The Bristol Care Center

Inspectors wroteBased on record review and interviews, the facility failed to provide supervision to prevent an elopement for a resident with a known history of wandering for one resident (#1) of two residents sampled. On 4/19/26 at approximately 10:30 a.m., Resident #1 left the facility unsupervised and was missing for 10 hours.

Inspectors wroteBased on record review and interview, the facility failed to provide evidence of a notification to the resident or responsible party of the patient trust account having reached $200 less than the SSI (Supplemental Security Income) resource limit of $2,000.00 for one (#2) of four residents reviewed for patient trust monies out of a total sample of ten residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement the grievance process for one (#8) of four residents reviewed. Resident #8 had been requesting assistance to obtain her Personal Need Allowance check of $130 from the Department of Children and Families (DCF) since 12/11/2024.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure resident rooms, common areas, equipment and furnishings were maintained in a clean, safe and sanitary manner in four units (Northeast, Southwest, Southeast and Central) out of five units during four days (6/23/25, 6/24/25, 6/25/25, and 6/26/25) out of four days observed.

Inspectors wrote4. A review of Resident #50's admission record revealed an initial admission date of 01/29/2025with diagnoses included but not limited to fibromyalgia, muscle weakness, emphysema, acute myocardium Infarction, pulmonary hypertension, Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure with hypercapnia, asthma, chronic bronchitis, generalized anxiety disorder, opioid dependence, major depressive disorder recurrent, hypertension. Review of a progress note for Resident #50 dated 06/19/2025, showed MD (Medical Doctor) note, marked [late entry] scanned in on 06/25/25, reason for appointment . A second progress note dated 06/12/2025, MD note, marked [ate entry], scanned in on 6/25/25, showed, Reason for Appointment . During an interview on 06/26/2025 at 9:18 a.m. [...]

Inspectors wrote3. An observation on 06/23/2025 at 1:07 p.m. revealed Resident #55 was lying in his bed on the right side in his room. Both the door and the curtain were open. The sheet was not covering his backside, and his buttocks were exposed to the hallway. The APRN (Advanced Practice Registered Nurse) and Staff A, Licensed Practical Nurse (LPN) the wound care nurse were observed providing wound care to the resident. Resident #55's bottom was able to be observed from the room across the hall, as well as by anyone walking down the hallway. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to provide language assistance to a resident with limited English proficiency for one resident (#210) of 65 sampled residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to accommodate residents needs related to 1.) Not having call light buttons placed within reach when in bed for five residents (#135, #79, #208, #15 and #25) out of sixty-five sampled residents and 2.) Not providing a wheelchair in order for resident (#135) to get up out from bed and out of her room per the resident's preference.

Inspectors wroteBased on interviews and record reviews the facility failed to notify the physician and/or family of changes in condition (CIC) and treatment and care changes for three residents (#50 #18, #5) of 65 sampled residents.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide enteral nutrition according to physician orders for one resident (#79) out of fourteen residents sampled.

Inspectors wroteBased on observations, interviews and record review the facility failed to follow infection control standards related to hand sanitizing during medication administration and use of gloves when cleaning equipment for five residents (#52, #63, #58, #31, and #219) out of sixty-five residents sampled.

Inspectors wroteBased on interviews and record review, the facility failed to ensure patient care equipment to include mechanical lifts were maintained in a safe operating condition for one resident (#142) of 65 sampled.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one resident (#1) out of three residents sampled were assessed immediately by a nurse after being found on the floor by facility staff.

Inspectors wroteBased on interview and record review, the facility failed to provide physician ordered medication for one resident (#1) out of three residents reviewed.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASRRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for five (#228, #145, #163, #25 and #60) of eight residents reviewed for PASRRs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide needed care and services for one resident (#200) of three residents reviewed with an immune deficiency syndrome, one resident (#170) of two residents reviewed for therapy services, and one resident (#60) of two residents reviewed for maintaining routine lab work.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to screen one (#123) resident for orthotic use and failed to apply orthotics for two (#14 and #31) of 23 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the medication error rate was less than five percent. Twenty-nine medication administration opportunities were observed, and four errors were identified for two residents (#135 and #220) out of five residents observed. These errors constituted a 13.79% medication error rate.

