Universal Health Care / Brunswick

F-F686: Based on observations, record review, staff, the Medical Director and the Wound Physician interviews, the facility failed to provide wound care according to the physician's order for a Stage IV pressure ulcer on the left heel and an unstageable deep tissue injury on the right heel. This occurred for 1 of 3 residents (Resident #60) reviewed for wound care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 13 345549 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40044 potential for actual harm Based on observations, record review, and staff interviews, the facility failed to provide bathing and showers Residents Affected - Some (Resident #39, Resident #53, and Resident #60) and incontinence care (Resident #7) to residents who were dependent on staff assistance with activities of daily living (ADL). This occurred for 4 of 5 residents reviewed for ADL care.

Findings included.

1a.) Resident #39 was admitted to the facility on [DATE REDACTED] with diagnosis including Alzheimer's disease.

The Minimum Data Set (MDS) admission assessment dated [DATE REDACTED] 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 REDACTED] with diagnoses including dementia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 13 345549 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 A care plan dated 11/25/24 revealed Resident #53 had an ADL self-care deficit related to dementia. Interventions included assistance by staff with bathing and showering. Level of Harm - Minimal harm or potential for actual harm The Minimum Data Set (MDS) quarterly assessment dated [DATE REDACTED] revealed Resident #53 had severely impaired cognition. She required extensive assistance by staff with activities of daily living. Residents Affected - Some

During an interview on 02/16/25 at 5:00 PM Nurse #5 stated Resident #53 did not receive her scheduled shower last night (Saturday 2/15/25). She stated that was reported to her this morning when she came on duty by the night nurse. She stated Resident #53 still had not had a shower as of now. She stated she did not know why the showers weren't done by the Nurse Aides. She stated Resident #53 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 stated he was made aware of who needed showers when he came on shift. He stated he was busy during the shift and just didn't get the showers done on any of the three residents who were scheduled which included Resident #53.

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 Resident #53 had not been given a bath today at this point because there was no time this morning to give baths.

c.) Resident #60 was admitted to the facility on [DATE REDACTED] with diagnoses including dementia.

A care plan revised 11/25/24 revealed Resident #60 had an ADL self-care deficit related to dementia with agitation. Interventions included to encourage resident to participate to the fullest extent.

The Minimum Data Set (MDS) quarterly assessment dated [DATE REDACTED] revealed Resident #60 had moderately impaired cognition. She required extensive assistance by staff with activities of daily living. She had no rejection of care.

During an interview on 02/16/25 at 5:00 PM Nurse #5 stated Resident #60 did not receive her scheduled shower last night (Saturday 2/15/25). She stated Resident #60 still had not had a shower as of now. She stated she did not know why the showers weren't done by the Nurse Aides. She stated Resident #60 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 13 345549 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 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 stated he was made Level of Harm - Minimal harm or aware of who needed showers when he came on shift. He stated he was busy during the shift and just didn't potential for actual harm get the showers done on either of the three residents who were scheduled which included Resident #60.

Residents Affected - Some 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 Resident #60 had not been given a bath today at this point because there was no time this morning to give baths.

During a phone interview on 2/18/24 at 4:00 PM Nurse #7 stated she was the assigned nurse on the locked unit on Saturday night 2/15/25. She stated she was an agency nurse, and it was her very first night working

in the facility. She indicated she was aware showers were scheduled on night shift but did not know why the nurse aides on duty Saturday night didn't do them. She indicated she reported this to the oncoming nurse the next morning.

During the survey three attempts were made to contact Nurse Aide #8 who was on duty in the locked unit from 7:00 PM until 7:00 AM on Saturday night 2/15/25. There was no response.

During an interview on 02/19/25 at 11:24 AM the Director of Nursing (DON) stated she was made aware of

the three residents who did not get showered on their scheduled shower day on Saturday night 2/15/25. She stated she did confirm after talking with Nurse Aide #7 and Nurse Aide #8 who were the nurse aides on duty that showers weren't given. She stated they chose not to do the showers, and they received disciplinary action and were pulled from the locked unit. She stated they typically had two nurse aides assigned to each shift on the locked unit and there were two nurse aides on duty from 7:00 AM until 7:00 PM. She stated the showers should have been given.

