Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Bristol Care Center during CMS and state inspections, most recent first.
Failure to supervise a resident with a known wandering history led to an elopement when the resident left the facility unsupervised and was missing for 10 hours. The resident had moderate cognitive impairment, a Wanderguard order, and prior exit-seeking behavior, but the care plan was not in place and staff did not recognize the resident as at risk. A receptionist confused the resident for a visitor, silenced the alarm, and let him out without notifying nursing staff.
A resident with hemiplegia and hemiparesis following a cerebral infarction had a personal trust fund with balances well above the $2,000 SSI resource limit and received monthly Social Security deposits, while Medicaid records showed a $0 patient liability. The BOM stated the room and board charge was incorrect, but when surveyors requested proof that the resident or representative had been notified that the account was within $200 of the SSI asset limit, no documentation was available, and no policy or procedure for such notifications could be produced.
A resident with major depressive disorder and chronic pain repeatedly reported not receiving an expected $130 Personal Needs Allowance check from the state and stated she had been asking about it for an extended period without results. The grievance log showed a grievance involving dietary, social services, and the business office marked as resolved, but the underlying grievance document was unavailable. The Business Office Manager acknowledged the resident began complaining months after admission, noted that the resident had previously received the $130 at another facility, and indicated that limited contacts were made with DCF and a Medicaid specialist about the missing payment. However, there was no documentation of timely investigation, written grievance findings, or effective follow-up to resolve the resident’s complaint, contrary to the facility’s grievance policy and the business office job responsibilities.
A resident did not receive the prescribed Pregabalin 75 mg three times a day due to a failure in obtaining the necessary prescription from the physician. Despite attempts to contact the pharmacy, the medication was not available, and there was no documentation of physician notification. The facility's process for handling new admissions and controlled medications was not followed, leading to the deficiency.
A resident with flaccid hemiparesis was found on the floor after being left in the bathroom for privacy. CNAs moved the resident back to a wheelchair before a nurse could assess him, contrary to facility protocol. The nurse assessed the resident only after he was moved, and the DON confirmed that CNAs should not move residents post-fall until assessed by a nurse.
A resident with significant medical conditions was found on the floor by facility staff and moved by CNAs without a nurse's immediate assessment. The nurse was informed after the resident was already moved, contrary to facility protocol requiring a nurse's assessment before moving a resident post-fall.
A resident did not receive the prescribed Pregabalin 75 mg three times a day due to the facility's failure to ensure the medication was available and administered. The pharmacy did not have the prescription, and there was insufficient follow-up by staff to obtain it, resulting in a deficiency.
The facility failed to update PASRRs for several residents with mental disorders, leading to deficiencies in care planning. A resident with multiple mental health diagnoses did not have an updated PASRR, and another resident's PASRR was not updated upon admission. Other residents had incomplete PASRRs, and the Social Services Director relied on the system for notifications, which did not occur.
The facility failed to provide necessary care for a resident with an immune deficiency syndrome, including timely lab work follow-up and communication of results. Another resident's request to change from a mechanical soft diet to a regular diet was not addressed, and routine lab work for a resident with chronic conditions was not conducted as ordered. The facility lacked policies for coordinating care and documenting refusals, leading to these deficiencies.
A LTC facility failed to consistently apply orthotic devices for residents, leading to deficiencies in care. One resident's orthotic was left out of reach, with no staff assigned to apply it. Another resident with contractures did not consistently receive prescribed orthotics, and a third resident's orthotic application was inconsistently documented. Staff interviews revealed confusion and lack of clear processes for orthotic application, particularly on weekends.
The facility failed to maintain a medication error rate below five percent, resulting in a 13.79% error rate. An LPN administered an incorrect dosage of Calcium Carbonate to a resident, and another LPN failed to administer three medications to a different resident, despite signing them off as given. The facility's policy on medication administration was not followed, leading to these errors.