Inspectors wroteBased on interviews and record review, the facility failed to obtain consent prior to utilizing funds for one resident (#46) of two reviewed.

Inspectors wroteBased on interviews and record review, the facility failed to act upon a resident's concerns and grievances for one (#102) of four residents reviewed.

Inspectors wroteBased on observations, review of reported incidents, and interviews, the facility failed to ensure a thorough investigation was conducted for one (#188) of four allegations of abuse related to a staff member allegedly slapping the resident.

Inspectors wroteBased on record review and interview, the facility failed to assess a resident within the three months required for one (#196) of three residents reviewed for submission of the quarterly Minimum Data Set (MDS).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to submit one (#188) of forty-one initially sampled residents for a Level II Pre-admission Screening and Resident Review (PASRR).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure two dependent residents (#123 and #283) of four sampled for Activities of Daily Living received showers per plan of care and choice.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure urinary drainage bags and tubing for two (#91 and #18) of 16 residents with urinary catheters were stored in a manner to prevent infections.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a physician order was available prior to providing oxygen administration for one resident (#150) of three residents reviewed for oxygen administration.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to prevent accidents and hazards related to smoking safety precautions, for 14 residents (#114, #96, #102, #198, #131, #188, #324, #162, #184, #191, #113, #57, #68, and #61) out of 14 residents sampled for smoking safety out of a 44 residents on the facility residents who smoke list. The facility failed to ensure the safety of all 229 residents in the facility as a result of the failure. On 9/22/23 at 5:11 p.m. Resident #61 was found smoking (alleged) marijuana in an unauthorized smoking area by the Nursing Home Administrator. On 10/21/23 at 4:03 a.m. the facility's fire alarm was triggered when Resident #102, while smoking in her room unsupervised, caused her mattress, privacy curtain, and oxygen concentrator to catch on fire. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process to investigate, develop, and implement an effective Performance Improvement Plan (PIP) to prevent continued accidents and hazards related to smoking safety precautions, for 14 residents (#114, #96, #102, #198, #131, #188, #324, #162, #184, #191, #113, #57, #68, and #61) out of 14 residents sampled for smoking safety out of 44 residents on the facility residents who smoke list. The facility failed to ensure the safety of all 229 residents in the facility as a result of the failure. On 9/22/23 at 5:11 p.m. Resident #61 was found smoking (alleged) marijuana in an unauthorized smoking area by the Nursing Home Administrator. On 10/21/23 at 4:03 a.m. [...]

Inspectors wroteBased on observations, record review, and interview, the facility failed to develop and implement an effective policy and procedure to address smoking safety and fire hazards for 14 residents (#114, #96, #102, #198, #131, #188, #324, #162, #184, #191, #113, #57, #68, and #61) out of 14 residents sampled for smoking safety out of 44 residents on the facility residents who smoke list. On 9/22/23 at 5:11 p.m. Resident #61 was found by the Nursing Home Administrator smoking (alleged) marijuana in an unauthorized smoking area of the facility. On 10/21/23 at 4:03 a.m. Resident #102, who was on oxygen, was permitted to keep smoking materials at the bedside and as a result Resident #102 was harmed when she smoked in bed on 10/21/23 and started a fire inside the facility. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to protect the resident's right to be free from abuse by not ensuring one resident (#30) out of two residents reviewed was free from restraints which caused physical harm (bruising and skin tear).

Inspectors wroteBased on observation, record review and interview the facility failed to ensure all allegations of abuse and injuries of unknown source were reported within the required two hour time frame for two residents (#30 and #137) out of two residents reviewed for reporting allegations of abuse.

Inspectors wroteBased on observations, policy review, and interviews, the facility failed to ensure dishes and utensils were air dried and food trays were in good condition in one of one kitchen.

