Bristol Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Bristol Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF656Sep 26, 2024

  Based 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 ([DATE]; [DATE]; [DATE] and [DATE]) 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). […]

• Immediate jeopardy, patternF689Sep 26, 2024

  Based 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 ([DATE]; [DATE]; [DATE] and [DATE]) 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) Findings include: Review of facility policies and standard procedures on Individual Service Plan Overview with an effective date of [DATE], reveal that under Definitions: For the purpose of this policy, that individual service plan is the written… […]

• Immediate jeopardy, isolatedF689Oct 30, 2024

  Based 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) Findings include: Facility policy titled Elopement Prevention and Management Overview (undated) indicated that the interdisciplinary team plans the least restrictive interventions to promote mobility and safety and to meet the individualized needs and goals of the resident. […]

• Actual harm, isolatedF600Jul 18, 2025

  Based 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. Findings include: Review of an undated facility policy, Skin Care and Wound Management Overview revealed: The facility staff strives to prevent resident skin impairment and to promote the healing of existing wounds. […]

• Actual harm, isolatedF686Mar 30, 2025

  Based 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. Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address… […]