A resident with moderate cognitive impairment reported missing clothing to the laundry staff, but no grievance was filed, and the issue remained unresolved. The facility's grievance policy was not followed, as confirmed by interviews with the Social Services Director, laundry supervisor, and DON.
A facility failed to thoroughly investigate an alleged abuse incident where a nurse reportedly slapped a resident's hand during a medication pass. The investigation was limited to interviews with the involved parties and did not include other residents who received care from the accused nurse. Additionally, there was a delay in obtaining statements from the residents involved, contrary to the facility's policy requirements.
Two residents in an LTC facility did not receive showers according to their care plans and preferences. One resident, with hemiplegia, preferred showers but documentation was inconsistent, and staff interviews revealed discrepancies in recording practices. Another resident, dependent on staff for bathing, had inaccurate records of bathing after being transferred to an acute care facility. The facility's policy on ADLs was not followed, leading to a deficiency in maintaining residents' hygiene and preferences.
A facility failed to obtain consent from a resident's POA before using funds to purchase a chair for a bed-bound resident. The BOM and DOR did not contact the family, and the OT assumed the BOM would notify them. The purchase was part of a Medicaid spend down, but the lack of communication and consent led to a grievance. The facility's policy requires informing residents of charges to their funds, which was not followed.
A resident's assessment was not updated within the required three-month period, leading to a deficiency. The resident, with multiple diagnoses, had a Quarterly MDS that was completed late. The MDS Coordinator admitted the MDS was closed late and was unsure of the exact due date, indicating it might have been due earlier.
A facility failed to conduct a Level II PASRR for a resident with serious mental illness, despite diagnoses of Major Depressive Disorder and Bipolar Disorder. The resident's initial Level I PASRR did not indicate the need for further evaluation, but a subsequent report identified the need for a Level II review. The facility's psychiatric meeting documentation also indicated the need for a Level II review, which was not conducted. The Social Service Director noted that the facility had a process for updating PASRRs but did not resubmit the resident for a Level II review after adding an anxiety diagnosis.
The facility failed to properly store urinary drainage bags for two residents, leading to potential infection risks. A resident's drainage bag was observed hanging from a wheelchair with tubing on the floor, while another resident's bag was on the floor under an over-bed table. Staff confirmed the improper storage, and the facility's policy lacked specific storage instructions.
A facility failed to obtain a physician order before administering oxygen to a resident with COPD and other conditions. The resident had been using oxygen therapy at night without a physician's directive, as confirmed by the resident and the DON. The facility's policy mandates a physician order for oxygen administration, which was not followed.
Failure to Supervise Resident with Wandering History
Penalty
Summary
The facility failed to provide supervision to prevent an elopement for a resident with a known history of wandering. The resident was admitted with diagnoses including other toxic encephalopathy, cellulitis of the lower limbs, generalized muscle weakness, adjustment disorder with depressed mood, and age-related physical debility. The MDS showed a BIMS score of 8 out of 15, indicating moderate impairment. Although an elopement evaluation later identified recent elopement or exit-seeking behavior within the prior 90 days and recommended placing the resident’s picture in the elopement book and applying a Wanderguard if available, the resident’s care plan did not include a wandering or elopement focus during the time of the incident. On the day of the incident, the resident left the facility unsupervised and was missing for 10 hours. A progress note documented that nursing staff discovered the resident was not in his room around 1 p.m., initiated a search of the unit, and learned from the receptionist that the resident had left earlier and appeared to sign out. Staff interviews confirmed the resident had wandering behaviors, that the receptionist confused him for a visitor, and that the receptionist let him out after the Wanderguard alarm sounded. The receptionist did not notify nursing staff when the alarm activated and silenced it before allowing the resident to leave. Additional interviews confirmed the Wanderguard had been ordered and placed, but the care plan had not been implemented, and staff stated that without the care plan the CNA task log would not show the interventions needed for monitoring and supervision. The DON confirmed the resident was missing, police and family were notified, and the resident was later returned by police unharmed. The facility policy required staff to investigate and report missing residents, attempt to prevent departure, notify nursing leadership, and initiate a search when a resident was missing.
