Health inspection·July 18, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. The interdisciplinary team works with the resident and /or family/responsible party to identify and implement interventions to prevent and treat potential skin integrity issues Each resident is evaluated upon admission and weekly thereafter for changes in skin condition . Skin care and wound management program includes but not limited to: Daily monitoring of existing wounds . Communicate changes to the care giving team .Complete for all skin impairment issues that require measurement to indicate if healing is occurring. Review and select the appropriate treatment for the identified skin impairment. Document treatment in the Electronic Treatment Administration Record .communicate changes to the caregiving team. Review of Resident R1's clinical record revealed, Resident R1 was admitted to the facility on [DATE], with diagnoses including Psoriasis Vulgaris, (chronic autoimmune disease where the immune system mistakenly attacks healthy skin cells leading to the formation of raised, red, scaly patches called plaques on the skin) and Absence of Left Foot. Review of the Comprehensive Minimum Data Set (MDS-periodic assessment of a resident's care needs), dated May 22, 2025, revealed a BIMS (Brief Interview for Mental Status- screening tool aids in detecting cognitive function or impairment) score of 14, which revealed Resident R1 was cognitively intact. Further review of MDS assessment revealed the resident required substantial to maximum assistance with lower body dressing, partial to moderate assistance with personal hygiene, supervision with rolling from left to right and partial to moderate assistance when lying to sitting on the side of the bed. The resident also was assessed at risk of developing pressure ulcers/injuries. Review of Resident R1's care plan, initiated on July 7, 2023, revealed Resident R1 was at risk for skin impairment. Interventions included completion of weekly skin assessments, educate resident on need for turning and repositioning, monitor for any signs/symptoms of infection-bogginess, drainage, erythema and notify physician, and provide appropriate off-loading mattress. Review of Resident R1's physician orders dated February 20, 2025, revealed an order to apply, Clobetasol Propionate Cream 0.05 %, (corticosteroid used to treat skin condition of psoriasis) to lower extremities topically every day and evening shift. Review of Resident R1's physician orders dated March 13, 2025, revealed an order for weekly skin assessment to be completed, every Monday. Review of skin assessment documentation for Resident R1 revealed, no wounds/pressure areas were Page 1 of 5 395258 395258 07/18/2025 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0600 Level of Harm - Actual harm Residents Affected - Few documented on the skin assessments dated April 5, 2025; April 25, 2025; May 2, 2025; May 9, 2025; May 17, 2025; or May 25, 2025. Further review of Resident R1's skin documentation dated April 11, 2025; and April 18, 2025, revealed Resident R1 refused the skin assessment on these dates. Additional review revealed on June 1, 2025, Employee E10, Licensed Practical Nurse answered on the skin assessment; Yes, to the question, are there any skin areas noted; and No to the question, is this area new since the last documented skin check. Review of nursing notes for dates beginning May 2025 through June 2, 2025, failed to reveal documented evidence of wounds and/or open skin areas identified on the resident's lower extremities. Review of Resident R1's May 2025 and June 2025 Medication Administration Record revealed Clobetasol Propionate Cream was administered by Licensed nurse, Employee E11, on May 24, 2025; May 25, May 26, May 27, May 28, and May 29, 2025, and on June 2, 2025, and June 3, 2025. Review of information dated June 3, 2025, and submitted by the facility to the State Survey Agency on June 3, 2025, revealed Resident R1 had wound which was not identified timely, and treatment provided. Further review of the information revealed, The complaint was substantiated and resulted in the termination of the employees who had been suspended pending the outcome of the investigation. An internal investigation was conducted, which included interviews with all care providers involved dating back to May 26, 2025. The investigation concluded, three licensed nurses and one nursing assistant failed to follow established facility policies regarding the reporting, documentation, assessment, and provider notification related to an alteration in a resident's skin integrity. Interview conducted with Nursing Home Administrator (NHA), Employee E1 on July 2, 2025, at 10:03 a.m. revealed during the investigation, it was determined the skin area of Resident R1 in question had not been identified prior to June 2, 2025. Staff reported they did not observe the skin area during routine care. During interview conducted by Nursing Home Administrator with [Nurse aide, Employee E12], on June 5, 2025, staff member revealed to NHA that she observed a closed, red area on resident's right leg on June 1, 2025, and informed the nurse. Continued interview with Nursing Home Administrator revealed, Employee E1 licensed nurse on duty on June 1, 2025, indicated during interview that she was unaware of any skin areas of concern and did not recall being notified. Nursing Home Administrator, Employee E1 added the facility concluded through investigation that neglect was substantiated on June 13, 2025. Review of Licensed nurse, Employee E10's employment record indicated, Employee E10 was terminated from service on June 13, 2025, with reason Employee E10 falsified documentation pertaining to the care of a resident; the falsified record concealed evidence of negligence, which subsequently contributed to the resident suffering harm. Review of Licensed nurse, Employee, E11's personnel file revealed that Licensed nurse, Employee