Inspection Reports for The Bridges on Parkview
105 W Parkview Dr Henderson, NC 27536, Henderson, NC, 27536
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 29, 2025, identified multiple deficiencies related to cleanliness, call bell system functionality, resident care, medication administration, and resident rights. Earlier inspections showed similar issues, including unclean floors, a non-functional call bell system, medication errors, and inadequate care plan updates, with one prior investigation noting a resident’s pressure wound that led to hospitalization and death. Inspectors cited recurring problems with pest control, medication management, personal care, and failure to ensure resident safety and privacy. Complaint investigations were substantiated, focusing on abuse allegations, medication errors, and inadequate supervision, with no enforcement actions or fines listed in the available reports. The pattern of findings suggests ongoing challenges without clear improvement over time.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
17.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
237% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
66% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Follow-Up
Census: 57
Capacity: 86
Deficiencies: 21
Date: Sep 29, 2025
Visit Reason
The Adult Care Licensure Section and the Vance County Department of Social Services conducted a follow-up survey and complaint investigation from 09/23/25-09/26/25 and 09/29/25. The complaint investigation was initiated by the Vance County Department of Social Services on 08/05/25.
Complaint Details
Complaint investigation initiated by the Vance County Department of Social Services on 08/05/25 related to cleanliness, pest control, call bell system, resident care, medication administration, resident rights, and abuse allegations.
Findings
The facility failed to maintain clean floors and pest control, had an inoperable call bell system, failed to update care plans after significant changes, did not provide adequate personal care and supervision, failed to administer medications as ordered, left medications unattended, failed to dispose of medications properly, and did not ensure resident rights including freedom from abuse and privacy.
Deficiencies (21)
Floors were not kept clean in hallways, common areas, and residents' rooms in the Assisted Living and Special Care Unit, with evidence of dirt, debris, dead insects, and pest infestations.
The electrical call bell system in the Assisted Living and Special Care Unit was not maintained in operating condition with audible and visual signals accessible by staff, resulting in delayed or no response to resident calls.
The facility failed to update assessments and care plans within required timeframes for residents with significant changes, including wounds, weight loss, and mobility decline.
The facility failed to provide personal care assistance and supervision according to residents' care plans, resulting in residents being left soiled, unassisted, and at risk for falls and skin breakdown.
The facility failed to ensure immediate response and intervention by staff for a resident who fell and broke her leg, delaying EMS notification and causing injury.
The facility failed to ensure physicians' orders were implemented, including medication administration and monitoring orders for multiple residents.
The facility failed to ensure medications were administered as ordered, including incorrect dosing and failure to hold medications per parameters.
The facility failed to ensure controlled substances were destroyed properly with required documentation and witness signatures.
The facility failed to follow up on pharmacy medication review recommendations, resulting in unaddressed medication concerns.
The facility failed to obtain a physician's order for the use of physical restraints for a resident who was restrained by locking wheelchair brakes and pushing her to a table to prevent falls.
The facility failed to ensure mealtime table service included a knife, fork, and spoon in the Special Care Unit and glasses for milk in both Assisted Living and Special Care Unit.
The facility failed to ensure assistance was provided for residents who could not open individual containers at mealtimes and failed to ensure residents were observed taking medications.
The facility failed to ensure residents were free from abuse, including residents with skin tears and bruising caused by staff, failure to provide privacy and security for a resident's room, and failure to respond timely to call bells and whistles.
The facility failed to ensure medications were administered as ordered for multiple residents, including blood thinners, blood sugar medications, nerve pain medications, and blood pressure medications, resulting in risk of harm.
The facility failed to ensure controlled substances were destroyed properly with required documentation and witness signatures for multiple residents.
The facility failed to ensure follow-up action was taken on pharmacy medication review recommendations for a resident.
The facility failed to ensure licensed health professional support was completed within 30 days of residents developing a need for new tasks including thrombo-embolic deterrent hose.
The facility failed to ensure medication carts were locked when not under direct supervision of medication aides.
The facility failed to ensure discontinued medications were disposed of or returned to the pharmacy within 90 days for residents, including inhalers and diabetes medications.
The facility failed to ensure controlled substances were destroyed at the facility with required witness signatures and documentation.
The facility failed to ensure medication administration was properly recorded by staff immediately following administration and observation of the resident taking the medication, prohibiting pre-charting.
Report Facts
Residents present: 57
Total licensed capacity: 86
Medication doses not administered: 10
Medication doses administered incorrectly: 44
Medication doses administered when should be held: 20
Medication doses wasted: 43
Medication doses wasted: 27
Medication doses wasted: 6
Medication doses wasted: 43
Medication doses wasted: 14
Medication doses wasted: 26
Medication doses wasted: 43
Medication doses wasted: 14
Medication doses wasted: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator | Responsible for updating care plans, medication cart audits, notifying PCPs, and overseeing medication administration. |
| Special Care Unit Coordinator | Special Care Unit Coordinator | Responsible for care plans, medication orders, and resident supervision in Special Care Unit. |
| Administrator | Administrator | Facility administrator responsible for oversight of care, medication administration, and compliance. |
| Medication Aide | Medication Aide | Administers medications, responsible for medication cart security and reporting discontinued medications. |
| Personal Care Aide | Personal Care Aide | Provides personal care and assistance to residents, including toileting and feeding. |
| Dietary Manager | Dietary Manager | Responsible for meal service and dietary staff. |
| Pharmacist | Pharmacist | Contracted pharmacy representative responsible for medication dispensing and order entry. |
| Resident | Multiple residents interviewed regarding care, call bell system, and meal service. |
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: Jul 14, 2025
Visit Reason
The Adult Care Licensure Section conducted a complaint investigation from 07/08/25 to 07/11/25 and 07/14/25 regarding multiple concerns including housekeeping, call bell system functionality, resident assessments, medication administration, infection control, and COVID-19 outbreak management.