Failure to Notify Resident of Trust Account Approaching SSI Resource Limit
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident or responsible party when the resident’s personal trust account balance came within $200 of the $2,000 Supplemental Security Income (SSI) resource limit. The resident, admitted in 08/2022, had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and required assistance with personal care. Review of the resident’s personal trust fund statements showed a balance of $7,871.13 on 07/01/2025, $5,469.30 on 11/04/2025, $6,264.65 on 12/04/2025, and $6,216.12 on 01/02/2025, with monthly deposits of $964.00 from 07/2025 through the survey date. The Business Office Manager (BOM) stated the resident was receiving a Social Security payment of $964.00 and acknowledged that the patient liability (room and board charge) was wrong. A Notice of Case Action from the Department of Children and Families dated 02/11/2025 documented that the resident had Medicaid eligibility with a $0.00 patient liability for 12/2024, 01/2025, 02/2025, and 03/2025 ongoing. Despite this, when surveyors requested evidence on 01/05/2026 that the resident or resident representative had been notified that the resident’s assets were within $200 of the $2,000 limit, no documentation was provided. When asked the same day for a policy and procedure for notifying residents when their assets are within $200 of the $2,000 asset limit, the BOM was unable to provide any such document. These findings show that the facility did not provide required notification or have documented procedures for this notification requirement.
Failure to Implement Grievance Process for Resident’s Missing PNA Funds
Penalty
Summary
The deficiency involves the facility’s failure to implement its grievance process and promptly resolve a resident’s ongoing complaint regarding non-receipt of a $130 Personal Needs Allowance (PNA) check from the Department of Children and Families (DCF). Resident #8, admitted with diagnoses including major depressive disorder and chronic pain, reported receiving a $30 SSI check and expecting an additional $130 state check that she had not received despite asking about it since 2024. During interview, she stated she had been requesting assistance with this issue with nothing happening. The facility’s grievance log for December 2024 showed a grievance from this resident involving dietary, social services, and the business office, marked as resolved the next day, and the Social Service Director stated the resident had requested to see the Business Office Manager (BOM) during that period. However, the actual grievance document was not available for review prior to survey exit. The BOM confirmed the resident was admitted in September 2024 and began complaining about the missing $130 check approximately three to four months after admission, requesting information on why she was not receiving it. The BOM stated there was likely a grievance and that social services would handle it, and reported sending a DCF fax cover sheet in early September 2025 noting the resident was not receiving the $130 state check and asking DCF to update from the time of admission. The BOM also stated the matter was turned over to the facility’s contracted Medicaid Specialist, and provided an email indicating the specialist had made an inquiry to DCF about the PNAS check in September 2025. No further information was available to show follow-up efforts or resolution of the PNAS issue with DCF prior to survey entrance. This inaction occurred despite facility policy requiring prompt efforts to resolve grievances, written investigation and reporting by the grievance officer within five working days, and maintenance of grievance records, as well as the BOM’s job description requiring maintenance of written records of resident complaints and follow-up with Medicaid in a timely manner.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident, who was admitted with a medical diagnosis that included subcortical and flaccid conditions affecting the right dominant side. The resident was prescribed Pregabalin 75 mg to be administered three times a day, starting from the day of admission. However, the resident did not receive the medication during five administration opportunities, as documented in the medical records. The deficiency arose because the prescription for Pregabalin was not sent to the pharmacy, and the medication was not available in the emergency drug kit. Despite the nurses' attempts to contact the pharmacy, they did not have the prescription, and there was no documentation indicating that the physician was notified to provide the necessary prescription. The facility's emergency medication drug list showed that Pregabalin 25 mg was available, but the required 75 mg dosage was not administered. Interviews with the nursing staff and the Director of Nursing revealed that the facility's process for handling new admissions and controlled medications was not followed. The nurses were expected to notify the physician and document the need for a prescription, but this was not done. The Director of Nursing confirmed that the medication should have been administered as prescribed, and the nurses should have continued to contact the physician until the medication was delivered.
