Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bladen East Health And Rehab during CMS and state inspections, most recent first.
Unqualified Dietary Manager: The facility failed to employ a DFM who met minimum qualifications. The Dietary Manager stated she lacked required certification, ServSafe, a related degree, and the required nursing facility DFM experience, and she was waiting to be enrolled in training. The Corporate RD visited weekly and provided training, while the Administrator stated she believed there was a grace period before certification was required.
Medication Cart Left Unsecured: A nurse was observed walking away from Skilled Unit Medication Cart #1 while it was not locked and not in her line of sight. The cart remained unsecured until the issue was brought to her attention. The nurse stated she usually locked the cart but forgot, and the DON and Administrator stated they expected nurses to lock carts before walking away.
Two residents with histories of aggressive and manipulative behaviors were involved in a physical altercation in a hallway, where one struck the other multiple times with a reacher-grabber tool, causing a finger injury. Staff and witnesses confirmed the incident occurred despite both residents being known for argumentative behavior and requiring interventions for aggression, indicating a failure to prevent resident-to-resident abuse.
The facility failed to label, date, and discard expired food items in the nourishment refrigerator, potentially leading to foodborne illnesses. Observations revealed expired yogurt cups and Ranch dressing, along with unlabeled and undated partially eaten chicken wings, corn on the cob, a soda bottle, and a bottle with orange liquid. The Dietary Manager and ADON confirmed that nursing staff were responsible for these tasks, and the Administrator stated that expired items should have been discarded.
The facility inaccurately coded MDS assessments for two residents, indicating the use of bed rails as restraints, despite the facility being restraint-free. Observations and resident statements confirmed the absence of bed rails. The errors occurred while the MDS Coordinator was on leave, and the Administrator and DON acknowledged the coding mistakes.
A facility failed to provide a resident's medical records to their RP after a verbal request was made. The Business Office Manager did not inform the medical records staff of the request, resulting in a delay. The facility's policy requires records to be provided within two working business days, which was not adhered to in this case.
A resident with cognitive impairment and mobility dependence fell from an elevated bed while receiving incontinence care, resulting in fractures and hospitalization. The nursing assistant left the resident unattended to retrieve supplies, leading to the fall. Interviews revealed that the assistant should have prepared all necessary items beforehand or sought help, as leaving the resident unattended in an elevated position was unsafe.
Unqualified Dietary Manager
Penalty
Summary
The facility failed to employ a director of food and nutrition services who met the minimum qualifications. During an interview, the Dietary Manager stated that she did not have certification as a dietary manager or food manager, national certification for food service management and safety, an associate's or higher degree in food service management or hospitality, or 2 or more years of experience as a Director of Food and Nutrition Services in a nursing facility setting. She also stated that she was not ServSafe certified and was waiting for the Administrator to enroll her in dietary/food manager training. She reported that she started in the position on 12/8/25 after the former Dietary Manager left abruptly and that she had previously worked as a cook for around 10 years. The Corporate RD stated that she oversaw another building and came to the facility once a week on Thursdays. She reported that she had been training the Dietary Manager on needed items, such as hour of sleep snack, and that she had not wanted to overwhelm her with the dietary/food manager course initially. The Administrator stated that she thought the Dietary Manager had a grace period to be certified and that she enrolled her in the food manager course after becoming aware on 6/17/26 that the Dietary Manager did not meet the minimum qualifications. The deficiency affected 58 of 62 residents who consumed food.
Medication Cart Left Unsecured
Penalty
Summary
The facility failed to ensure the Skilled Unit Medication Cart #1 was secured while unattended. On 06/16/2026 at 4:29 PM, Nurse #1 was observed walking on an adjacent hall away from the medication cart, and the cart was not in her line of sight because the surveyor had to turn a corner to return to it. When the nurse and surveyor returned to the cart at 4:31 PM, the lock button had not been pushed in to secure the cart, and the nurse locked it only after the issue was brought to her attention. During interview, Nurse #1 stated she usually locked her cart but forgot to lock it when she walked away. The DON stated she expected all nurses to make sure all carts were locked prior to walking away, and the Administrator stated she expected nurses to lock their carts prior to leaving them.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident was not protected from resident-to-resident abuse, resulting in one resident striking another multiple times with a grabber-reacher tool, causing injury to the victim's finger. Both residents involved had documented histories of manipulative or aggressive behaviors, and their care plans included interventions for managing aggression and ensuring safety. On the day of the incident, one resident approached the other in the hallway, and after a verbal exchange, was struck several times with the reacher-grabber tool, leading to a bleeding injury. Multiple staff and resident interviews confirmed that the altercation took place in the hallway outside one resident's room, not inside as one party claimed. Witnesses, including staff and another resident, observed the aggressor using the reacher-grabber tool to hit the other resident, who attempted to defend himself. Staff were present in the area and attempted to intervene, but were unable to prevent the physical assault before it occurred. The injured resident was treated for his wound, and law enforcement was notified, but the victim declined to cooperate with the police investigation. Both residents were known to have a history of argumentative and aggressive interactions with each other and with others in the facility. Staff and medical personnel acknowledged that both individuals lacked effective coping mechanisms for anger and aggression, and that their behavioral issues were well-documented. Despite these known risks, the incident was not prevented, and the facility failed to protect the resident from abuse as required.
