Pines at Bristol for Nursing & Rehabilitation, The

In the surveyor’s words

From the most serious findings on record at Pines at Bristol for Nursing & Rehabilitation, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF658Aug 20, 2021

  Based on review of the clinical record, facility documentation, facility policy and staff interviews for one (1) of five (5) residents reviewed for hospitalization (Resident #1), the facility failed to ensure nursing staff monitored the Resident #1's leg subsequent to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of the lack of assessment and failing to order an INR, the resident was without the benefit of an anticoagulant for two (2) days resulting in a finding of Immediate Jeopardy. During the on-site visit, the Immediate Jeopardy was verified as corrected when the facility implemented an immediate action plan to mitigate further risk to all residents. […]

• Immediate jeopardy, isolatedF684Aug 20, 2021

  Based on review of the clinical record, facility documentation, facility policy and staff interviews for one (1) of five (5) residents reviewed for hospitalization (Resident #1), the facility failed to ensure treatment and care provided met resident care needs as evidenced by lack of ongoing monitoring and assessments of Resident #1's left lower extremity (LLE) after developing a [CONDITION(S)] (DVT) that progressed to no visualized blood flow in the extremity. Additionally, the facility failed to ensure the APRN ordered an International Normalized Ration (INR) blood test to ascertain a baseline level prior to ordering another anticoagulant and failed to communicate Resident #1's DVT treatment plan to the covering provider and facility nursing staff resulting in Resident #1 not receiving… […]

• No harm, potential for more than minimal, patternF580Mar 26, 2025

  Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 5 residents (Resident #59, 63, 72, 121, and 346), reviewed as part of the sufficient competent nurse staffing review, the facility failed to ensure that the physician and resident representatives were immediately notified when medication omissions/errors were identified. The findings include: 1. Resident #59 was admitted to the facility in September 2023 with diagnoses that included psychiatric disorder with delusions, dementia, and chronic obstructive pulmonary disease The care plan dated 8/23/24 identified Resident #59 required psychotropic medications. Interventions included to administer medications as ordered. […]

• No harm, potential for more than minimal, patternF684Mar 26, 2025

  Based on review of the clinical record, facility documentation, facility policy, and interviews for 7 residents (Resident #59, 63, 68, 72, 85, 121 and 346), the facility failed to provide care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. For 1 of 2 residents (Resident #59) reviewed for edema, the facility failed to follow the physician's order for compression stockings. For 2 of 2 residents (Resident #68 and 85) reviewed for edema, the facility failed to ensure the staff monitored the intake and output for a resident on a fluid restriction. […]

• No harm, potential for more than minimal, patternF726Mar 26, 2025

  Based on observation, review of the clinical record review, facility documentation, facility policy, and interviews, the facility failed to ensure all facility nursing staff were educated on the identifying mechanism for enhanced barrier precautions (EBP). The findings include: Observations on 3/23/25 at 11:37 AM of the 1st floor Passport unit identified multiple bright pink circular stickers placed on several exterior name plates for residents on the unit. No other information identifying what the pink stickers were for was observed. […]