35173

2) Resident #7 was admitted to the facility on [DATE REDACTED]. Diagnoses included history of urinary tract infections, muscle wasting and atrophy, and need for assistance with personal care.

The Minimum Data Set (MDS) quarterly assessment dated [DATE REDACTED] revealed Resident #7 was cognitively intact and was coded for impairments to both sides of upper and lower extremities and dependent with one staff physical assistance for ADL care. Resident #7 was always incontinent of bowel and bladder.

A care plan updated on 02/11/25 for Resident #7 revealed a plan of care was in place for incontinent care and required staff assistance with toileting and bowel and bladder incontinence. The goal of care was to receive the appropriate level of staff assistance for toileting and incontinence care. Interventions included providing one person assistance with toileting and incontinence care. A plan of care was in place for limited physical mobility related to weakness, impaired mobility and incontinence with a goal that resident would be free of complications related to immobility to include skin breakdown. Interventions included observing for any signs or symptoms of skin breakdown. A plan of care updated on 02/13/25 revealed the resident had a Stage IV pressure ulcer to her coccyx (a small bone at the base of the spinal column above the buttocks) related to immobility and incontinence with a goal that the pressure ulcer would show signs of healing and remain free from infection. Interventions included observing any changes in skin status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 13 345549 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 An observation and interview with Resident #7 on 02/16/25 at 10:30 AM revealed an alert and oriented resident lying in bed on her back. Resident #7 reported that her brief had not been changed since early this Level of Harm - Minimal harm or morning and stated it was well before breakfast. Resident #7 stated she was wet with urine at this time and potential for actual harm wanted to be changed. Resident #7 stated she would ring her call bell to get assistance.

Residents Affected - Some A follow up observation and interview was conducted with Resident #7 on 02/16/25 at 1:15 PM. Resident #7 stated she rang her call bell and told the Nurse Aide (NA) #2 that she needed her brief to be changed. The call light was not sounding upon entry to Resident #7's room. Resident #7 reported NA #2 stated she would be right back but she did not come back. Resident #7 stated she believed it was about 10:30 AM or so when

she pressed her call bell, but she could not remember the actual time. Resident #7 stated she wanted her brief to be changed, but she did not want to keep bothering the nurse aide.

An interview was conducted with Nurse Aide (NA) #2 on 02/16/25 at 1:15 PM. NA #2 was asked when the last time was that she checked on and changed Resident #7's brief. NA #2 responded I don't know, I don't keep track of that. I am so busy with the 18 residents on my hall. NA #2 stated she did not recall Resident #7 ringing her call bell to ask for assistance or telling Resident #7 she would be back. NA #2 stated she would check Resident #7 at this time.

An observation of NA #2 was conducted on 02/16/25 at 1:15 PM. NA #2 was noted to have checked Resident #7's brief and it was noted to be saturated with a significant amount urine. NA #2 was observed changing Resident #7's brief at this time. Resident #7's dressing to her coccyx was noted to be intact.

A follow up interview was conducted with NA #2 on 02/16/25 at 1:45 PM. NA #2 stated she was doing the best the could with keeping up with changing her residents. NA #2 stated she tried to check her residents every 2 - 3 hours per the facility protocol to see if the residents needed to be changed, but that Resident #7 had gone over 4 hours before she was changed again. NA #2 stated she did not remember when she first changed Resident #7 but she thought it was at the start of her shift around 7:30 AM. NA #2 stated she should have checked her for incontinence again after 2-3 hours since she was one of her residents known to urinate a lot.

An interview was conducted with the Administrator on 02/21/25 via phone at 1:35 PM. The Administrator stated he would have expected the nurse aides to check and change all residents on their assignment every 2 - 3 hours to ensure they were kept dry and clean to maintain the resident's skin integrity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 13 345549 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40044 potential for actual harm Based on record review, and staff, Registered Dietician and Physician interviews, the facility failed to provide Residents Affected - Some a nutritional supplement ordered twice a day for 30 days for wound healing to a resident who was at risk for malnutrition and had a facility acquired unstageable deep tissue injury of the right heel and a deep tissue injury to the left heel that developed into a Stage IV pressure wound. This occurred to 1 of 10 residents (Resident #60) reviewed for nutrition.

