Bristol Health & Rehab Center

Inspectors wroteBased on review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan related to hearing loss for one of eight residents reviewed (Resident R1).

Inspectors wroteBased on a review of clinical records, facility policies, observations and staff interviews, it was determined the facility failed to ensure one of seven residents reviewed (Resident R1) was free from neglect by not timely identifying, assessing, and providing treatment to Resident R1's right lower extremity wound. This failure resulted in actual harm to Resident R1, who developed a new and worsening wound on the right lower extremity, requiring transfer to the hospital and a right leg wound infection. This deficiency is identified as past non-compliance.

Inspectors wroteBased on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to preventing cross-contamination for one of eight residents reviewed (R3).

Inspectors wroteBased on the review of clinical records, facility policies, professional standards of practice, observations and staff interviews, it was determined that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the development of a pressure ulcer resulting in actual harm to Resident R1 who developed Stage II pressure ulcer to the right heel for one of 14 residents reviewed.

Inspectors wroteBased on, review of facility policies and procedures, observations and interviews with staff, it was determined that the facility failed to ensure treatment and services were provided to the resident to prevent development of wounds met the professional standards of practice for 4 of 14 residents reviewed. (Resident R1, R2, R4 and R5).

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to implement interventions to maintain acceptable parameters of nutrition for two of 14 residents reviewed (Residents R6 and R7).

Inspectors wroteBased on the review of clinical records, facility policies, facility documentation, interview with staff, it was determined that the facility failed to follow acceptable standard of practice for medical record documentation for one of 14 residents reviewed. (Resident R6) Findings Include: Review of undated facility policy entitled, Height and Weight, revealed that Nurses will follow the basic standards of practice for documentation including but not limited to providing a timely and accurate account of resident information in the medical record, documenting legibly in English using only acceptable medical abbreviations. Timeliness and accuracy. a. Chart in real time when an event is occurring or shortly thereafter as is practicable. b. avoid over use of late entries. Late entries may be confusing and contradictory and only use sparingly. [...]

Inspectors wroteBased on review of clinical records, observations, review of facility policies and procedures and interviews with staff, it was determined that the facility failed to promptly notify resident's physician and representative of a change in skin condition of for one of 14 residents reviewed (Resident R2).

Inspectors wroteBased on review of clinical records, observations, review of facility policies and procedures and interviews with staff, it was determined that the facility failed to ensure treatment and services were provided to the resident with bilateral lower extremity venous ulcer as recommended by the physician for one of 14 residents reviewed. (Resident R3) Findings Include: Review of wound care practitioners' recommendation dated March 19, 2025, revealed a recommendation to apply tubi-grip to lower extremity daily during the day and off at night. Review of wound care practitioners' recommendation dated March 26, 2025, revealed a recommendation to apply tubi-grip to lower extremity daily during the day and off at night. Observation of Resident R3 on March 30, 2025, at 11:00 a.m., with Employee E4, Licensed Practical Nurse Supervisor, revealed that the resident was sitting in her wheelchair. [...]

Inspectors wroteBased on the review of clinical records, facility documentation, interview with staff, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with PICC line ( a tube placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests quickly) for two of two employee records reviewed. (Employee E7 and E8). Findings Include: Observation of Resident R8 on March 26, 2025, at 11:00 a.m., revealed that the resident had a left upper extremity PICC line insertion. There was no documentation on the dressing to indicate the date and time the dressing last changed. Review Resident R8's active physician order on March 26, 2025, revealed an order to measure external catheter length with dressing change. [...]

Inspectors wroteBased on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to the wound treatment and enhanced barrier precaution for 4 of 14 residents reviewed. (Resident R1, R6, R9 and R11)

Inspectors wroteBased on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to serve foods that accommodate residents' allergies for one of 5 reviewed reviewed (Residents R1).

Inspectors wroteBased on review of clinical records, facility policies, and interview with resident and staff, it was determined that the facility failed to provide adequate supervision for one of six residents reviewed (Resident R1) who exited through two doors that were designed to lock and one to alarm. This failure resulted in Resident R1 eloping from the facility for approximately 4 hours and placed Resident R1 at high risk for injury that resulted in an Immediate Jeopardy situation. (Resident R1)

Inspectors wroteBased on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to the elopement of one of six residents reviewed (Residents R1) which resulted in an Immediate Jeopardy situation.

Inspectors wroteBased on the review of clinical record, interview with resident and staff, it was determined that the facility failed to ensure that each resident receive the medications that were ordered for by their physician and do not be administer medications ordered for another resident for 1 of 4 residents reviewed. (Resident R 1) Findings Include: Review of facility policy Administering Medication states that observe the five right in giving each medication, the right resident, the right time, the right medication, the right dose and the right route. Review Physician Orders policy states medication administration record/ treatment administration record the legal medical record for recording medication and treatment. Review of Resident's R1 clinical record, revealed the diagnosis of dementia (progressive degenerative disease of the brain) without behaviors and high blood pressure. [...]

