Health inspection·October 30, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of facility documentation revealed 12 interviews were completed by the facility. Two interviews indicated that Resident R1 was last observed in bed at approximately 11:10 p.m. All staff statements stated that no alarm sound was heard throughout the facility when Resident R1 eloped. Interview with Nurse Aide, Employee 4, on October 30, 2024, at 11:25 a.m. revealed no alarm sound was heard on October 12, 2024, when Resident R1 eloped from the facility and staff was unaware until notified by police. Review of facility documentation from September 23, 2024 through October 25, 2024 revealed doors, locks, and alarms were checked throughout the facility by an outside company Monday through Friday to ensure functionality. All dates reviewed revealed all doors, locks, and alarms passed inspection. Further review revealed doors, locks, and alarms were not tested by the outside company on October 12, 2024. Interview with Director of Nursing, Employee E2, and Assistant Director of Nursing, Employee 3, on October 30, 2024 at 10:20 a.m. stated that doors are checked every shift by supervisors and no issues were noted with all doors on October 12, 2024. Both employees confirmed that both doors Resident R1 exited through were working properly after Resident R1 eloped. Further interview with Director of Nursing, Employee E2, and Assistant Director of Nursing, Employee 3, revealed when the alarmed door is pushed on for 15 seconds the door opens and an alarm sounds, due to fire safety reasons. Interview conducted with Resident R1 on October 30, 2024, at 12:05 p.m. revealed the first door to the kitchen was unlocked and Resident R1 was able to push on the door and walk to the alarmed door. Resident R1 stated that she held the door for 15 seconds, which opened the door. Resident R1 stated she then walked a few miles and fell multiple times and revealed she did not sustain major injuries, but states her right knee hurts and Tylenol helps with the pain. Review of Resident R1's clinical records revealed Resident R1 had a fall on October 7, 2024 after getting up from bed at night, feeling dizzy causing her to fall. Resident R1 was assessed by physician on October 8, 2024 and was noted to have right knee pain and chronic lower back pain. Further review revealed Resident R1 was assessed by the physician on October 14, 2024. Physician note dated October 14, 2024, at 1:00 p.m. revealed Resident R1 had no physical complaints. Physician note dated October 15, 2024, at 5:27 p.m. revealed Resident R1 requested a brace for right knee pain. Right knee was examined with no issues noted. Physician concluded pain most likely related to arthritic pain on acute injury and Tylenol ordered as needed. Based on the above findings, an Immediate Jeopardy situation was identified to the Nursing Home Administrator, Employee E1, on October 30, 2024 at 1:13 p.m. for failure to ensure that Resident R1 received adequate supervision and safety of the resident's environment. Resident R1was able to exit through two doors that were designed to lock. This failure resulted in Resident R1 eloping from the facility for approximately 4 hours. An immediate action plan was requested from the Nursing Home Administrator, Employee E1 and the Immediate Jeopardy template was provided to the Nursing Home Administrator on October 30, 2024 at 1:22 p.m. On October 30, 2024, at 2:55 p.m. the facility submitted an immediate plan of action that included the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395258 If continuation sheet Page 2 of 5 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 10/30/2024 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few - Incident Response: On October 13, 2024 Resident was assessed by facility registered nurse and found to have no injuries. Resident was placed on 1:1 observation awaiting psychiatric evaluation. Charge nurse completed wandering risk assessment, skin assessment, and pain assessment. The care plan was updated to include elopement risks on October 13, 2024, All facility doors were inspected by maintenance on the same date, and all were found to be in working order. A head count was conducted by nursing staff, confirming all residents were accounted for. All access codes for egress doors were changed on October 13, 2024. - Wandering risk assessment: an order listing report for all residents with Wander Guards was generated and checked for proper placement and function on 10/13/24 by Unit Managers. Care plans were reviewed and elopement book was updated. Resident named in deficient practice was added to the elopement risk list. Full house assessed for elopement risk, no new residents noted. Audit completed by Unit Managers. - Staff Education: All staff present received education on the elopement process, effective rounding, and proper operation of all egress doors on 10/13/2024 from the RN Supervisor. Staff not present received the same training from the Staff Development Coordinator/ designee. New staff will receive education on the elopement process during their orientation