Plan Of Correction
Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on. Identification of other residents having the potential to be affected: Current residents in the facility were reviewed by to ensure their medications requiring hard scripts were available in the medication cart. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed nurses by to ensure physicians are notified when a hard script is needed for a new medication and will continue to follow up with physician and/or pharmacy until medication is received. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review new admissions to ensure hard scripts were received or sent to pharmacy to ensure medication is delivered and available to the resident 3 times a week for 2 weeks then 2 times a week for 2 weeks then weekly. The administrator will oversee audit completion and report findings in the monthly Risk Management/QA Committee meeting for 3 months or until substantial compliance is achieved.
Failure to Follow Protocol for Resident Fall Assessment
Penalty
Summary
The facility failed to provide adequate and appropriate health care by not ensuring that a resident was assessed immediately by a nurse after being found on the floor. The incident involved a resident who was originally admitted with diagnoses including flaccid hemiparesis affecting the right dominant side. On the day of the incident, the resident was assisted to the bathroom by two CNAs and left there for privacy. Shortly after, the resident was found on the floor by a housekeeper, and the CNAs lifted the resident back into a wheelchair before a nurse could perform an assessment. Interviews with staff revealed that the protocol requires a nurse to assess a resident before they are moved after a fall. However, in this case, the CNAs moved the resident without waiting for the nurse's assessment. The nurse, who was administering medication in another room at the time, assessed the resident only after the CNAs had already moved him. The Director of Nursing confirmed that CNAs are not allowed to move a resident after a fall until a nurse has conducted an assessment, which was not followed in this instance.
Plan Of Correction
D-Right to Adequate and Appropriate Health Care Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on. Identification of other residents having the potential to be affected: Residents within the past 30 days were reviewed to ensure they were evaluated by a licensed nurse prior to being moved to the bed or chair. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed clinical staff by on ensuring residents with are evaluated by a licensed nurse prior to the resident being moved to the bed or chair. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review residents with weekly for 4 weeks then monthly x3 months to ensure residents are being evaluated by the nurse prior to being moved to the bed or chair. The administrator will oversee audit completion and report findings in the monthly Risk management/QA committee.
Failure to Assess Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident was assessed immediately by a nurse after being found on the floor by facility staff. The incident involved a resident with a history of significant medical conditions, including subcortical and flaccid paralysis affecting the right dominant side. On the day of the incident, the resident was placed on the toilet by two CNAs and left alone for privacy. Shortly after, the resident was found on the floor by a housekeeper, and the CNAs assisted the resident back into a wheelchair without waiting for a nurse to conduct an assessment. Interviews with staff revealed that the nurse, who was administering medication in another room, was informed of the incident after the CNAs had already moved the resident. The nurse assessed the resident only after the CNAs had placed the resident in a wheelchair. Facility protocol dictates that CNAs should notify a nurse immediately and wait for an assessment before moving a resident who has fallen. The Director of Nursing and other staff confirmed that the CNAs did not follow the required protocol, which includes notifying the nurse, conducting an assessment, and completing an incident report before moving the resident.