Inspectors wroteBased on the review of clinical records, facility policies and interview with staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for Resident R135, with a documented history of substance abuse, to prevent relapse and access to illegal substances. This failure resulted in Resident R135, accessing and using illegal substance and experiencing four incidents (December 3, 2023; December 5, 2023; March 17, 2024 and July 23, 2024) of drug overdose which required immediate medical treatment/emergency medical intervention and resulted in an Immediate Jeopardy situation for one of four residents reviewed (Resident R135).

Inspectors wroteBased on the review of clinical records, facility policies and interview with staff, it was determined that the facility failed to provide supervision for Resident R135 with documented history of substance abuse. This failure resulted in Resident R135 accessing and using illegal substance which resulted in four incidents (December 3, 2023; December 5, 2023; March 17, 2024 and July 23, 2024) of drug overdose which required immediate medical treatment / emergency medical management and resulted in an Immediate Jeopardy situation for one of four residents reviewed (Resident R135)

Inspectors wroteBased on observations, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that meals were served timely on two of three nursing units observed (First floor and Second floor nursing units).

Inspectors wroteBased on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to infection surveillance for two of two residents reviewed with infections (Residents R154 and R33), infection data reporting, enhanced barrier precautions and infection committee meetings, and Enhanced Barrier Precaution for one of one resident reviewed (Resident R165).

Inspectors wroteBased on observations, review of facility's policies, interview with staff and resident, it was determined that the facility did not ensure that residents were treated with dignity and respect for 1 of 35 residents reviewed (Resident R62)

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address a resident's dementia care needs for one of 35 residents reviewed (Residents R 141). Findings Include: Review of the admission sheet of Resident 141, revealed that Resident R141 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for two of six residents observed during medication administration (Resident R33, and R89).

Inspectors wroteBased on observations, interviews, and clinical record reviews, it was determined that the facility failed to correctly administer medications in accordance with physician orders, for one of six residents' medication administration observed, and one of 32 resident records reviewed resulting in significant medication error ( Resident R159).

Inspectors wroteBased on review of facility documentation, observations and resident and staff interviews it was determined that the facility failed to ensure residents were provided meals that honor food preferences for one of three nursing units. First floor).

Inspectors wroteBased on observations, interviews with staff, and review of facility policy, it was determined that the facility did not ensure that food was stores, prepared, distributed, and served in accordance with professional standards for food service safety related to labeling and dating of refrigerated food items and the use of hair nets.

Inspectors wroteBased on review of facility policies, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that the QAA (Quality Assessment and Assurance) committee meets at least quarterly to coordinate and evaluate activities under the QAPI (Quality Assurance and Performance Improvement) program as required.

Inspectors wroteBased on review of facility policies, review of facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain an effective antibiotic stewardship program for two of two of residents reviewed for antibiotics (Residents R154 and R33).

Inspectors wroteBased on review of facility policies and interviews with staff, it was determined that the facility failed to designate one or more individuals as the infection preventionist who work at least part time at the facility.

Inspectors wroteBased on observation and interviews with staff, it was determined that the facility failed to equip corridors with safe handrails on each side, for two of three nursing units observed (First and Second floor nursing units).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of a misappropriation of medication to rule out neglect for one of 3 residents (Resident R1).

Inspectors wroteBased on reviewof clinical record, review of facility documentation and interview with staff, it was determined that the facility failed to ensure that hospital recommendation were address for one of three clinical records reviewed. (Resident R1)

Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to provide treatment and interventions to promote the healing of pressure ulcers for one of three sampled residents with pressure ulcers. (Resident 1)

Inspectors wroteBased on observations, resident and staff interview, and a review of facility documentation, it was determined that the facility was not maintaining an effective pest control program.