by the DON or designee. - Elopement Drills: Elopement drill will be conducted across all shifts, beginning on 10/13/24 and concluding on 10/16/24, overseen by the NHA and maintenance director. - Interdisciplinary Team Meeting: The IDT convened to discuss the resident's high risk for elopement, and the care plan was updated accordingly. - Behavior Monitoring: The DON or designee will monitor the clinical dashboard for any changes in behavior, including exit-seeking. Findings will be reviewed by the IDT, and new interventions will be implemented as needed to prevent future incidents. - Security Enhancements: The lock on the kitchen door was changed to an automatic lock, and the key code for all egress doors was updated. The action plan was reviewed and interviews were conducted with staff to verify the implementation of the action plan. Staff confirmed that in-service education was provided and were able to verbalize the elopement process and the importance of effective rounding. Following verification of the immediate action plan the Immediate Jeopardy was lifted on October 30, 2024 at 3:53 p.m. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395258 If continuation sheet Page 3 of 5 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 10/30/2024 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)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to the elopement of one of six residents reviewed (Residents R1) which resulted in an Immediate Jeopardy situation. Residents Affected - Few Findings include: Review of the job description for the Nursing Home Administrator (NHA) stated that the primary purpose of the NHA's job description is to lead the nursing home facility and is responsible for the overall management and operational oversight of the facility, ensuring that high standards of care are maintained and regulatory requirements are met. This role requires strong leadership, excellent communication skills, and a commitment to providing outstanding care to our residents. Review of the job description for the Director of Nursing (DON) stated that the primary purpose of the Director of Nursing's job description is to oversee nursing services, ensure compliance with regulations, and foster a supportive and professional environment for nursing staff. The DON will possess strong leadership skills, clinical expertise, and a commitment to patient centered care. Review of Resident R1's clinical record revealed an admission date of July 31, 2024, with a diagnosis of schizoaffective disorder (mental health condition that combines symptoms of psychosis and mood disorders), bipolar disorder (extreme mood swings), intellectual disabilities, and epilepsy (seizures). Review of Resident R1's most recent Minimum Data Set (MDS- assessment of resident care needs) completed October 1, 2024, revealed Resident R1 was assessed with a BIMS (Brief Interview of Mental Status) score of 10, which indicated that the resident had moderate memory impairment. Further review of Resident R1's MDS revealed on section E0800-Wandering- Presence and Frequency, Resident 1 did not exhibit wandering behaviors. Review of facility documentation revealed on October 12, 2024, Resident R1 left the facility at approximately 11:30 p.m. and walk approximately 4.2 miles, where Resident R1 stopped at a convenience store and asked a [NAME] to call police. Police arrive and Resident R1 requested to be returned to the facility. Resident R1 arrived back to the facility at 3:30 a.m. Resident R1 refused to go to emergency room for evaluation. Resident 1 was placed on 1:1 until psych cleared. Interview conducted with Resident R1 on October 30, 2024, at 12:05 p.m. revealed the first door to the kitchen was unlocked and Resident R1 was able to push on the door and walk to the alarmed door. Resident R1 stated that she held the door for 15 seconds, which opened the door. Resident R1 stated she then walked a few miles and fell multiple times. Review of facility documentation revealed 12 interviews were completed by the facility. Two interviews indicated that Resident R1 was last observed in bed at approximately 11:10 p.m. All staff statements stated that no alarm sound was heard throughout the facility when Resident R1 eloped. Interview with Nurse Aide, Employee 4, on October 30, 2024, at 11:25 a.m. revealed no alarm sound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395258 If continuation sheet Page 4 of 5 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 10/30/2024 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)

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was heard on October 12, 2024, when Resident R1 eloped from the facility and staff was unaware until notified by police. Based on the deficiencies identified in this report, the Nursing Home Administrator and Director of Nursing failed to fulfill essential duties and responsibilities of their position, contributing to the Immediate Jeopardy situation. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.12(c)(d)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395258 If continuation sheet Page 5 of 5