Findings included.

Resident #60 was admitted to the facility on [DATE REDACTED] with diagnoses including muscle wasting with atrophy, dysphagia, and dementia.

A wound physician's report dated 11/20/24 revealed Resident #60 had bilateral deep tissue injuries to her left and right heels.

A care plan revised 11/25/24 revealed Resident #60 was at nutritional risk due to cognitive decline associated with dementia, dysphagia with a modified diet order, age-related physiological decline and debility, skin breakdown, diabetes, and aphasia. She was at risk for malnutrition, and for hydration alterations and weight fluctuations secondary to diuretic use. Interventions included in part: to observe for signs of malnutrition and provide and serve supplements as ordered. The Registered Dietician will evaluate and make diet change recommendations as needed.

The Registered Dietician review note dated 12/17/24 revealed that she evaluated Resident #60. The head-to-toe skin review indicated that Resident #60 had a suspected deep tissue injury on the right and left heel. The current weight on 12/4/24 was 111 pounds, which was up over the past month. The Registered Dietician recommended for wound healing Arginaid twice a day for 30 days. (Arginaid is a nutritional supplement in a powder or drink mix that contains arginine. Arginine is an amino acid that's essential for wound healing. It stimulates the release of growth hormone and insulin-like growth factor, which can improve wound healing.)

Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) dated December 2024 revealed no documentation that Arginaid nutritional supplement was administered to Resident #60.

Review of Resident #60's progress notes from 12/17/24 through 12/31/24 revealed no documentation as to why Arginaid was not administered.

Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) dated January 2025 revealed no documentation that Arginaid nutritional supplement was administered to Resident #60.

Review of Resident #60's progress notes from 1/1/25 through 1/17/25 revealed no documentation as to why Arginaid was not administered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 13 345549 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 The Minimum Data Set (MDS) quarterly assessment dated [DATE REDACTED] revealed Resident #60 had moderately impaired cognition. She had two deep tissue injuries. She had no rejection of care. Level of Harm - Minimal harm or potential for actual harm A wound physician's report dated 2/12/25 for Resident #60 revealed the deep tissue injury to the left heel had now revealed itself to be a Stage IV pressure injury. The right heel wound remained unstageable due to Residents Affected - Some necrosis.

The Registered Dietician review note dated 2/13/25 revealed that she evaluated Resident #60 for pressure areas and weight loss. The wound report indicated Resident #60 had wounds to the left and right heel. The Registered Dietician recommended for wound healing and weight stability Arginaid twice a day for 90 days.

Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) dated February 2025 revealed no documentation that Arginaid was administered to Resident #60.

Review of Resident #60's progress notes from 2/1/25 through 2/28/25 revealed no documentation as to why Arginaid was not administered.

Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) dated March 2025 revealed no documentation that Arginaid was administered to Resident #60 as of 3/5/25.

During an interview on 2/17/25 at 2:30 PM Nurse #8 stated she was consistently assigned to care for Resident #60. She stated Resident #60 had pressure wounds, but she did not recall Resident #60 receiving Arginaid at any time since December 2024. She stated she did not see the order on the MAR or the TAR for Arginaid for Resident #60 in December 2024, or January 2025 or through today 2/17/25.

During an interview on 02/18/25 at 2:44 PM the Registered Dietician stated she last evaluated Resident #60

on 2/13/25. The progress notes indicated Resident #60 continued with deep tissue injuries and Stage III and Stage IV pressure wounds. She stated she was not aware that the Arginaid recommendation for wound healing was not implemented in December 2024, but a new recommendation was made for Arginaid on 2/13/25. She stated she did not enter her recommendations as orders. She stated when she wrote the recommendations, she emailed them to the Director of Nursing, then the physician would sign off on the order then the nursing staff would enter it into the resident's electronic medical record to be implemented.

During an interview on 02/20/25 at 1:04 PM the Director of Nursing (DON) stated that when the Registered Dietician made recommendations following her evaluations, she emailed the recommendations to her. She stated she would then forward the email to the Unit Manager to complete the order process. She indicated that she gave the recommendations made by the Registered Dietician to Unit Manager #1 following the December 2024 evaluation of Resident #60.