Plan Of Correction
F 684 D- Quality of Care Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on. Identification of other residents having the potential to be affected: Residents within the past 30 days were reviewed to ensure they were evaluated by a licensed nurse prior to being moved to the bed or chair. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed clinical staff by on ensuring residents with are evaluated by a licensed nurse prior to the resident being moved to the bed or chair. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review residents with weekly for 4 weeks then monthly x3 months to ensure residents are being evaluated by the nurse prior to being moved to the bed or chair. The administrator will oversee audit completion and report findings in the monthly Risk management/QA committee.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide physician-ordered medication for a resident, resulting in a deficiency. The resident was admitted to the facility with a hospital discharge medication list that included Pregabalin 75 mg to be administered three times a day. However, the resident did not receive the medication during five administration opportunities from admission until discharge. The medication administration record indicated that the medication was not available, and the pharmacy did not have the prescription. Interviews with staff revealed that the medication was not in the medication cart, and the pharmacy was contacted but did not have the prescription. The staff did not remember if the physician was contacted to obtain the prescription. The facility's emergency medication drug list showed that Pregabalin 25 mg was available, but the required 75 mg dose was not administered. The Director of Nursing confirmed that Pregabalin is a controlled medication requiring a prescription and that the medication was not delivered because the pharmacy did not receive a prescription. The facility's policy on administering medications states that medications should be administered safely, timely, and as prescribed. The Director of Nursing indicated that if a controlled medication is not available, the physician should be notified, and there should be documentation of this notification. Despite these procedures, the resident did not receive the prescribed Pregabalin, and there was a lack of documentation and follow-up to ensure the medication was provided.
Plan Of Correction
F 755 D- Pharmacy Services/Procedures/Pharmacist/Records Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on Identification of other residents having the potential to be affected: Current residents in the facility were reviewed by to ensure their medications requiring hard scripts were available in the medication cart. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed nurses by to ensure physicians are notified when a hard script is needed for a new medication and will continue to follow up with physician and/or pharmacy until medication is received. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review new admissions to ensure hard scripts were received or sent to pharmacy to ensure medication is delivered and available to the resident 3 times a week for 2 weeks then 2 times a week for 2 weeks then weekly. The administrator will oversee audit completion and report findings in the monthly Risk Management/QA Committee meeting for 3 months or until substantial compliance is achieved.
Failure to Update PASRRs for Residents with Mental Disorders
Penalty
Summary
The facility failed to complete or update the Pre-admission Screening and Resident Reviews (PASRRs) for several residents with mental disorders or intellectual disabilities. This deficiency was identified for five out of eight residents reviewed. The PASRR process is crucial for determining the appropriate level of care and services required for residents with mental health diagnoses. The failure to update these screenings can lead to inadequate care planning and service provision. Resident #228 was admitted with multiple mental health diagnoses, including generalized anxiety disorder, bipolar disorder, and depression. A new diagnosis of brief psychotic disorder was added, but the Level I PASRR was not updated, and a Level II PASRR was not submitted. The Social Services Director (SSD) acknowledged the oversight, citing a timing issue in reviewing and updating the PASRR. Other residents, such as Resident #145 and Resident #163, also had outdated or incomplete PASRR screenings. Resident #145's PASRR was not updated upon admission to the current facility, and Resident #163's PASRR did not mark qualifying diagnoses. Resident #25 and Resident #60 had similar issues, with their PASRRs not reflecting their current mental health diagnoses or the need for a Level II evaluation. The SSD admitted to relying on the system to notify her of the need for a Level II PASRR, which did not occur, leading to these deficiencies.
Deficiencies in Resident Care and Lab Work Follow-Up
Penalty
Summary
The facility failed to provide necessary care and services for a resident with an immune deficiency syndrome. The resident expressed concerns about not receiving timely blood work results to assess the effectiveness of their antiretroviral therapy medication. Despite having a care plan that included obtaining labs as ordered and reporting results to the physician, there was a lack of follow-up on abnormal lab results. The Director of Nursing (DON) admitted to not being aware of the resident's treatment for immune deficiency syndrome and did not ensure timely lab work follow-up. The resident also reported a negative experience with a health department appointment, which led to a lack of further appointments being scheduled. Another resident, who had been on a mechanical soft diet due to previous speech therapy recommendations, expressed a desire to switch to a regular diet. Despite being cognitively intact and having communicated this request to the staff, there was no follow-up on the diet change. The resident's speech therapy had been discontinued due to exhausted benefits, and there was no recent evaluation to reassess the dietary needs. The facility lacked a policy for coordinating care with therapy, which contributed to the oversight. Additionally, the facility failed to maintain routine lab work for a resident with multiple diagnoses, including chronic kidney disease and diabetes. The resident's lab work, ordered to be completed on a specific date, was not found in the electronic results tab, indicating it was not conducted. The DON later provided a lab log showing the bloodwork had been refused, but there was no documentation of this refusal in the resident's records. This lack of documentation and follow-up on lab work orders highlights a deficiency in the facility's care processes.