Inspectors wroteBased on review of facility policy, observations, and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Inspectors wroteReview of facility documentation and interview with residents, it was determined that the facility failed to ensure that residents preferences were honored on two of two floors. (2nd floor)

Inspectors wroteBased on observations, it was determined that the facility failed to ensure a clean, homelike environment for two of two nursing floors of 32 residents reviewed. (Rooms 105, 120, 128, 131 and 211)

Inspectors wroteBased on review of facility policy, observations, and interviews with residents and staff, it was determined that the facility failed to ensure a formal grievance process was in place for one of 32 residents reviewed (Resident R108). Findings Include: Review of facility policy titled Resident Grievances with a review date of May 5, 2019 states, The facility will make available to all residents posting in a prominent location in the facility information of the right to file grievances orally or in writing; the right to file grievances anonymously; contact information for the Grievance Official; a reasonable timeframe for completing the review of the grievance, the right to obtain a written decision regarding the grievance; and contact information for independent entities with whom grievances may be filed. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to update care plans to meet care needs for three of 32 residents reviewed (R90, R127, R135) Findings Include: Review of the care plan policy titled Plan of Care Review undated reads, It is the policy of this facility to provide resident centered care that meets psychological, physical and emotional needs and concerns of residents. Safety is a primary concern for our residents, staff and visitors. [...]

Inspectors wroteBased on observation, review of clinical record, review of facilty policy and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and services for two of two residents reviewed (Residents R65 and Resident R28).

Inspectors wroteBased on the review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with tracheostomy (a surgical airway management procedure which consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea) and PICC and Midline line ( a tube placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests quickly) dressing changes for 20 of 20 staff reviewed (Employee 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49 and 50)

Inspectors wroteBased on observations, review of facility documentation, and interview with staff and resident, it was determined that facility failed to utilize and implement non-pharmacological approaches to care in accordance with the resident's abilities, customary daily routine, interests, preferences, and choices on one of 32 residents reviewed. (Resident R7)

Inspectors wroteBased on review of facility policy, interviews with residents and staff, and review of resident documentation, it was determined that the facility failed to routinely offer evening snacks to residents. Findings Include: Review of facility policy titled Snacks with a revision date of September 2017 states, Snacks and beverages will be provided as identified in the individual plans of care. Bedtime (a.k.a HS) snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times. Further review of the policy states, 3. Snacks will be assembled, labeled, and dated in accordance with the individual plan of care for each resident and those items will be delivered to patient care areas in a timely manner. Interview with Resident R21 on December 4, 2023 at 10:34 a.m. [...]

Inspectors wroteBased on review of facility policy, interviews with staff, and review of clinical records, it was determined that the facility failed to ensure that neurological checks were documented one of 32 residents reviewed. (Resident R144).

Inspectors wroteBased on review of clinical records, facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure that the physician ordered hospice care was provided for one of 32 residents reviewed. (R105).

Inspectors wroteBased on review of facility policies, review of clinical records and interview with residents and staff, it was determined that the facility failed to ensure that medical consultations with specialists were scheduled for one of nine residents reviewed. (Resident R1)

Inspectors wroteBased on the review of facility policies, review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner, in writing and in a language and manner they understood after a selected resident was transferred to the hospital for one of two residents reviewed. (Resident R3) Findings Include: Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R2 dated May 16, 2023, revealed that the resident had a BIMS score of 3 which indicated that the cognitive status was severely impaired. Review of nursing note for Resident R3 dated May 22, 2023, revealed that the resident was observed with increased lethargy, abnormal labs, and hyperglycemia (increased blood sugar). [...]

Inspectors wroteBased on a review of clinical records, facility documentation and staff interview, it was determined that the facility failed to develop, re-evaluate and implement an individualized discharge plan for two of four residents reviewed (Resident R1 and R2). Findings Include: Review of facility care plan Discharge Planning dated July 7, 2020, revealed, A process that generally begins on admission and involves identifying each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge. Procedure: 1) The discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and 2) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. [...]

Inspectors wroteBased on observations of the physical environment, reviews of the pest control operator's reports, and interviews with residents, staff, and family member, it was determined that the facility failed to maintain an effective pest control program to ensure that the facility was free of pests for two nursing units (First floor and Second floor)

Inspectors wroteBased on observation, clinical record review and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed related to an indwelling urinary catheter and that a care plan was implemented related to nutrition for two of the 34 residents reviewed (Residents R267 and Resident R7).

Inspectors wroteBased on observations, reviews of resident clinical records, facility policies and procedures, and interviews with staff and residents, it was determined that the facility failed to follow physician orders related to an indwelling urinary cather for one of 34 residents reviewed. (Resident R27)

Inspectors wroteBased on observation, clinical record review and staff interview, it was determined that the facility failed to to administered intravenous therapy in accordance with professional standards of practice for one of one resident receiving intravenous therapy. (Resident R216)

Inspectors wroteBased on clinical record review, observation and staff interview, it was determined that the facility failed to to follow physican orders related to the tracheostomy care for one of one resident review with a tracheostomy. (Resident R30)

Inspectors wroteBased on observations of the Food and Nutrition Services, reviews of policies and procedures, food committee meeting minutes, and interviews with residents, it was determined that the facility failed to ensure that each resident received foods and beverages that were at appetizing temperatures.