Failure to Label and Discard Expired Food Items
Penalty
Summary
The facility failed to properly label, date, and discard expired food items in the nourishment refrigerator, which could potentially lead to foodborne illnesses. During an observation with the Dietary Manager, it was found that the refrigerator contained two yogurt cups and a Ranch dressing bottle, both past their expiration dates. Additionally, there were partially eaten chicken wings and corn on the cob on a disposable plate, a two-thirds full 2-liter soda bottle, and a plastic bottle with orange-colored liquid, all without labels or dates. The Dietary Manager acknowledged that nursing staff were responsible for labeling, dating, and discarding expired items. The Assistant Director of Nursing (ADON) confirmed this responsibility during an interview and disposed of the items. The facility Administrator also stated that expired items should have been discarded and all food should have been labeled and dated before storage.
Inaccurate MDS Coding for Restraint Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents regarding the use of physical restraints, specifically bed rails. Resident #15 was reported to have bed rails used daily as a restraint according to the MDS, but both the resident and observations confirmed that no bed rails were present. The MDS Coordinator, who was not present during the assessment, and the Director of Nursing (DON) confirmed that the coding was an error, as the facility was restraint-free. The Administrator also acknowledged the error, stating that she and the DON completed the MDS assessments while the MDS Coordinator was on leave. Similarly, Resident #62's MDS indicated the use of bed rails less than daily, but observations and the resident's statement confirmed the absence of bed rails. The MDS Coordinator and the DON both stated that this was a coding error, as the facility did not use restraints. The Administrator reiterated that the facility was restraint-free and that the MDS should have been coded correctly. These errors in MDS coding were attributed to the absence of the MDS Coordinator during the assessments, leading to inaccuracies in the documentation of restraint use.
Failure to Provide Medical Records Upon Request
Penalty
Summary
The facility failed to provide copies of a resident's medical records after a request was made by the resident's Responsible Party (RP). The resident, who was admitted to the facility and assessed with severe cognitive impairment, had a family member listed as their RP and Power of Attorney. The RP verbally requested copies of the resident's medical records from the Business Office Manager approximately two months prior to the survey. However, the RP did not receive the requested records and was not informed of the need to sign a release form to obtain them. The Business Office Manager confirmed the RP's request but did not forward it to the medical records staff, as she was unaware that a verbal request was sufficient and that the records should be provided within two working business days. The Medical Records staff stated that they were not informed of the request and would have complied with the policy if notified. The facility's Administrator acknowledged the requirement to provide the records within the specified timeframe and indicated that the Medical Records staff should have either sent the records or arranged for the RP to collect them within two working business days.
Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a resident, resulting in a fall from an elevated bed. The resident, who was moderately cognitively impaired and dependent on staff for bed mobility and toileting, was receiving incontinence care from a nursing assistant. During the care process, the nursing assistant turned away from the resident to retrieve clean bed sheets, leaving the resident unattended on an elevated bed. This action led to the resident falling off the bed and sustaining significant injuries, including fractures to the left clavicle and ribs. The resident had a history of heart failure, diabetes, and dementia, and was receiving hospice care. Prior to the fall, the resident was on morphine for pain management. The incident report indicated that the nursing assistant had raised the bed to her waist level to provide care and turned her back to the resident to get supplies, which were placed on a wheelchair by the door. When the nursing assistant turned back, the resident had fallen to the floor, resulting in hospitalization for further evaluation and treatment of the injuries. Interviews with the nursing assistant, the nurse on duty, and the Director of Nursing revealed that the nursing assistant should have prepared all necessary supplies before starting care or called for assistance to avoid leaving the resident unattended. The Director of Nursing and the Administrator both acknowledged that the nursing assistant should not have left the resident unattended with the bed in an elevated position, which directly contributed to the accident and subsequent injuries.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 29 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Elizabethtown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elizabethtown Healthcare & Rehab Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Liberty Commons Nursing And Rehabilitation Center | 19.6 mi | ★★★★★ | 0 | 0 |
| Shoreland Health Care And Retirement Center Inc | 20.5 mi | ★★★★★ | 10 | 0 |
| Premier Living And Rehab Center | 21.3 mi | ★★★★★ | 0 | 0 |
| The Carrolton Of Lumberton | 21.5 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bladen East Health And Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.