Complaint Details
Complaint investigation conducted due to concerns about housekeeping, call bell system, resident care, medication administration, infection control, and COVID-19 outbreak management.
Findings
The facility failed to maintain clean floors in hallways, common areas, and residents' rooms; the call bell system in the Assisted Living was non-functional for months causing residents to rely on whistles or other devices; Resident #4 had a worsening pressure wound that was not properly managed leading to hospitalization and death; medication administration errors were found including missed doses and improper documentation; expired and discontinued medications were not properly disposed; controlled substance counts were inaccurate; and COVID-19 infection control measures were not properly implemented during an outbreak.
Deficiencies (13)
Facility failed to ensure floors were kept clean in hallways, common areas, and residents' rooms in Assisted Living and Special Care Unit.
Electrical call bell system in Assisted Living was not maintained in operating condition for months, residents lacked proper means to summon staff, and call bell system was not repaired timely.
Failed to ensure an assessment and care plan was updated within 10 days following a significant change in condition for Resident #4 who became non-ambulatory and required extensive assistance.
Failed to ensure health care referral and follow-up for Resident #4 with worsening pressure wound leading to hospitalization and death; and Resident #3 with significant weight loss without proper notification to physician.
Failed to ensure physicians' orders were implemented for Resident #5 related to blood sugar checks, medication administration errors for multiple medications, and failure to administer medications as ordered.
Failed to ensure medications prepared for administration in advance were kept in sealed containers labeled with resident's name and protected from contamination for 5 residents.
Medication aide picked up pills with bare hands prior to administration, contaminating medication and not discarding contaminated pills.
Failed to ensure expired and discontinued medications were disposed of or returned to pharmacy within 90 days for Resident #1.
Failed to ensure a readily retrievable record accurately reconciled receipt, administration, and disposition of controlled medication for Resident #5.
Failed to ensure implementation of infection prevention and control policies during COVID-19 outbreak; residents with COVID-19 were not confined to rooms and mingled with others.
Failed to ensure medication administration record (eMAR) was accurate for Resident #9 related to donepezil medication scheduled for evening but packed in morning multi-dose pack.
Failed to ensure medication administration record (eMAR) was signed immediately after medication administration for Residents #12 and #22.
Failed to ensure feeding assistance was provided for residents in Special Care Unit; staff did not open milk cartons for residents and did not provide feeding assistance for Resident #7.
Report Facts
Medication error rate: 6.4
Residents with COVID-19: 5
Residents in dining room: 36
Residents at dining table: 4
Residents with unopened milk cartons: 12
Residents with unopened milk cartons: 12
Medication administration opportunities: 31
Medication administration errors: 2
Polyethylene glycol administration opportunities: 31
Polyethylene glycol administration opportunities: 28
Polyethylene glycol administration opportunities: 8
Acetaminophen administration opportunities: 15
Hydrocodone-acetaminophen administration opportunities: 8
Hydrocodone-acetaminophen administration opportunities: 17
Hydrocodone-acetaminophen tablets remaining: 13
Medication administration opportunities: 31
Medication administration opportunities: 31
Medication administration opportunities: 31
Medication administration opportunities: 31
Medication administration opportunities: 31
Medication administration opportunities: 31
Medication administration opportunities: 31
Medication administration opportunities: 31
Medication administration opportunities: 31
Medication administration opportunities: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Mentioned in relation to multiple findings including call bell system, medication administration, infection control, and COVID-19 outbreak | |
| Resident Care Coordinator (RCC) | Mentioned in relation to updating care plans, medication administration oversight, wound care communication, and controlled substance counts | |
| Special Care Coordinator (SCC) | Mentioned in relation to medication administration oversight, wound care communication, and infection control | |
| Medication Aide (MA) | Mentioned in relation to medication administration errors, contamination, documentation, and controlled substance counts | |
| Personal Care Aide (PCA) | Mentioned in relation to resident care, feeding assistance, and medication administration | |
| Primary Care Provider (PCP) | Mentioned in relation to resident care, medication orders, and wound management | |
| Pharmacist | Mentioned in relation to medication dispensing and order management | |
| Home Health Nurse | Mentioned in relation to wound care and resident education | |
| Maintenance Supervisor | Mentioned in relation to housekeeping and call bell system maintenance | |
| Operations Specialist | Mentioned in relation to call bell system maintenance | |
| Regional Vice President of Operations | Mentioned in relation to call bell system maintenance | |
| Kitchen Manager | Mentioned in relation to dining room floor cleaning | |
| Dietary Aide | Mentioned in relation to dining room floor cleaning and meal service |
Inspection Report
Original Licensing
Census: 41
Deficiencies: 1
Date: Dec 18, 2024
Visit Reason
The Adult Care Licensure Section conducted an initial survey of the facility on 12/18/2024 to assess compliance with nutrition and food service regulations.
Findings
The facility failed to ensure that 8 ounces of milk or equivalent dairy products were served three times daily to residents in the Assisted Living and Special Care Unit. Observations, record reviews, and interviews confirmed milk was not served at breakfast, lunch, or dinner on 12/17/24 and 12/18/24, despite milk being ordered and available.
Deficiencies (1)
Failed to ensure that 8 ounces of milk or other equivalent dairy products were served three times daily to residents in the Assisted Living and Special Care Unit.
Report Facts
Residents present: 41
Milk gallons ordered: 4
Residents observed at breakfast AL: 21
Residents observed at breakfast SCU: 14
Residents observed at lunch SCU: 14
Unopened gallons of milk: 2
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