Below average — CMS composite of the measures below.
The next survey window likely opens 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 Rehab Center At Bristol during CMS and state inspections, most recent first.
A resident with significant physical and cognitive impairments, requiring substantial assistance and identified as high fall risk, was left unsupported on a shower bench when a CNA turned away to retrieve a towel. Due to unclear documentation and lack of staff awareness regarding the required level of assistance, the resident fell and sustained a head injury requiring hospitalization. The facility's investigation did not address the underlying causes or clarify staff responsibilities for supervision during bathing.
The facility did not thoroughly investigate multiple abuse allegations, failing to document interviews with other potentially affected residents or staff, and did not always assess residents for injury after allegations. In one case, a CNA accused of rough care was suspended, but there was no evidence that other residents were interviewed. In another, a CNA was alleged to have kicked a resident and behaved inappropriately with a roommate, but the investigation lacked documentation of interviews or injury assessments. Additionally, a physical therapist accused of causing harm was not suspended, and no steps were documented to protect other residents or gather their input during the investigation.
A resident with a history of blood clots and other medical issues alleged that a therapist's actions led to hospitalization, reporting these concerns to therapy staff and later through a grievance. Despite policy requiring immediate reporting of such allegations, staff did not notify the Administrator or state agency within the required timeframe, resulting in a delayed report to authorities.
Failure to complete a baseline care plan for a newly admitted resident. The resident had dx including noninfective gastroenteritis and colitis, severe cognitive impairment (BIMS 0), and was dependent on staff for all ADLs and mobility. Staff interviews showed the baseline care plan was expected within 24 hours to 48 hours of admission, but the Care Plan Report showed no data found and the ADM could not locate one.
Care plans were not developed or updated to address indwelling urinary catheters, a midline IV catheter, or supplemental O2 for several residents. Records and observations showed residents with diagnoses including dementia, stroke, BPH, breast cancer, weakness, and dependence on O2 had active orders and confirmed use of these devices/therapies, but their care plans lacked related focus areas and interventions. Staff interviews confirmed that MDS nurses and nursing leadership expected these needs to be care planned.
Failure to change oxygen tubing as ordered for two residents receiving supplemental oxygen. One resident had moderate cognitive impairment and an order for continuous O2 at 2 L/min with weekly tubing changes, while another resident with COPD, SOB, and O2 dependence had an order for O2 at 3 L/min with weekly Sunday night tubing changes. Staff documented tubing changes on the MAR, but observations showed tubing dated well outside the weekly change schedule, and an LPN confirmed the missed changes.
A resident with dementia and an indwelling urinary catheter was not placed on EBP signage at the room door, and PPE was not readily available in or around the room. Observations confirmed the missing signage, and staff interviews showed that an LPN and the ADON stated residents with indwelling urinary catheters needed EBP and that staff used door signage to determine required PPE.
A resident with severe cognitive impairment and multiple medical conditions was not given notice of rights and services prior to or upon admission. Admission paperwork was delayed by three days due to staff scheduling, and the required documents were only signed after this period.
Facility staff did not notify a resident's responsible party when the resident's antipsychotic medication, Seroquel, was discontinued. The resident, who had severe cognitive impairment and multiple diagnoses, had the medication stopped due to falls, but there was no documentation of RP notification as required by facility policy. Staff interviews confirmed the lack of notification, and leadership acknowledged the issue but cited difficulty reaching the RP.
Staff failed to include required documentation in the clinical records for two residents transferred to the hospital, omitting details such as paperwork sent, contacts made at the ER, and the receiving facility, despite facility policy requiring this information to be recorded.
Facility staff failed to follow provider orders for two residents, including not transcribing a seizure medication order upon admission for a resident with epilepsy and not adhering to the prescribed administration schedule for Seroquel or documenting the application of geri-sleeves for another resident with dementia. Documentation was incomplete or missing for both medication administration and ordered treatments.
Facility staff did not provide evidence that a provider-ordered urinalysis was obtained for a resident with severe cognitive impairment and urinary incontinence. Although the order was marked as completed, no lab results or documentation explaining the absence of results were found. Interviews indicated that standard procedures for urine collection and documentation were not followed, and administrative staff cited issues such as the resident being sent out and the laboratory company going out of business.