During a phone interview on 02/21/25 at 2:05 PM Unit Manager #1 stated she gets the Registered Dietician recommendations from the DON. She stated once she gets the recommendation, she sends it to the Nurse Practitioner or the Physician to be signed off, then she would enter the order into the electronic medical record, and it would flow to the Medication Administration Record. She stated she looked back for the recommendation for Resident #60 from December 2024 for Arginaid and she could not find where the recommendation was sent to her. She indicated it was missed and was never implemented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 345549 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During a phone interview on 3/4/25 at 2:00 PM the Physician stated Resident #60 had an unstageable deep tissue injury on her right heel and a Stage IV pressure wound on her left heel. She stated Resident #60 had Level of Harm - Minimal harm or multiple comorbidities that contributed to her wound development and the wounds were unavoidable. She potential for actual harm stated she was made aware of the Arginaid order not getting entered for Resident #60 following the onsite survey period. She stated Arginaid had not been used in the facility for several years, however if it was Residents Affected - Some recommended by the Registered Dietician then she would have signed off on the recommendation and expected the order to be entered and administered to the resident.

A phone interview was conducted on 3/5/25 at 2:00 PM with the Registered Dietician, along with the Administrator and the Corporate Nurse. The Registered Dietician stated her recommendations had to have approval by the Physician before they were entered as an order. She stated she made another recommendation for Arginaid for Resident #60 during her last evaluation on 2/13/25 to aid in wound healing.

The Corporate Nurse stated there had been an issue with the Registered Dieticians emails getting transmitted to the DON. The Administrator stated they just ordered the Arginaid for Resident #60, and it arrived at the facility on Monday 3/3/25. He stated Resident #60 would get the Argnaid by tomorrow 3/6/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 345549 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35173

Residents Affected - Few Based on observations, record review, staff, and resident interviews the facility failed to provide sufficient nursing staff to provide incontinence care to a dependent resident (Resident #7). Nurse Aide #2 reported she changed Resident #7's brief at approximately at 7:30 AM and had not checked the resident for incontinence needs again until 1:15 PM. This occurred for 1 of 24 residents reviewed for sufficient staffing.

Findings included:

Resident #7 was admitted to the facility on [DATE REDACTED]. Diagnoses included history of urinary tract infections, muscle wasting and atrophy, and need for assistance with personal care.

The Minimum Data Set (MDS) quarterly assessment dated [DATE REDACTED] revealed Resident #7 was cognitively intact and was coded for impairments to both sides of upper and lower extremities and dependent with one staff physical assistance for ADL care. Resident #7 was always incontinent of bowel and bladder.

A review of the staffing assignment sheet on 02/16/25 revealed there was one nurse aide assigned to each of the 100 hall, 200 hall, 300, and 400 hall from 7:00 AM to 7:00 PM, one nurse aide on the 500 hall (locked unit) due to a call out, and 2 nurse aides from 10:00 AM until 7:00 PM.

The facility census (number of residents residing in the facility) posting on 02/16/25 was 81 residents.

The staffing assignment sheets on 02/16/25 revealed the following:

Nurse Aide #2 assigned to the 100 Hall with 16 residents

Nurse Aide #3 assigned to the 200 Hall with 15 residents

Nurse Aide #4 assigned to the 300 Hall with 17 residents

Nurse Aide #1 assigned to the 400 Hall with 17 residents

Nurse Aide #5 and Nurse Aide #6 assigned to the 500 hall with 16 residents

The total number of nurse aides working on 02/16/25 during the 7:00 AM to 7:00 PM was 6. There was a medication aide who was not working as a nurse aide who was administering medications on the 200 hall.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 345549 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 An observation and interview with Resident #7 on 02/16/25 at 10:30 AM revealed an alert and oriented resident lying in bed on her back. Resident #7 reported that her brief had not been changed since early this Level of Harm - Minimal harm or morning and stated it was well before breakfast. Resident #7 stated she was wet with urine at this time and potential for actual harm wanted to be changed. Resident #7 stated she would ring her call bell to get assistance.

