was slowly keeping up with facility repairs. He said he did not know what the black greenish substance was around some of the commodes commode base caulking in resident rooms (200, 201, 205, 207, 208, 209, 305, and 411). He said maintenance was responsible for repairing or replacing items in the facility, and that some of the commodes caulking needed to be replaced.
345549
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 345549 B.
Wing 03/05/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bolivia Rehabilitation and Healthcare Center 1070 Old Ocean Highway Bolivia, NC 28422
Findings included:
a. On the current recertification and complaint investigation survey the facility failed to maintain hot water temperatures in two shower rooms used by residents.
During the complaint investigation and follow up survey of [DATE] the facility failed to maintain hot water temperatures in a shower room used by residents.
An interview was conducted on [DATE] at 12:00 PM with the Administrator.
The Administrator confirmed he was responsible for providing a safe and homelike environment for all residents, and for making sure the plan of correction (POC) that was in place for the cold shower citation of