Failure to Provide Adequate Supervision During Bathing Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of cerebrovascular disease, muscle weakness, and moderate cognitive impairment was left unsupported on a shower bench during bathing. The resident, who required substantial to maximal assistance for activities of daily living and was at high risk for falls, was left unattended by a CNA who turned away to retrieve a towel. The resident subsequently fell from the shower seat, hitting their head and sustaining an injury that required hospitalization. Facility documentation, including the resident's care plan and Kardex, did not specify the level of staff assistance required for bathing, despite the resident's known physical limitations and high fall risk. Interviews with staff revealed uncertainty and lack of clarity regarding the number of staff needed to safely assist the resident during bathing. The CNA involved was unaware of the specific assistance requirements, and the Kardex section for bathing assistance was left blank, leaving staff without clear guidance. The facility's investigation into the incident was limited to collecting witness statements and did not include a review of the resident's need for support while sitting or an analysis of the circumstances that led to the fall. There was no evidence that the facility identified the risk created by leaving the resident unsupported or that staff were adequately informed of the resident's care needs during bathing. As a result, the resident experienced a preventable fall and injury.
Failure to Thoroughly Investigate Abuse Allegations and Protect Residents
Penalty
Summary
The facility failed to provide evidence that allegations of abuse were thoroughly investigated for four residents and did not implement interventions to prevent further potential abuse or neglect for one resident while an investigation was in progress. Facility policy required all allegations of abuse, neglect, exploitation, or misappropriation to be thoroughly investigated, with specific steps including interviews with all relevant parties, documentation, and protection of residents and reporters from retaliation. However, in multiple cases, the facility did not document interviews with other residents or staff who may have been affected or had contact with the accused employee, nor did they always assess residents for injury following allegations. For one resident with moderate cognitive impairment and on anticoagulant therapy, an allegation was made that a CNA was rough during care, resulting in bruising. While the accused CNA was suspended and some interviews were conducted, there was no documented evidence that other residents cared for by the CNA were interviewed or assessed. In another case, a resident with intact cognition alleged that a CNA kicked their leg and had inappropriate interactions with their roommate, who had severe cognitive impairment. The investigation did not include documented interviews or statements from other staff, family members, or other residents, nor was there documentation of injury assessments for the involved residents. In a third case, a resident with a history of blood clots and on anticoagulant therapy alleged that a physical therapist caused harm during treatment, leading to hospitalization. The facility did not suspend the therapist during the investigation and did not document any steps taken to protect other residents or to interview them about their experiences with the therapist. Across all cases, the facility's failure to follow its own investigative procedures and to document thorough investigations led to the deficiency.
Failure to Timely Report Allegation of Abuse/Neglect
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported within the required two-hour timeframe, as outlined in its own policy and regulatory requirements. A resident with a history of anemia, deep vein thrombosis, and other medical conditions alleged that a physical therapist's actions led to hospitalization due to a blood clot. The resident voiced these concerns to therapy staff on multiple occasions, including to an occupational therapist and a physical therapist, and later filed a grievance with the Social Services Director. Despite these reports, there was no documented evidence that the allegations were immediately reported to the Administrator or to the state survey agency as required. The facility's policy mandates that any suspicion of abuse, neglect, or exploitation must be reported immediately, defined as within two hours for allegations involving abuse or serious bodily injury. However, the documentation shows that the initial report to the state survey agency was not made until well after the resident's allegations were first communicated to staff. Specifically, the facility submitted the report to the state agency a day after the resident filed a formal grievance, and several days after the initial concerns were raised with therapy staff. Interviews with staff revealed a lack of clarity and timely action regarding the reporting process. Therapy staff and the Director of Rehabilitation were aware of the resident's allegations but did not escalate the matter to the Administrator or report it to the state agency in accordance with policy. The Administrator only became aware of the situation during a morning meeting after the grievance was filed, at which point the report was made to the appropriate authorities. This delay in reporting constitutes a failure to follow established procedures for timely reporting of suspected abuse or neglect.
Failure to Complete Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #97 within 48 hours of admission. The facility policy titled, Care Plans - Baseline, stated that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. Resident #97 was admitted on 08/05/2025 and had diagnoses including noninfective gastroenteritis and colitis. The admission record also showed the resident later discharged home on [DATE]. The resident's MDS, with an ARD of 08/11/2025, showed a BIMS score of 0, indicating severe cognitive impairment, and that the resident was dependent on staff for all ADLs and mobility. The Care Plan Report for Resident #97 showed no data found. During interviews, CNA #9 stated a baseline care plan was needed to review what care the resident required, RN #10 stated nurses were responsible for initiating baseline care plans, and the MDS Coordinator stated nursing staff should complete them within 24 hours of admission. The Administrator stated she could not find a baseline care plan for Resident #97 and later stated baseline care plans should be completed on admission.