E11 was terminated from service on June 13, 2025, with reason, on June 2, 2025, [Employee E11] failed to provide necessary treatment and failed to ensure that appropriate care was in place for a resident. Review of Certified Registered Nurse Practitioner (CRNP), Employee E7, progress note dated May 29, 2025, indicated, Musculoskeletal: Denies reported redness, swelling change in gait, pain. Skin: Visible skin; Clean, Dry, and Intact (CDI); no redness; swelling or rashes present. Continued review of Certified Nurse Practitioner (CRNP), Employee E7, progress note dated June 3, 2025, indicated, Chief Complaint / Nature of Presenting Problem: Unstageable wound to left foot, History of Present Illness: Resident was seen today for acute visit for unstageable wound to left foot. Resident has history of all toes amputation and impaired circulation. Wound care nurse was made aware of the wound on his medication nurse. Resident also has history of noncompliance with medications. Resident denies pain reports mild discomfort intermittently. Discussed in IDT (Interdisciplinary team) meeting, and with Medical Director; Skin: Dressing CDI to Right foot Wound noted open, with tendons exposed and sloughing. Interview conducted on July 7, 2025, at 9:52 a.m. 395258 Page 2 of 5 395258 07/18/2025 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0600 Level of Harm - Actual harm Residents Affected - Few with Certified Nurse Practitioner (CRNP), Employee E7 revealed, I did not observe the wound of [Resident R1] on June 3, 2025, but wrote the order based on the report given by the Charge Nurse. Review of nursing note dated June 3, 2025, by the Unit Manager, Registered Nurse, Employee E8, revealed she was called to resident room by facility wound nurse, resident in bed, wound on right foot noted, facility CRNP notified, order to send resident to ER (Emergency Room) for eval (evaluation) . Primary Care Provider responded with the following recommendations: send resident to ER for eval. (evaluation). Interview conducted on July 7, 2025, at 10:40 a.m., with Registered nurse, Employee E8 revealed that on June 3, 2025, I just saw the wound of [Resident R1], and called the facility [CRNP, Employee E7], and the CRNP ordered to send the resident to hospital. Review of nursing note completed by the Director of Nursing, E2, dated June 3, 2025, revealed Patient with wound that appears to be worsening, wound Nurse Practitioner (NP) made aware, and gave order to send to ED (Emergency Department) for further evaluation, order transcribed, call placed to ED, report given to Nurse, transport arrangements made, MD/RP aware. Interview conducted on July 2, 2025, at 12:26 p.m., with Wound Nurse Practitioner, Employee E5, revealed, I was following [Resident R1] for an abrasion to the left great toe which was resolved on April 30, 2025. I was not informed of any other wounds until June 3, 2025, when the Administrator reported a new area on the right medial ankle of [Resident R1]. Resident was not on the scheduled wound rounds for that day. A picture of the wound was presented and noted exposed bone. A decision was made with the DON (Director of Nursing) and Administrator to send resident out to hospital. Employee E5 further stated[Resident R1] was diagnosed with a right femoral artery blockage upon Hospital admission. Current diagnoses of [Resident R1] supports Arterial Insufficiency and supports quick decline of the circulation to the right lower extremity. Interview conducted on July 7, 2025, at 9:52 a.m., with the Director of Nursing (DON), Employee E2, revealed on June 3, 2025, she observed the wound on the right leg shin area of Resident R1, did not measure it, but the wound appeared having approximately 5 cm length, 2 cm width, and 1 cm depth, and Employee E2 did see the bone exposed. Review of hospital records of Resident R1, dated June 9, 2025, revealed; [Resident R1] presented to the emergency department with the complaint of worsening Right Lower Extremity Wound. Patient is poor historian who noted that (his/her) right shin had been painful and is very warm to the touch . The patient was admitted for Right Lower Extremity Cellulitis (Cellulitis is a bacterial infection of the skin and underlying tissues, commonly caused by streptococcus or staphylococcus bacteria. It appears as a red, swollen, painful area of skin that can spread rapidly if left untreated). CTA (Computed Tomography Angiography. A medical imaging technique that uses X-rays and a contrast dye to visualize blood vessels) of lower extremity right showed occluded right common Femoral Artery, Right Superficial Femoral Artery, Distal Left Superficial Femoral Artery. Mid Anterior Tibia with skin ulcers and subcutaneous infiltration of fat along the anterior Tibialis Muscle. Podiatry, Plastics, Vascular Surgery saw the patient and determined that he was not a candidate for Vascularization (process of blood vessel formation in a tissue or organ. This process is essential for delivering oxygen and nutrients to cells and removing waste products, supporting tissue growth, repair, and overall function). Interview with the Nursing Home Administrator and the Director of Nursing on July 7, 2025, at 11:20 p.m., confirmed the facility failed to identify, develop and implement interventions to prevent Right Lower Extremity Wound Development, and to promote wound healing in accordance with the resident's plan of care, facility polices and professional standards of practice. The Nursing Home Administrator presented information indicating the facility initiated a plan of correction on June 2, 2025. The facility plan of correction included the following: -On June 2, 2025, during the 3-11 shift, the Charge Nurse contacted the Wound Nurse to request an evaluation of Resident R1 for the 395258 Page 3 of 5 395258 07/18/2025 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0600 Level of Harm - Actual harm Residents Affected - Few following