East Carolina Health And Rehabilitation Center
East Carolina Health and Rehabilitation Center in Greenville, NC — inspection on September 11, 2025.
Found 3 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
According to the DON, Nurse # 2 had worked a double shift which included 7:00 AM to 11:00 PM on 8/10/25.
There was a notation on the shift change report that the information had been passed along to the nurse who started work at 11:00 PM on 8/10/25 that the resident had a sacral wound.
According to the DON, Nurse # 3 cared for Resident # 8 on the following day of 8/11/25 starting at 7:00 AM.Nurse # 3 was interviewed on 9/11/25 at 12:15 PM and reported she could not recall specifically what she did when the information had been passed along to her in shift change report that Resident # 8 had a sacral wound on 8/11/25.
She reported she would have passed the information along to the Wound Care Nurse.From 8/11/25 until 8/20/25 there was no further documentation the physician was notified about pressure sores.On 8/20/25 the Wound Physician documented she saw Resident # 8 and found a dressing to the resident's sacrum dated 8/12/25 on 8/20/25.
The Wound Physician further documented the following.
Resident # 8 had a Stage 4 pressure sore to the sacrum which measured 2.3 cm X 2 cm X 1 cm.
There was 90 % slough and 10 % granulation tissue in the wound bed.
The Wound Physician noted the area had not been known to exist by her or the Wound Care Nurse until that date (8/20/25).
The treatment plan was for a medical honey and calcium alginate to be applied daily.
The Wound Physician also noted Resident # 8 had deep tissue injury to her right heel which measured 5.1 x 4.7 x Not Measurable cm.
The treatment plan was for a daily application of skin prep.The Wound Physician was interviewed on 9/10/25 at 4:32 PM and clarified she was not aware of the resident's sacral pressure sore until 8/20/25 and on 8/20/25 there was a dressing that was dated 8/12/25.
The Wound Physician reported the facility could contact her at any time to obtain orders.The Wound Care Nurse was interviewed on 9/10/25 at 11:13 AM and reported the following information.
She did not recall an old dressing being on Resident # 8's sacrum when the pressure sore was found on 8/20/25.
She did not know about the pressure sore until 8/20/25.
She had been on vacation from 8/11/25 to 8/15/25.On 9/8/25 an order was entered into the electronic record per the Nurse Practitioner for a hospice referral.During an interview with the DON on 9/11/25 at 7:55 AM, the DON reported the following information.
Resident # 8 had been declining recently.
She used to eat and be involved in activities in the facility but had stopped eating and attending activities. Resident #8 also had some underlying medical problems and recent gynecological bleeding problems that had not fully been diagnosed yet.
Regarding the care of Resident # 8's pressure sores, the DON reported the nurses should contact the physician about new pressures sores and obtain orders to treat any new pressure sores.On 9/10/25 at 1:30 PM the Wound Care Nurse was observed as she provided wound care for Resident # 8.
Resident # 8's right heel appeared to have both pink and black tissue in the wound bed and was approximately the size of a baby food jar lid.
The sacral pressure sore wound bed appeared to be pink and healing.
During the interview with the Wound Care Physician on 9/10/25 at 4:32 PM the Wound Care Physician reported Resident # 8's sacral pressure sore had improved, and she did not think a lack of notifying the physician and carrying out wound care orders had resulted in the resident having a negative outcome.
During an interview with the facility Medical Director on 9/11/25 at 11:45 AM, who served as the resident's primary physician, the physician reported the following information.
The NP who had given the hospice order was not available that day. If Resident # 8 was appropriate for hospice services and also a diabetic, then it might be that the wounds would not heal regardless of treatment.
She had not been aware of problems with communication about wound care to the facility's Wound Physician.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/11/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
East Carolina Health and Rehabilitation Center
2575 W 5th Street Greenville, NC 27834
SUMMARY STATEMENT OF DEFICIENCIES
was right when they cared for Resident #8.During the interview with the Wound Care Physician on 9/10/25 at 4:32 PM the Wound Care Physician reported that if the air mattress was set for a weight more than what an individual weighed then this meant there would be more pressure on the resident.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/11/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
East Carolina Health and Rehabilitation Center
2575 W 5th Street Greenville, NC 27834
SUMMARY STATEMENT OF DEFICIENCIES
had orders for acetaminophen and tramadol (a controlled medication used for pain control) to be used as needed for pain.
She was discharged back to the facility on 1/7/25 at 5:01 PM in stable condition according to hospital records. On 9/10/25 at 3:40 PM a Representative from the manufacturing company of the mechanical lifts was interviewed and reported the following information. It would be hard to say what had occurred with the sling without viewing the sling. It could have been that the sling was worn from normal use and laundering, or it could have been defective.
The Representative indicated when incidents occur, the facility was welcome to call one of their regional representatives and the representative would come and view the sling to see if they could determine what had occurred.The Director of Nursing (DON) was interviewed on 9/8/25 at 7:38 AM and reported the following information.
The lift sling was assessed by the facility after the incident, and it had been broken.
The weight limit for all their slings was 600 pounds and Resident # 3 had not exceeded the weight limit of the sling.
After the incident the Administrator and the Maintenance Director looked at all the lift slings and any old slings were thrown away by them.
New slings were ordered by the Administrator.
Every resident had a lift sling. If a lift sling was sent to laundry for laundering, the laundry personnel checked the sling before it was returned for use.
There were two laundry staff members during the day and then a staff member who worked from 3:00 PM to midnight in the laundry room.
These laundry staff were available to give the lift slings to a Nurse Aide after laundering.
There was an in-service for the laundry room staff incident regarding checking the lift slings after laundering.
The Administrator and the Maintenance Director were interviewed on 9/11/25 at 9:07 AM.
The Administrator reported the following information. He had obtained the broken sling after the 1/7/25 incident and saw that it was ripped at the seam.
The hook itself was not broken. He did not want the sling to ever be used again and therefore he threw it in the dumpster that day.
The sling wasn't very old.
Slings were replaced every six months.
Resident # 3's weight had not been an issue because the sling went up to 600 pounds.
After the incident, maintenance went through every sling in the facility to ensure they were in good condition and did not find other slings in disrepair. He (the Administrator) ordered new slings as well.
Because the slings were seen by laundry the most, the laundry staff were inserviced to check the slings after they went through the laundry each time they were laundered to ensure they remained in good condition after the laundry process.The Administrator presented a corrective action plan which they had implemented on 1/7/25 and completed on 1/8/25. A review of the corrective action plan revealed it did not include training for the nursing staff regarding the safety of the slings.
Therefore, the corrective action plan was not accepted.
Facility ID:
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 Greenville, 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 East Carolina Health and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.