Care plans did not address catheters or oxygen therapy
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for 5 sampled residents who had indwelling urinary catheters, IV access, or oxygen therapy. Facility policy stated that comprehensive care plans must include measurable objectives and timetables to meet each resident’s physical, psychosocial, and functional needs, and that care plans are to be revised as resident conditions change. The deficiency was identified through record review, observation, and staff interviews. Resident #7 was admitted with a history of cerebral infarction and had severe cognitive impairment on the quarterly MDS. The resident had an order for an indwelling urinary catheter, but the care plan did not include a focus area or interventions related to the catheter. Resident #4 was admitted with dementia, dependence on supplemental oxygen, blindness in one eye, muscle weakness, difficulty walking, and need for assistance with personal care. The resident’s MDS showed an indwelling urinary catheter and oxygen therapy, and observations confirmed supplemental oxygen use, but the care plan did not address either the catheter or oxygen therapy. Resident #34 had diagnoses including dementia, peripheral vascular disease, and type 2 diabetes mellitus, and had severe cognitive impairment on the MDS. The resident had an order for a midline IV catheter to receive IV antibiotics, but the care plan did not address the IV catheter. Resident #45 had diagnoses including BPH and dependence on supplemental oxygen, and the MDS showed both oxygen therapy and an indwelling urinary catheter; observations and a nursing note confirmed oxygen use and catheter change, but the care plan did not include either need. Resident #2 had a history of breast cancer and weakness, had moderate cognitive impairment on the MDS, and had an order for continuous oxygen at 2 L/min via nasal cannula; observation confirmed oxygen use, but the care plan did not include oxygen-related interventions. Staff interviews indicated the MDS nurses were responsible for updating care plans, and multiple leaders stated that oxygen use and indwelling catheters should have been care planned.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards of practice for 2 residents who had physician orders for supplemental oxygen and weekly oxygen tubing changes. A facility policy titled Departmental (Respiratory Therapy) - Prevention of Infection stated oxygen cannulae and tubing were to be changed every seven days or as needed. Resident #2 was admitted with diagnoses including breast cancer and weakness, had moderate cognitive impairment, and had an active order for oxygen at 2 L/min continuously via nasal cannula with tubing to be changed weekly on the night shift. Although the September 2025 MAR documented the tubing was changed on 09/21/2025, an observation on 09/22/2025 showed the tubing dated 09/15/2025, and LPN #17 later observed the same date on the tubing and stated night shift was responsible for changing it. Resident #49 was admitted with diagnoses including COPD, shortness of breath, and dependence on supplemental oxygen, and had intact cognition. The resident had an active order for oxygen at 3 L/min as tolerated via nasal cannula with tubing to be changed weekly on Sunday night shift. The September MAR documented the tubing was changed on 09/21/2025, but observations on 09/22/2025 and 09/23/2025 showed the tubing dated 09/01/2025. LPN #17 confirmed the tubing date, and LPN #18 stated oxygen tubing was supposed to be changed every Sunday night and that she must have missed the resident when changing tubing. RN #13 stated she checked each room to ensure tubing was changed, the ADON stated unit managers were responsible for monitoring that tubing was changed, and the Administrator stated unit managers were responsible for monitoring and charge nurses were expected to change the tubing.
Failure to Post EBP Signage for Resident With Indwelling Urinary Catheter
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for 1 of 21 sampled residents, Resident #4, by not posting signage to communicate to staff that EBP was required. Facility policy stated that infection control practices were intended to help prevent and manage transmission of disease and infections and included guidelines for implementing isolation precautions. CDC guidance reviewed in the report stated that EBP includes gown and glove use during high-contact resident care activities for nursing home residents with wounds and/or indwelling medical devices, and that clear signage should be posted outside the resident room indicating the precautions and required PPE. Resident #4 was admitted with diagnoses including dementia, urinary tract infection, and need for assistance with personal care. The admission MDS showed a BIMS score of 15, indicating intact cognition, and identified an indwelling urinary catheter. The order summary and progress note also documented the indwelling urinary catheter. Observations on two separate dates showed no posted signage on the resident’s room door to indicate EBP and no PPE readily available in or around the room. During interviews, an LPN stated that residents with indwelling urinary catheters should be placed on EBP and that staff relied on door signage to determine required PPE, while the ADON stated that any resident with an indwelling urinary catheter needed to be placed on EBP.
Failure to Provide Notice of Rights and Services Upon Admission
Penalty
Summary
Facility staff failed to provide a resident with a notice of rights and services prior to or upon admission, as required. The resident, who had diagnoses including atrial fibrillation, traumatic brain injury, epilepsy, and anxiety disorder, was admitted on a Friday and had a BIMS score of 5, indicating severe cognitive impairment. Admission paperwork, including resident rights and responsibilities, was not provided or signed until three days after admission, on the following Monday. The admissions staff confirmed that paperwork was delayed due to their work schedule, and the administrator noted that resident rights were posted throughout the facility. No additional information was provided to the survey team before the exit conference.