Inconsistent Application of Orthotic Devices in LTC Facility
Penalty
Summary
The facility failed to provide appropriate care for residents requiring orthotic devices, as evidenced by observations, record reviews, and interviews. Resident #123 was observed with a left-hand brace/splint lying out of reach, and the resident reported that no staff applied the orthotic device, relying instead on a family member. The resident's care plan did not include instructions for applying the orthotic, and staff interviews revealed confusion about who was responsible for its application. The Director of Rehabilitation noted that the resident had trialed a splint but did not require it anymore, yet the resident expressed a need for the device. Resident #14 was observed with contractures and was not wearing the prescribed orthotic devices. The resident's care plan included orders for bilateral palm guards and elbow splints, but documentation and staff interviews indicated inconsistent application of these devices. The Director of Rehabilitation reported that a palm guard was missing and had been discarded by a CNA due to soiling, despite being washable. The facility lacked a clear process for applying splints on weekends, leading to further inconsistencies in care. Resident #31 was observed with orthotic devices not being consistently applied as per the care plan. The resident's records indicated orders for wearing a right elbow orthotic and a right-hand splint, but observations and documentation showed these were not consistently applied or documented. Interviews with staff revealed that the rehab tech was responsible for applying the splints, but there was no scheduled time for application, and documentation was incomplete. The facility's policies on range of motion and specialized rehabilitative services were not adequately followed, contributing to the deficiencies observed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 13.79% error rate during the observed period. Twenty-nine medication administration opportunities were observed, and four errors were identified involving two residents. For Resident #135, a Licensed Practical Nurse (LPN) administered a 750 mg Calcium Carbonate chewable tablet instead of the prescribed 600 mg tablet. This discrepancy was noted during a review of the resident's active medication orders. For Resident #220, another LPN prepared and administered several medications but failed to administer Metoprolol 50 mg, Omeprazole 20 mg, and Metformin HCL 1000 mg, despite signing them off as given. The LPN later admitted to not seeing these medications on the screen during the initial administration and claimed to have administered them later. However, the Medication Admin Audit Report indicated that all medications were signed off as given at the same time, raising concerns about the accuracy of the administration records. The facility's policy on medication administration emphasizes the importance of verifying the right medication, dosage, and time, which was not adhered to in these instances.
Failure to Address Resident's Grievance on Missing Clothing
Penalty
Summary
The facility failed to address a resident's grievance regarding missing clothing, which was reported by the resident during a facility tour. The resident, who had a moderate cognitive impairment with a BIMS score of 11, stated that she was missing a couple of pairs of pants and undershirts that her family had brought in. Despite informing the laundry staff about the missing items approximately three weeks prior, no grievance was filed on her behalf, and the issue remained unresolved. Interviews with facility staff revealed that the Social Services Director had not received any grievances from the resident or staff, and the grievance log showed no entries for this resident. The laundry supervisor and her assistant confirmed that the resident had reported the missing clothes, but a grievance was not initiated as per the facility's policy. The assistant laundry supervisor admitted to providing the resident with clothes from the donations pile instead of filing a grievance. The Director of Nursing stated that a grievance should have been initiated if the resident reported missing laundry. The facility's grievance policy requires prompt efforts to resolve grievances, which was not adhered to in this case.
