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Complaint Investigation

The Rehab Center At Bristol

October 1, 2025 · Bristol, VA · 301 Village Circle
Citations 3
CMS Rating 2/5
Beds 90
Provider ID 495425
Healthcare Facility
The Rehab Center At Bristol
Bristol, VA  ·  View full profile →
Inspection Summary

THE REHAB CENTER AT BRISTOL in BRISTOL, VA — inspection on October 1, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0609
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

During an interview on 09/28/2025 at 12:06 PM, the Administrator stated Resident #98's concerns were brought to her attention on 01/14/2025, during a 10:00 AM morning meeting after the grievance was filed, and she then notified the SSA of the allegations via fax.

She stated that the time on the Facility Reported Incident Fax Cover Sheet was the time she notified the appropriate agencies.

During a follow-up interview on 09/26/2025 at 1:49 PM, the Administrator stated that when she saw the grievance and the team reported what happened, they decided it would be better to make a report to the SSA rather than a completing a grievance because the resident was making an accusation against the therapist.

She stated that allegations of abuse should be reported within two hours.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/01/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Rehab Center at Bristol

301 Village Circle Bristol, VA 24201

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 09/26/2025 at 9:17 AM, PT #8 stated Physical Therapy Aide (PTA) #6 voiced concerns about Resident #98's leg and asked him to look at the resident. PT #8 stated that he assessed the resident and assessed the resident again upon readmission from the hospital, which was when the resident made an allegation of abuse.

According to PT #8, he was not suspended from work but did not treat Resident #98 during the investigation.

During an interview on 09/26/2025 at 11:58 AM, Therapy Staff #29, who was the Director of Rehabilitation, stated PT #8's employment was not suspended during the investigation, and she could not recall how they protected Resident #98 or other residents from further potential abuse during the investigation.

During an interview on 09/26/2025 at 12:48 PM, the Assistant Director of Nursing (ADON) stated she would have to review the facility's policy to determine whether PT #8 should have been suspended because she did not know the whole situation.

During an interview on 09/26/2025 at 1:49 PM, the Administrator (ADM) revealed that Resident #98 alleged that PT #8 caused them to go to the hospital.

The ADM stated that she was not sure if any other residents were interviewed.

According to the ADM, PT #8 was not suspended pending the investigation but was removed from Resident #98's assignment and did not take care of the resident anymore.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/01/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Rehab Center at Bristol

301 Village Circle Bristol, VA 24201

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 09/27/2025 at 4:20 PM, LPN #3 stated she recalled Resident #101.

She stated the resident had weakness on the left side and sometimes was observed to lean to the left side while seated in the wheelchair. LPN #3 stated she occasionally had to prop the resident up in the wheelchair. LPN #3 stated Resident #101 required the assistance of two staff members for bed mobility.

LPN #3 stated she was trained that moderate assistance indicated the resident required one-person physical assistance, and maximal assistance indicated the resident required the assistance of two people to perform care.

During an interview on 09/28/2025 at 9:21 AM, CNA #34 stated she knew how much assistance a resident needed by looking at the print-outs at the nurses' station.

She stated these documents were printed by the night shift nurse and were kept at the nurses' station.

She walked over to the nurses' station and provided a copy from a drawer and stated, They are shredded at the end of the day and that they were a working document, so there are no old copies.

During an interview on 09/28/2025 at 9:41 AM, RN #12, the Unit Manager for the Rehab Unit, stated she was unsure if the staff had a report sheet that they used to communicate resident care needs.

During an interview on 09/28/2025 at 11:23 AM, MDS Coordinator #11 stated residents' Kardex information was derived from the information he entered into the MDS assessments. He reviewed the Kardex Report for Resident #101 and acknowledged the section for bathing was blank. He stated he thought the resident would have required two people to transfer to the shower and one person to perform the shower.

During an interview on 09/28/2025 at 11:48 AM, the ADON reviewed the Kardex for Resident #101.

She acknowledged Resident #101's Kardex contained a section designated to address bathing assistance but that this section was blank; therefore, she was unsure how much assistance was required to provide bathing assistance for Resident #101.

She was unable to explain how staff would have been able to determine the number of staff required to assist the resident with bathing.

The ADON indicated she was unfamiliar with Resident #101 but stated if a resident leaned in their wheelchair, the resident was at risk to fall if not supported on that side of their body.

During an interview on 09/28/2025 at 12:00 PM, the Administrator (ADM) stated she was not on duty at the time of Resident #101's fall.

The ADM stated when she returned to work after that weekend, both she and the Director of Nursing (DON) spoke with CNA #1, who told them Resident #101 fell when she turned away to retrieve a towel.

When asked what steps were taken to investigate the fall, the ADM stated she obtained written witness statements from CNA #1 and LPN #24 and determined that the fall was an accident.

The ADM stated the fall was not reported to the state agency because it was not an incident/injury of unknown origin.

Review of the facility's investigation documentation for Resident #101's fall revealed the investigation consisted only of obtaining witness statements from CNA #1 and LPN #24.

The facility's investigation contained no evidence that the facility reviewed Resident #101's need for assistance or support while sitting and did not identify that CNA #1 turning her back, and leaving the resident unsupported on their weak/flaccid side created a situation in which the resident was at risk for experiencing a fall. As a result, the resident experienced a fall that resulted in a head injury requiring hospitalization.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BRISTOL, VA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THE REHAB CENTER AT BRISTOL or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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