day after the resident refused treatment. On June 3, 2025, between approximately 7:30 and 8:00 AM, the Wound Nurse assessed Resident R1, who was not previously on the wound rounds list, and identified an open area on the right shin. The finding was immediately reported to the Director of Nursing (DON), Nursing Home Administrator (NHA), and the medical provider. At approximately 11:00 AM, the Wound CRNP evaluated the wound and issued orders to transfer the resident to the hospital for further evaluation. Resident R1 was sent to the Hospital emergency room and was admitted with a diagnosis of wound infection. An internal investigation was initiated, including staff interviews with a two-week lookback period. A full skin sweep of the facility was conducted and completed on June 3, 2025, with no new areas identified. Notifications were made to the appropriate parties, including the DON, NHA, and provider. A full-house skin audit was completed, as all residents could potentially be affected. No unreported injuries or areas of concern were identified during the assessment. Clinical Staff education initiated 06/03/2025: Educate nurses and aides on Abuse and Neglect, process for providing and documenting baths/ showers, including changes in skin, identifying and notifying providers of change in condition including skin injuries, proper performing of weekly skin checks, shower sheet/body skin inspection form for nurse aides and completion of stop and watch alerts in POC/PCC (Point Click Care). Training of nurses and aides on scope of practice for completion of treatments and medications. 100% completion 06/05/2025. Corrective actions will be monitored to ensure that the deficient practice does not reoccur. The facility will conduct audits of five resident skin checks daily for five days, then weekly for three weeks, and monthly for two months. In addition, shower sheet completion will be audited for five residents daily for five days, then weekly for three weeks, and monthly for two months. Findings will be reviewed by the DON or designee, and results will be discussed during the facility's Quality Assurance Performance Improvement (QAPI) meetings for continued monitoring and compliance. The facility indicated their date of compliance was June 5, 2025. Review of facility documentation revealed the corrective action plan was implemented on June 2, 2025. Reviews conducted of staff education confirmed nursing staff were in-service on Abuse and Neglect, process for providing and documenting baths/ showers, changes in skin, and proper performing of weekly skin checks. Interviews with facility staff were conducted on July 18, 2025. Facility staff provided extensive feedback and understanding of the facility's abuse and neglect policy and scope of practice for completion of treatments and medications. Review of random resident clinical records reviewed with identified wounds revealed that residents received proper skin checks, wound checks and care and treatments, as ordered by the physician. The facility's action plan was accepted on July 18, 2025, and identified as past non-compliance. This deficiency was identified as actual harm past non-compliance for resident neglect in the facility failure to timely identify, assess and provide treatment to Resident R1's right lower extremity wound. This failure resulted in the resident developing a wound, requiring transfer to the hospital and diagnosis of a wound infection. 28 Pa Code 211.10(a)(d) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(3) Nursing services 28 Pa Code 211.12(d)(5) Nursing services 395258 Page 4 of 5 395258 07/18/2025 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to preventing cross-contamination for one of eight residents reviewed (R3).Findings include:Review of Facility Policy on Skin Care and Wound Management undated indicated; application of treatment protocols based on clinical best practice standards for promoting wound healing.Review of Centers for Disease Control and Prevention's (CDC) ‘Core Infection Prevention and Control Practices for Safe Healthcare Delivery in all Settings , dated April 12, 2024, insisted to maintain separation between clean and soiled equipment to prevent cross contamination. In addition, the literature on ‘ Wound Care Observation Checklist for Infection Control' of Pennsylvania Department of Health, dated April 2018, indicated; wound care supply cart should never enter the patient/resident's immediate care area nor be accessed while wearing gloves or without performing hand hygiene firs. These are important to preventing cross-contamination of clean supplies and reiterates the importance of collecting all supplies prior to beginning wound care.Review of literature revealed that Enhanced Barrier Precautions are infection control Intervention designed to reduce the transmission of novel or Multi-Drug-Resistant Organisms. Enhanced Barrier Precautions require to employ the use of targeted personal protective equipment (PPE) during high contact patient/resident activities. Review of Resident R3's clinical record revealed that the resident was admitted to the facility on [DATE]. Diagnoses included Need for Assistance with Personal Care.Review of physician order dated May 28, 2025, for R3, indicated an order stating, Sacrum- Cleanse with wound cleanser, apply Prisma, cover with boarded dressing daily and as needed, every dayshift, for stage four pressure ulcer .On July 2, 2025, at 12:40 a.m., observed wound treatment administered to R3, by Employee E6, a License Nurse. The nurse did follow physician order for sacral wound treatment, except the infection prevention protocol. Employee E6, transported the whole wound care supply cart into the Resident R3's immediate care area, in R3's room. At the time of the finding, the same was confirmed with E6.28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 201.18(d) Management Residents Affected - Few 395258 Page 5 of 5