Inspection Reports for
Village Green of Bristol Rehabilitation and Health Center

The facility was found deficient in multiple areas including resident dignity, environmental cleanliness, care planning, pressure ulcer prevention, accident prevention, respiratory care, nurse aide competencies and evaluations, infection control, call system accessibility, and safety of equipment. Several residents' care plans were incomplete or not updated, and staff failed to consistently follow policies and procedures.

The facility failed to develop and implement comprehensive care plans for residents at risk of elopement, seizures, and respiratory care needs. Additionally, the facility failed to ensure adequate supervision and accident prevention measures, resulting in a resident fall with injury and unsafe conditions in the designated smoking area.

The investigation was triggered by a complaint regarding failure to perform neurological checks after a fall. The deficiency was substantiated with findings that multiple neurological checks were missed despite physician orders and facility policy.

The facility failed to complete neurological checks in full per protocol for Resident #1 after an unwitnessed fall. Several neurological checks were missed during the required monitoring periods despite physician orders to continue them.

The facility failed to implement required transmission-based precautions for Resident #5, who had multiple drug-resistant infections. Observations and interviews revealed staff did not properly remove personal protective equipment or perform hand hygiene, increasing risk of infection transmission.

The facility failed to ensure complete and accurate clinical record documentation for wound care and resident care for multiple residents. Additionally, wound care was not consistently provided in accordance with accepted infection control practices, including improper glove use and failure to perform hand hygiene during wound care.

The complaint involved allegations that two nursing assistants were rough with Resident #1, threw him/her like a rag doll, and swore at him/her during care on the day of an x-ray. Resident #1 was afraid to report due to fear of retaliation. The facility did not report all allegations to the State Agency timely and did not fully investigate the abuse claims.

The facility failed to timely report allegations of abuse to the State Agency and failed to investigate allegations of abuse properly. Additionally, the facility failed to revise the care plan to indicate refusals of personal care for Resident #1.

The complaint investigation substantiated that a resident aspirated thin milk instead of nectar-thickened milk as ordered, causing respiratory distress and hospitalization. Staff error and supply issues contributed to the incident.

The facility failed to ensure a resident with dysphagia received the correct nectar-thickened liquids according to physician orders, leading to aspiration, respiratory distress, and hospitalization. The investigation revealed a staff error in not thickening the milk, compounded by a lack of pre-thickened milk availability due to vendor backorder.

The complaint investigation was substantiated with findings that Resident #1 attempted to smother Resident #2 with a pillow. Resident #1 was transferred to the hospital and later discharged from the facility. Resident #2 expressed fear and emotional distress but had no physical injuries.

The facility failed to ensure Resident #2 was free from mistreatment by Resident #1, who was observed attempting to smother Resident #2 with a pillow. The incident was investigated through clinical record reviews, interviews, and psychiatric evaluations, confirming minimal harm and emotional distress to the residents.

The facility failed to provide appropriate pressure ulcer care, including initial wound assessment and weekly skin audits, and failed to obtain and transcribe physician orders for PEG tube maintenance, resulting in minimal harm or potential for actual harm to a few residents.

The complaint alleged neglect of Resident #1 on 5/6/2023 when care was not provided from 6 AM to 1 PM. The allegation was substantiated with video evidence and staff interviews. The allegation was not reported to supervisors timely, with a delay of three days before the facility was notified.

The facility failed to provide timely care to Resident #1 for seven hours on 5/6/2023, resulting in neglect. Additionally, staff failed to report the allegation of neglect promptly, and there was inadequate oversight of nursing assistant assignments contributing to the care failure.

The facility was found to have multiple deficiencies including failure to maintain a clean and sanitary environment, inadequate notification of hospital transfers to the State Long-Term Care Ombudsman, inaccurate resident assessments, failure to implement behavior monitoring for psychotropic medications, improper labeling of enteral feeding systems, incomplete smoking assessments, failure to monitor medication administration via feeding tubes properly, incomplete nursing competencies, lack of coordination with hospice providers, infection control lapses, incomplete antibiotic use monitoring, and failure to ensure residents were offered and educated about influenza and pneumococcal vaccines.

The facility failed to maintain a sanitary and clean environment in resident bathrooms and equipment, with visible soiling noted on toilet seats and commodes. Additionally, the facility failed to provide written notice of the bed-hold policy to residents and their representatives during hospital transfers.