Eastcastle Pl Bradford Ter Conv Ctr

Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents with pressure injuries received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent pressure injuries from developing for 1 (R38) of 4 residents reviewed with pressure injuries. R38 was admitted to the facility on [DATE] and was at risk for the development of pressure injuries. R38's admission assessment does not indicate R38 has pressure injuries. Hospital discharge paperwork dated 12/5/25 does not indicate R38 had pressure injuries or had treatment orders for pressure injuries. On 12/7/25 a registered nurse documents a list of skin concerns including scabbed areas on R38's bilateral heels. These areas are not comprehensively assessed. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure food was served in accordance with professional standards for food service safety.* The 5th floor kitchen server for lunch was observed. The Cook-E used gloves for multiple tasks, including handling ready-to-eat foods. The food thermometer had a tethered string that was not maintained to prevent food contamination. This had the potential to affect all 20 residents on the 5th floor.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R2) of 1 resident received the necessary assessment to self-administer medications. On 2/16/26 at 9:44 a.m. Surveyor interviewed R2. Surveyor observed an Advair inhaler on the table beside the bed. Surveyor asked R2 if she uses the inhaler independently. R2 stated she does and has been using that inhaler for many years. Surveyor asked R2 if the nurses leave the inhaler in R2 possession and R2 stated yes. Surveyor reviewed R2 assessments, and a self-administration of medications assessment was not completed.

Inspectors wroteBased on record review and interview, the facility did not ensure a resident with psychotropic medications was comprehensively assessed for their use. This was observed with 1 (R38) of 5 resident medication reviews.* R38 was admitted [DATE] with Duloxetine (antidepressant), Bupropion (antidepressant) and Trazadone (antidepressant). The diagnosis for Duloxetine is for depression, Bupropion for dysthymia and Trazadone for insomnia. The medical record does not have documentation of a comprehensive assessment for the use of these medications.

Inspectors wroteBased on record review and interview, the facility did not document additional assessments for the Care Area Assessment (CAA) triggered by the Minimum Data Set (MDS) assessment information. This would include a summary of the information to complete a comprehensive assessment. This was observed with 3 (R38, R23, and R62) of 12 resident reviews. * R38 had an admission MDS assessment completed on 12/12/25. The MDS triggered CAAs for Falls, Pressure Injury, Psychotropic Drug Use, Psychosocial Well-Being and Behavioral Symptoms. The CAAs did not have an additional assessment summary analyzing the MDS data and need for an individualized care plan. * R23 had a Significant Change in Status (SCS) MDS assessment completed on 11/19/25. The MDS triggered a CAA for Falls. The CAA did not have an additional assessment summary analyzing the MDS data and need for an individualized care plan. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R52) of 12 residents reviewed received a completed Minimum Data Set (MDS). R52 was discharged to the hospital on 9/10/25 due to a change in condition. A discharge MDS was not completed.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R2) of 12 residents reviewed received an accurate comprehensive Minimum Data Set (MDS) assessment. R2 was admitted on [DATE] and the admission MDS dated [DATE] assess R2 with the need for tracheostomy care. Surveyor notes R2 does not have a tracheostomy.

Inspectors wroteBased on interview and record review, the facility did not ensure a baseline care plan was developed and implemented within 48 hours of a resident's admission for 1 (R38) of 12 sampled residents reviewed for baseline care plans.*R38's baseline care plan was not thoroughly completed as every section of R38's baseline care plan was not completed. Findings Include:The facility did not provide a baseline care plan policy and procedure for review. [...]

Inspectors wroteBased on interview and record review, the facility did not complete neurological (neuro) checks in accordance with policy and procedure for 1 (R38) of 4 residents reviewed for unwitnessed falls.*R38 did not receive neurological checks in accordance with facility's policy and procedure for 1 of 3 unwitnessed falls. Findings Include:The facility's Falls policy and procedure revised 12/25 documents:2. In addition, the nurse shall assess and document/report the following:e. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure a resident (R23) with hearing and vision impairment received proper treatment and assistive devices to maintain vision and hearing abilities.*Surveyor observed R23 to not be wearing R23's bilateral hearing aids and glasses during the survey process. Findings Include:The facility's Hearing Impaired Resident, Care of policy and procedure revised 2/18 documents:Policy Statement:Staff will assist hearing impaired residents to main effective communication with clinicians, caregivers, other residents and visitors. Policy Interpretation and Implementation:3. Staff will assist residents with care and maintenance of hearing devices.4. Staff will help residents who have lost or damaged hearing devices in obtaining services to replace the devices.j. Evaluate resident's adaptive needs and progress at regular intervals. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 3 (R23, R38 and R62) of 4 sampled residents received adequate supervision and assistance devices to prevent and be free of accidents. * On 2/2/26 R23 was evaluated by physical therapy, after the facility risk management team determined R23 was doing better, to assess changing R23's transfer status from the use of a mechanical lift to being transferred with a sit to stand or through a stand-pivot transfer. Following the evaluation R23 was upgraded to transfer with the assist of two staff using a sit to stand. R23's power of attorney for healthcare was not consulted with or notified of this change in care for R23. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R6) of 3 residents observed during medication pass received medications without errors or that the medication error rate was not 5 percent or greater. The medication error rate was 33.33%.*On 2/17/26 at 9:00 a.m., Surveyor observed R6 receive his medications through his G (gastrointestinal) tube. Surveyor observed RN (Registered Nurse)- F dispense R6's morning medications into individual medication cups and then crush them individually. RN-F instilled all the medications at the same time without water flushes in between each medication.

Inspectors wroteBased on record review, observation and interviews, the facility did not ensure the required nurse staff posting information was posted. The facility did not document the total amount of hours for Certified Nursing Assistants (CNAs). This had the potential to affect all 39 residents in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R1) of 1 facility reported incidents reviewed for an allegation of misappropriation, was reported to the local law enforcement agency.*On 6/26/25, facility staff was made aware of R1's missing narcotic pain medication. The facility did not report the incident to local law enforcement.

Inspectors wroteBased on observation and interview the facility did not ensure the call light was within reach for 1 (R290) of 12 residents reviewed. *R290 was observed in R290's room without a call light within reach.

Inspectors wroteBased on observation, interview, and record review, the Facility did not ensure staff followed infection control procedures for 3 (R13, R22 and R290) of 12 residents sampled. * Wound care preformed for R13- staff did not follow standard of practice for hand hygiene in between glove changes and did not sanitize scissors for wound treatment. *R290 noted to be on Enhanced Barrier Precautions (EBP), staff member observed not following standards of practice while providing high contact, incontinence care. *Incontinence cares observed for R22, staff member observed not changing soiled gloves and did not perform hand hygiene prior to applying lotion to R22.