Health inspection·July 23, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Residents Affected - Few Findings include: Review of facility policy Pennsylvania Abuse, Neglect and Misappropriation undated, indicated neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnosis of fracture of unspecified part of neck of left femur, acute kidney failure, postlaminectomy syndrome; difficult in walking, need assistance with personal care, neuromuscular dysfunctional of bladder, urinary tract infection. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated July 21, 2024, indicated has a Brief interview for mental status (BIMS) indicated a score of 15 - cognition intact. On July 23, 2024, at 9:15 a.m. interview with Resident R1 reveal that on June 15, 2024, the medications Keppra (seizure medication) and Depakote were given which did not belong to Resident R1. A review of the progress note dated June 15, 2024 stated by licensed nurse, Employee E9 medication error noted. Resident received 100 mg of Keppra meant for another resident. Resident being monitored Q (every) shif x 48 H (hours), BP (blood pressure) 128/68 HR (heart rate) 66 T (temperature) 97.5. All parties notified. A further review of the clinical record did not indicate that the medication Depakote was given to Resident R1. On July 23, 2024, at approximately 11:30 a.m. an interview with the Assistant Director of Nursing, Employee E2 confirmed that there was no investigation conducted. On July 23, 2024, at 12:17 p.m. an interview with the Nursing Home Administrator, Employee E1 confirmed that the facility failed to conduct a thorough investigation regarding the medication error. 28 Pa Code: 201.18 (e)(1)(2) Management Page 1 of 5 395258 395258 07/23/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0610 28 Pa Code: 201.29 (a )(c)(d) Resident Rights Level of Harm - Minimal harm or potential for actual harm 28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services Residents Affected - Few 395258 Page 2 of 5 395258 07/23/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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) Residents Affected - Few Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis of fracture of unspecified part of neck of left femur, acute kidney failure, postlaminectomy syndrome (chronic pain following back surgery); difficult in walking, need assistance with personal care, neuromuscular dysfunctional of bladder, urinary tract infection. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated July 21, 2024, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact. Continued review Resident R1's clinical record revealed that the resident developed a right heel suspected deep tissue injury on January 31, 2024. Review of wound tracking documentation dated July 17, 2024, revealed that resident's right heel wound was assessed at Stage 4 pressure ulcer (ulcer involving loss of skin layers, exposing muscle). Review of hospital records dated April 2, 2024, indicated that Resident R1 was prescribed a Rom Knee Brace. Further review of discharge hospital record dated July 17, 2024 indicated to schedule a cardiologist appointment with in two weeks. On July 23, 2024, at 9:23 an interview with the license nurse, Employee E3 confirmed that Resident R 1 did have a Rom Knee Brace in place. On July 23, 2024, at 4:15 p.m. an interview with the Assistant Director of Nursing, Employee E2 and Administrator, Employee E1 confirmed that Resident R1 should have had the physician orders per the nurse practitioner's recommendation and per the hospital record for the Rom Knee Brace and there should have been a cardiologist appointment scheduled. 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(1) Nursing services 395258 Page 3 of 5 395258 07/23/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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) Residents Affected - Few Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis of fracture of unspecified part of neck of left femur, acute kidney failure, postlaminectomy syndrome (condition characterized by chronic pain following back surgery); difficult in walking, need assistance with personal care, neuromuscular dysfunctional of bladder, urinary tract infection. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated July 21, 2024, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact. Continued review Resident R1's clinical record revealed that the resident developed a right heel suspected deep tissue injury on January 31, 2024. Review of wound tracking documentation dated July 17, 2024, revealed that right heel wound was assessed at a Stage 4 pressure ulcer (ulcer involving loss of skin layers, exposing muscle). Review of the progress note of the License Nurse Practitioner, Employee E10 on May 1, 2024, revealed a recommendation to Float heels while in bed with use of heel boots. On July 23, 2024, at 9:15 a.m. interview with Resident R1 while resident was in bed revealed no heel boots in place. Resident R1 reported that his physician permitted either a pillows around his right ankle or a boot heel. Resident R1 prefers pillows and there were no pillows around the right heel. On July 23, 2024, at 9:23 an interview with the License nurse, Employee E3 confirmed that Resident R1's heels were not floated in bed with pillows or the use of a heel boots. Continued review of Resident R1's clinical record revealed a Skin assessment dated [DATE] revealed that the resident was identified with a skin tear on the left thigh . Review of physician order dated May 23, 2023 revealed an order to clean skin alteration to left posterior thigh with ns (normal saline solution), apply Santyl and cover with bordered gauze daily and pm every evening shift. Review of wound tracking documentation dated July 17, 2024, indicated the skin tear developed into a unstageable pressure ulcer. The Resident's July 2024 Treatment Administration Record was reviewed on July 23, 2024 at 4:30 p.m. with Licensed nurse, Employee E11. On July 4, July 9, July 12, July 13, 2024 it was coded 9- see nursing note related to the administration of the treatment to the left thigh pressure ulcer. 395258 Page 4 of 5 395258 07/23/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0686 Review of nursing notes for the dates noted above revealed no note related to the treatment administration. Level of Harm - Minimal harm or potential for actual harm In an interview on July 23, 2024, at 4:35 p.m. with Assistant Director of Nursing, Employee E2 and Administrator, Employee E1 confirmed that the wound care had not been completed on July 4, July 9, July 12, July 13, 2024, as per the physician order. Residents Affected - Few 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(1) Nursing services 395258 Page 5 of 5