Failure to Notify Responsible Party of Antipsychotic Medication Discontinuation
Penalty
Summary
Facility staff failed to notify the responsible party (RP) when a resident's antipsychotic medication, Seroquel, was discontinued. The resident had diagnoses including Alzheimer's disease, dementia, anemia, hypertension, anxiety, and restlessness and agitation, and was assessed as having severe cognitive impairment. The clinical record showed that Seroquel was discontinued, but there was no documentation indicating that the RP had been informed of this change. Staff interviews confirmed that no note was made regarding RP notification, and the Assistant Director of Nursing stated that it was the hall nurse's responsibility to report such changes. The facility's policy requires that the resident representative be notified of significant changes, but during the survey, staff could not provide evidence that this notification occurred. The nurse practitioner documented that the medication was discontinued due to falls, but again, there was no record of RP notification. The facility leadership acknowledged the issue and noted difficulty in reaching the RP, but no further information or documentation was provided to the survey team before the exit conference.
Failure to Document Required Information During Hospital Transfers
Penalty
Summary
Facility staff failed to ensure that required documentation related to hospital transfers was included in the clinical records for two residents. For one resident with a history of acute and chronic respiratory failure, obstructive sleep apnea, and COPD, staff did not document what paperwork was sent with the resident, who was contacted at the emergency department, or the name of the facility to which the resident was transferred. The resident was found unresponsive and was transferred to the hospital, but the clinical record lacked the necessary details as outlined in the facility's Transfer to Hospital Checklist. Another resident, who had diagnoses including hypertension, dementia, and chronic pain, also experienced a deficiency in documentation during a hospital transfer. The resident complained of chest pain and requested to go to the emergency room. While the nurse's note indicated that the daughter and 911 were notified, there was no further documentation regarding the transfer, such as what information was sent with the resident or which hospital the resident was transferred to. The facility's Transfer to Hospital Checklist specifies that staff should document the bed hold policy, care plan, MAR/TAR, facesheet, DNR form, and details of the report given to the emergency room, as well as the name of the hospital and notifications made. Interviews with the DON confirmed that this documentation was expected but not consistently completed. The lack of proper documentation was discussed with facility leadership, but no additional information was provided before the survey exit.
Failure to Follow Provider Orders and Document Care for Two Residents
Penalty
Summary
Facility staff failed to follow provider orders for two residents. For one resident with diagnoses including epilepsy, atrial fibrillation, traumatic brain injury, and anxiety disorder, nursing staff did not transcribe an order for the seizure medication Lamictal from the hospital discharge instructions onto the admission paperwork. The medication order was only entered into the clinical record the day after admission. The resident had severe cognitive impairment, and the care plan included administration of seizure medication as ordered. There was no documentation of seizures during the resident's stay, and laboratory results for Lamotrigine were within the reference range. For another resident with Alzheimer's disease, dementia, and other conditions, staff failed to follow provider orders for Seroquel and the application of geri-sleeves. The Seroquel order was for 7 days, but the medication administration record allowed for 11 doses, and staff documented administration on some days and held the medication on others due to family request or sedation. Additionally, there were multiple days with no documentation that geri-sleeves were applied as ordered, and staff did not use the appropriate codes to indicate refusal. Facility policy required all services provided to be documented in the medical record.
Failure to Obtain and Document Provider-Ordered Urinalysis
Penalty
Summary
Facility staff failed to provide evidence that a provider-ordered urinalysis (UA) was obtained for a resident with multiple diagnoses, including atrial fibrillation, traumatic brain injury, epilepsy, and anxiety disorder. The resident had severe cognitive impairment, was always incontinent of urine, and had recently completed antibiotics. The provider ordered a UA with culture and sensitivity due to complaints of dysuria and confusion, and the order was marked as completed in the clinical record. However, no laboratory results were found in the resident's record, and there was no documentation explaining the absence of the results or any progress note indicating an inability to collect the specimen. Interviews with nursing staff revealed that standard procedures for collecting urine samples were not followed or documented, especially in cases where collection was not possible. Administrative staff later stated that the resident was sent out at the spouse's request, possibly before the UA was collected, or that the sample may have been discarded. Additionally, the laboratory company used by the facility had gone out of business, leaving no way to retrieve the results. No further information or documentation regarding the missing UA was provided to the survey team.
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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.
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Nursing homes near Bristol
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, Bristol | 5.7 mi | ★★★★★ | 3 | 0 |
| Deer Meadows Rehabilitation And Nursing | 11.1 mi | ★★★★★ | 0 | 0 |
| Waters Of Bristol A Rehabilitation And Nursing | 11.9 mi | ★★★★★ | 7 | 0 |
| Abingdon Health & Rehab Center | 13.9 mi | ★★★★★ | 0 | 0 |
| Maple Grove Nursing & Rehab Center | 18.5 mi | ★★★★★ | 1 | 0 |
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