Incomplete Investigation of Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident and a staff member. The incident was reported by a roommate who claimed that a nurse slapped the resident's hand during a medication pass. The resident involved, who had intact cognition and a history of mental health conditions, initially denied any mistreatment when interviewed. However, later statements indicated that the nurse may have lightly slapped the resident's hand after the resident pushed the nurse's hand away. The facility's investigation was incomplete as it only involved interviews with the directly involved parties and did not include other residents who received care from the accused staff member. Additionally, there was a delay in obtaining statements from the involved residents, which took seven days instead of the typical five-day window. The facility's policy required interviews with other residents and a review of all events leading up to the incident, which was not fully adhered to. The report highlights that the facility's abuse investigation guidelines were not thoroughly followed, as the investigation did not extend beyond the immediate parties involved. The facility's policy emphasizes the importance of protecting residents from abuse and ensuring a comprehensive investigation, which was not achieved in this case.
Failure to Provide Showers Per Care Plan and Resident Preference
Penalty
Summary
The facility failed to ensure that two dependent residents received showers according to their plan of care and personal preferences. Resident #123, who has diagnoses including hemiplegia and hemiparesis, expressed a preference for showers over bed baths, which was documented as very important in their care plan. However, the facility's documentation did not consistently indicate whether the resident received showers as preferred, with discrepancies noted in the timing and type of bathing provided. Interviews with staff revealed inconsistencies in documentation practices, with some staff unaware of the specific requirements for recording the type of bathing provided. Resident #283, who was dependent on staff for bathing and had a history of medical conditions such as hypotension and myocardial infarction, also did not receive showers as per their care plan. The facility's documentation showed that the resident was dependent on staff for bathing, but it did not specify the type of bathing received. Additionally, there were instances where the documentation inaccurately recorded bathing after the resident had been transferred to an acute care facility, indicating a lack of accurate record-keeping. The facility's policy on supporting activities of daily living (ADLs) emphasizes the importance of providing care to maintain or improve residents' abilities to perform ADLs. However, the facility did not adhere to this policy, as evidenced by the lack of proper documentation and failure to provide showers according to the residents' preferences and care plans. This deficiency highlights a gap in the facility's ability to ensure that residents receive the necessary care and services to maintain their hygiene and personal preferences.
Failure to Obtain Consent for Resident Fund Usage
Penalty
Summary
The facility failed to obtain consent from the designated Power of Attorney (POA) before utilizing funds from a resident's account to purchase a chair. The resident, who was incapacitated and bed-bound, had a chair purchased for her without the knowledge or consent of her responsible party or POA. The Business Office Manager (BOM) and Director of Rehabilitation (DOR) confirmed that they did not attempt to contact the resident's family or POA regarding the purchase. The Occupational Therapist (OT) conducted an assessment and determined the need for a chair, but did not notify the family, assuming the BOM would do so. The facility's policy requires residents to be informed in advance of any charges to their personal funds, which was not adhered to in this case. The resident's responsible party expressed dissatisfaction with the purchase, stating that the resident did not use the chair and was in hospice care. The BOM stated that the purchase was made as part of a Medicaid spend down, and the facility was acting as the resident's payee at the time. Despite the OT's assessment and trial of the chair, the lack of communication and consent from the POA led to the grievance. The Nursing Home Administrator acknowledged the POA's concerns and planned to address the issue, but the deficiency highlights a failure in the facility's process for managing resident funds and obtaining necessary consents.
Late Submission of Resident Assessment
Penalty
Summary
The facility failed to update a resident's assessment within the required three-month period, resulting in a deficiency. Resident #196, who was admitted with diagnoses including cerebral infarction, confusional arousals, white matter disease, cognitive communication deficit, and major depressive disorder, had a Quarterly Minimum Data Set (MDS) that was completed late. The MDS, which was supposed to be completed by a specific due date, was closed on 01/03/25 and not submitted until 01/07/25. During an interview, the MDS Coordinator, Staff A, acknowledged that the MDS was closed late and was unsure of the exact due date, suggesting it might have been due on 01/02/25. The delay in closing the MDS even by a minute past the due date was considered a late submission.
