Health inspection·October 9, 2024

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 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) Residents Affected - Few 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. Reviewed the investigation reported revealed that on October 5, 2024, at 0900 (9:00 a.m.), resident a [AGE] year-old male with Diagnosis of dementia and HTN (hypertension- high blood pressure) and a BIM (Brief Interview of Mental Status)'s score of 7, was administered medications in error. Resident R1 received Ferrous Sulfate 325mg (milligrams), Gabapentin 800 mg, Lipro insulin 2 units and Keppra 750 mg, that were entered into his chart in error. Doctor and RR (responsible party) made aware. Resident R1 placed on enhanced monitoring. Blood sugar 99. Resident's family requested that resident be sent to the ER (emergency room) for evaluation routine change in mental status. Resident R1 sent 911 (Emergency Medical Services) to ER for evaluation and admitted . Facility administration director nursing made aware. Reviewed witness statements from the Registered Nurse, Employee E4 revealed on October 4, 2024, at 6:45 pm, [Resident R2] was transferred to Sliver Lake health care center. I transcribed some of [Resident R2] medication from 3-b under [Resident R1] in room [ROOM NUMBER]-A not re realizing they were different residents with the same last names. On October 5, 2024, at 2:30am, I was informed by supervisor that some of the [Resident R2] meds were transcribe under [Resident R1]. I immediately rushed in the room to assess the resident. Vital includes, 114/70, 58, 97.6, 20, 98 quickly informed manger and [Resident R1] daughter at bed side made aware. 911 called never alone called, [Resident R1] send to . ER Via Ambulance for evaluation. Reviewed witness statements from the licensed practical nurse, Employee E5 revealed on October 5, 2024, I dispensed all AM medications ordered in the facility for [Resident R1]. After I passed (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395258 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)