Brunswick Cove Nursing Center
Brunswick Cove Nursing Center in Winnabow, NC — inspection on February 20, 2026.
Found 1 citation. 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
that common side effects of a 2 mg dose include sleepiness and a calming effect, with the goal of
symptoms, including QT prolongation (an electrical abnormality seen on an EKG in which the heart
respiratory depression and coma in overdose situations.
The Consultant Pharmacist stated that 20 mg was not automatically considered an overdose.
She stated she reviewed the Haldol package insert and noted the maximum recommended dose listed was 30 mg.
The Consultant Pharmacist stated that although 20 mg was below the listed maximum dose, it was a high dose given at one time and sending Resident #2 to the ED for monitoring was appropriate. An interview was conducted with the DON on 2/19/26 at 12:23 PM.
The DON stated the medication error occurred during an incident in which the resident was combative and aggressive toward staff.
The DON stated the nurse (Nurse #1) who received the order did not repeat the order back to the NP.
She stated this breakdown in the process contributed to the medication error.
The DON stated it was her expectation that nurses follow best practices when receiving and implementing medication orders and indicated that best practices included repeating the verbal order back to the NP. An interview with the Administrator was conducted on 2/20/26 at 9:28 AM.
The Administrator stated it was his expectation the nurses follow the physician's medication orders. He stated that nurses should check and double-check orders to ensure they administer the correct medication and dose.
The facility provided a corrective action plan that was not acceptable to the state survey agency.
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.