Inspectors wroteBased on interview and record review, the facility failed to follow-up on concerns, complaints and/or grievances identified during three Resident Council meetings (September 2023, October 2023, and November 2023) of five Resident Council meeting minutes reviewed.

Inspectors wroteBased on interview, record review and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II upon a new qualifying mental health diagnosis and/or ensure the accuracy of a PASRR Level I for eight residents (#27, #48, #68, #92, #140, #154, #188, #200) of 10 sampled residents with mental health diagnoses.

Inspectors wroteReview of admission Record showed Resident #57 was initially admitted to the facility on [DATE] with diagnoses including but not limited to Chronic Embolism and Thrombosis of other specified veins, Difficulty walking, not elsewhere classified, Chronic Obstructive Pulmonary Disease, Insomnia and Parkinson's Disease. A physician order dated 04/07/21 showed, Oxygen 2 L/min per nasal cannula as needed to keep oxygen sats above 92% A second physician order dated 04/14/23 showed May leave on LOA [leave of absence] independently. The Quarterly Minimum Data Set (MDS) showed a brief interview for mental status (BIMS) score of 11 (moderate cognitive impairment). Review of Resident #57's care plan showed a focus of [Resident #57] has a history of smoking in the community and wants to continue smoking while at the facility. Smoking with supervision. [...]

Inspectors wrote7. Review of the admission Record for Resident #48 showed an admission to the facility on 8/29/23 with diagnoses to include unspecified dementia, unspecified severity without behavioral disturbance, major depressive disorder, and unspecified mood (affective) disorder. Review of the Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating severe cognitive impairment and or nonsensical verbal response. Review of Resident #48's active physician orders as of 11/30/23 revealed: - an order with a start date of 8/29/23 for Donepezil HCL 10 milligrams (mg) with the following instructions: Give one tablet by mouth at bedtime for dementia. - an order dated 8/30/23 for Duloxetine HCL delayed release particles 60 mg with the following instructions: Give two tablets by mouth one time a day for depression. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to implement and maintain an infection prevention and control program related to medication administration by four staff members (D, E, G and H) for five residents (#73, #93, #96, #103, #137) of six sampled residents; cleaning and disinfecting of a glucose monitoring machine for one resident (#137) of one sampled resident of six sampled residents; and staff failed to offer hand hygiene to residents before meals in one of one secured unit for three days (11/27/23, 11/28/23 and 11/29/23) of three days observed.

Inspectors wroteBased on record review and interview the facility failed to ensure two residents (#30 and #203) were treated with respect and dignity out of fifty eight residents sampled.

Inspectors wroteBased on observations and interviews the facility failed to ensure housekeeping and maintenance services maintained a safe and sanitary homelike environment related to a one resident's (#149) toilet with a rust like substance and ceilings in disrepair (Southwest Wing) in a resident occupied area in one of five wings.

Inspectors wroteBased on record review and interview the facility failed to ensure a prompt effort was made to resolve a grievance voiced by one resident (#137) out of one resident reviewed for grievances related to care and treatment.

Inspectors wroteBased on record reviews and interviews, the facility failed to develop and implement an effective discharge plan to meet the needs and goals for one resident (#190) out of the sampled four residents.

Inspectors wroteBased on interview and record review the facility failed to ensure the code status accurately reflected the Advance Directive wish for one resident (#219) out of 58 sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the provision of respiratory care was in accordance with professional standards of practice for three residents (#61, #322, and #102) of the three sampled residents receiving oxygen therapy.

Inspectors wroteBased on record reviews and interviews, the facility failed to monitor medication parameters for two residents (#73 and #27) out of the sampled eight residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were stored in a locked medication cart and not left at bedside for one resident (#103) of six sampled residents for medication administration observations.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure professional standards and practices were followed related to accurate documentation on a Medication Administration Record (MAR) for one resident (#137) of 58 sampled residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure hospice services were being provided in accordance with accepted professional standards and principles due to a lack of communication and documentation in the medical record for one resident (#191) of one resident reviewed for hospice.