Residents Affected - Few A follow up observation and interview was conducted with Resident #7 on 02/16/25 at 1:15 PM. Resident #7 stated she rang her call bell and told Nurse Aide (NA) #2 that she needed her brief to be changed. The call light was not sounding upon entry to Resident #7's room. Resident #7 reported NA #2 stated she would be right back but she did not come back. Resident #7 stated she believed it was about 10:30 AM or so when

she pressed her call bell, but she could not remember the actual time. Resident #7 stated she wanted her brief to be changed, but she did not want to keep bothering the nurse aide.

An observation of NA #2 was conducted on 02/16/25 at 1:15 PM. NA #2 was noted to have checked Resident #7's brief and it was noted to be saturated with a significant amount urine. NA #2 was observed changing Resident #7's brief at this time.

An interview was conducted with NA #2 on 02/16/25 at 1:15 PM. NA #2 was asked when she last checked and changed Resident #7's brief. NA #2 responded I don't know, I don't keep track of that. I am so busy with

the 18 residents on my hall. NA #2 stated she did not recall Resident #7 ringing her call bell to ask for assistance or telling Resident #7 she would be back. NA #2 stated she had 18 residents and it was very difficult to meet all the needs of the residents, and she was not always able to meet their needs during her shift. NA #2 stated she was working from 7:00 AM to 7:00 PM on this hall. She stated she could not always find a staff member to assist her because the other aides were busy too. She stated 18 residents on the 100 hall were a lot of residents to care for during the day and evening shift and it was difficult to do it alone and provide the care needed.

A follow up interview was conducted with NA #2 on 02/16/25 at 1:45 PM. NA #2 stated she was doing the best she could with keeping up with changing her residents. NA #2 stated she tried to check her residents every 2 - 3 hours per the facility protocol to see if the residents needed to be changed, but that Resident #7 had gone over 4 hours before she was changed again. NA #2 stated she did not remember when she first changed Resident #7 but she thought it was at the start of her shift around 7:30 AM. NA #2 stated she should have checked her for incontinence again after 2-3 hours since she was one of her residents known to urinate a lot. At this time, the actual number of residents she was assigned was confirmed by Nurse Aide to be 16 residents on 02/16/25. NA #2 stated 16 residents on day shift was a lot of care to provide with one nurse aide.

An interview with the Scheduler on 02/18/25 at 1:30 PM revealed on day shift (7:00 AM until 7:00 PM) she was allocated to have 7 nurse aides. The scheduler stated if a staff member called off, they had to try and replace the call out. She stated normal scheduling was based on the facility census and with the census being 81, she would schedule 7 nurse aides but someone almost always called out.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 345549 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During an interview on 02/18/25 at 11:55 AM Nurse Aide #1 stated it was difficult for her to get all of her care done for the residents when she worked the 400 hall by herself. Nurse Aide #1 stated she usually had at Level of Harm - Minimal harm or least 17 residents on day shift on her assignment. Nurse Aide #1 stated a lot of her residents on the 400 hall potential for actual harm required two person assistance or the need for a mechanical lift and it was not easy to find the second person to help. Nurse Aide #1 stated she would ask the upper management staff to assist, but they were not Residents Affected - Few always available to assist. Nurse Aide #1 stated she would then not be able to get the residents out of bed until she found help.

During a phone interview on 03/04/25 at 8:00 PM Nurse Aide #14 stated they needed more Nurse Aides assigned to all the halls. NA #14 stated care to the residents was not always getting done such as incontinence care when there was not enough staff. NA #14 stated he had worked each hall and it was always staffed with the bare minimum (1 nurse aide per hall) and it was hard to get care done for the residents.

A phone interview was conducted with the Administrator on 02/21/25 at 1:35 PM. The Administrator stated

the census on 02/16/25 was 81 and he had scheduled 7 Nurse Aides. He stated they were allocated 7 Nurse Aides on day shift, and they scheduled seven but that included a Medication Aide as well. He stated the 7th person was a Nurse Aide/Medication Aide and was assigned to a medication cart on the 02/16/25 which left only 6 Nurse Aides for 81 residents. The Administrator stated he did not feel it was a concern and that one Nurse Aide to 16 - 17 residents was a manageable assignment. The Administrator stated the assignment was tough but doable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 345549