Failure to Conduct Level II PASRR for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to submit a resident for a Level II Pre-admission Screening and Resident Review (PASRR) despite the presence of serious mental illness diagnoses. The resident, who was observed lying in bed and covering her head with a blanket, had an admission comprehensive assessment indicating active psychiatric diagnoses, including depression and bipolar disorder. The initial Level I PASRR, completed by another facility, did not indicate a need for a Level II evaluation. However, a subsequent Level II PASRR Determination Summary Report identified the resident as having a Serious Mental Illness, with diagnoses such as Major Depressive Disorder and Bipolar Disorder, and recommended a Level II review if there was a significant change in mental status. Despite these findings, a later Level I PASRR screening did not require a Level II evaluation, and the facility's psychiatric meeting documentation indicated the need for a Level II review, which was not conducted. The Social Service Director stated that the facility had a process for updating PASRRs but did not resubmit the resident for a Level II review after adding an anxiety diagnosis, as the resident already had a previous Level II evaluation. The facility's policy requires all new admissions to be screened for mental disorders and referred for a Level II evaluation if necessary, but this process was not followed in this case.
Improper Storage of Urinary Drainage Bags
Penalty
Summary
The facility failed to ensure proper storage of urinary drainage bags and tubing for two residents with urinary catheters, leading to potential infection risks. Resident #91 was observed with a urinary drainage bag hanging from the wheelchair frame under the seat, with the catheter tubing dragging on the floor. This was confirmed by a registered nurse who assisted the resident into the shower room to adjust the tubing. The resident's treatment administration record indicated that staff were required to ensure the use of a securing device for the urinary catheter, perform catheter care with soap and water every shift, and change the urinary catheter bag and tubing as needed for blockage or signs of infection. Similarly, Resident #18 was observed with a urinary drainage bag on the floor under the over-bed table. A certified nursing assistant acknowledged that the bag should not be on the floor and repositioned it to hang from the bed frame. The resident's treatment administration record also required staff to ensure the use of a securing device for the urinary catheter every shift, perform catheter care with soap and water every shift, and change the urinary catheter bag and tubing as needed. The Director of Nursing/Infection Preventionist confirmed that urinary bags should not be on the floor, although the facility's urinary catheter care policy did not specify how the drainage bag should be stored.
Lack of Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure a physician order was available prior to providing oxygen administration for a resident. An observation revealed an oxygen concentrator with a nasal cannula at the bedside of a resident who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), ataxia, heart failure, and major depressive disorder. A review of the physician orders showed no current order for oxygen administration, despite the resident having been provided with oxygen therapy starting on a specific date as noted in the Nurses Note. Interviews with the resident and the Director of Nursing (DON) confirmed the absence of a physician order for the oxygen therapy. The resident stated that he had been using oxygen therapy at night for a couple of weeks and managed the oxygen concentrator himself. The DON acknowledged that a physician order is necessary to guide staff on the oxygen administration specifics, such as the number of liters, frequency, and form of delivery. The facility's policy on oxygen administration also requires verification of a physician's order before proceeding with the procedure.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 380 citations issued within 25 miles in the last 12 months — including the 25 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tampa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Excel Care Center | 1 mi | ★★★★★ | 1 | 0 |
| Palm Garden Of Tampa | 1.2 mi | ★★★★★ | 1 | 0 |
| Blue Palms Health And Rehabilitation Center At Fle | 1.4 mi | ★★★★★ | 1 | 0 |
| Aviata At Fletcher | 1.5 mi | ★★★★★ | 4 | 0 |
| Fairway Oaks Center | 1.8 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Bristol Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.