The Rehab Center At Bristol

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

that OT #31 did not mention anything about a staff member being aggressive; subsequently, she did not think abuse was being discussed. She stated that on 12/30/2024, Resident #98 had also told PT #2 that a therapist had squeezed their leg, hard; however, Therapy Staff #29 did not know whether she was notified of the concern or if she saw PT #2's statement. Per Therapy Staff #29, she spoke with staff and Resident #98's family member. She stated she was not aware there were any further concerns until the SSD gave her a grievance form on 01/14/2025. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Rehab Center at Bristol

301 Village Circle Bristol, VA 24201

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2024, revealed Resident #98 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition.

Resident #98's “Care Plan Report” included a focus area initiated 12/12/2024, that indicated

the resident had a deep vein thrombosis (DVT; a blood clot) of the lower extremity, was on anticoagulant therapy, and had edema. Interventions initiated 12/12/2024 directed staff to assess the resident's fingers and toes for warmth and color, obtain the resident's vital signs, and notify the medical doctor of significant abnormalities.

A facility document titled, “Facility Reported Incident (FRI),” dated 01/14/2025, revealed Resident #98 alleged that on 12/18/2024, a physical therapist “aggressively messaged” behind the resident's knee, “cutting off blood flow” to the resident's leg, and resulted in the resident going to the hospital. Per the FRI, the resident made the allegation on 12/31/2024 to an occupational therapist. The FRI indicated that concerns were addressed with the facility providers, who stated that treatment could not have caused numbness or pain. The FRI indicated that the pain was related to a blood clot and hematoma for which the resident was previously admitted to the hospital. The FRI indicated that it was explained to the resident's family member, there was no further discussion, and the team felt everything was okay until Resident #98 complained again to the SSD on 01/13/2025. The FRI indicated that the facility completed a grievance form; however, the resident then stated that they felt neglected. The “Employee action initiated or taken” section of the document indicated that Physical Therapist (PT) #8 “has not treated [Resident #98] since [their] return from the hospital.”

The facility's investigation revealed no evidence that other residents were interviewed regarding the treatment they received from PT #8 or interventions implemented to protect other residents from abuse from PT #8 during the investigation.

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.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Rehab Center at Bristol

301 Village Circle Bristol, VA 24201

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

one side and needed maximal assistance for mobility. Therapy Staff #29 stated Resident #101 was extensively evaluated for their mobility and the assistance they required. She said the physical and occupational therapists were expected to communicate the level of care needed for each resident to the nursing staff. She indicated she would consider moderate assistance to be assistance of one person and maximal assistance times two (x 2) would have indicated the resident required the assistance of two people. 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.

Event ID:

Facility ID:

If continuation sheet