The Bradford at Brookside

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free from significant medication error, in excessive dose (including duplicate drug therapy) for 1of 6 residents (Residents #2) reviewed for unnecessary medications. The facility failed to ensure Resident #2's routine pain medication, Hydrocodone-Acetaminophen Tablet (prescribe for acute pain, opioid agonist and a Schedule II controlled substance) 10-325 mg one tablet by mouth four times a day was not duplicated on 04/06/2026 at 9:00 p.m. by LVN C. The failure could place residents at risk for being administered unnecessary pain medication and could have adverse reactions including over sedation and decline in health condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Residents #1) observed for infection control. The facility failed to implement EBP for Resident #1 during a wound care and dressing change on 04/23/2026. This failure could place residents at risk of communicable diseases. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the social worker had the required qualifications for 1 of 1 facility reviewed for social worker qualifications. The Social Worker hired on 12/09/2024, as a full-time social worker was not licensed by the Texas State Board of Social Worker Examiners. This failure could place all residents at risk for unmet social services and psychosocial needs. Record review of an employee file on 08/27/2025 indicated the SW was not a licensed social worker and held a bachelor's degree in social work. The facility hired her as a social worker on 12/09/2024. Review of the facility's January 2017 job description for the Social Worker position indicated Qualifications: Minimum of a bachelor's degree in social work or in human services fields. Licensed per state requirements or eligible for licensure. [...]

Inspectors wroteBased on interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 18 Residents (Resident #7) who were reviewed for dignity. The facility failed to ensure LVN J spoke to Resident #7 in a way that promoted his dignity and self-worth. The failure could place residents at risk of decline in their sense of dignity level of satisfaction with life and feeling of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was consulted regarding a need to alter treatment for 1 of 18 residents reviewed for notification of changes. (Resident #4) The facility did not consult with Resident #4's physician about the pattern of low blood pressure over multiple days and of the blood pressure medication being held for 5 of 50 opportunities in August 2025. This failure could place residents at risk for complications due to delayed or failed physician intervention. Record review of the face sheet for Resident #4, an [AGE] year-old female, indicated admission to facility on 05/16/2025 with diagnosis including hypertension (high blood pressure). Record review of Resident #4's admission MDS dated [DATE] included diagnoses of coronary artery disease and high blood pressure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain personal privacy during delivery of personal care and services to 1 of 18 residents (Resident #47) reviewed for privacy. The facility failed to provide Resident #47 with a privacy curtain that would close completely. This failure could place residents at risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident assessments accurately reflected the resident's status for 1 of 18 resident (Resident #2) reviewed for accuracy of assessments. The facility failed to accurately complete the MDS assessment to indicate Resident #2's tobacco use. This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 2 (Resident #67) residents reviewed for respiratory care with tracheostomy. The facility failed to ensure Resident #67's oxygen was administered at the correct setting of 4-6 liters per minute on 08/25/25 as ordered by the physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 18 residents reviewed for medication administration. (Resident #3)The facility failed to follow the physician's orders related to blood pressure medication and did not administer a PRN medication for Resident #3. This failure could place the residents at risk of not receiving necessary medications and a decline in health. Record review of the face sheet for Resident #3, indicated a [AGE] year-old male, with a readmission date of 07/27/2025 with diagnoses including hypertension (high blood pressure) and anxiety disorder. Record review of Resident #3's Quarterly MDS dated [DATE] indicated a BIMS of 14 indicating cognition intact. Diagnoses included high blood pressure and anxiety disorder. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 18 residents reviewed for medication administration. (Resident #3). The facility failed to ensure clonidine 0.2 mg (used to lower blood pressure) was administered to Resident #3 as ordered from 08/01/2025 - 08/27/2025. (there were 9 opportunities) This failure could place residents at risk for not receiving medications as ordered by their physician. Record review of the face sheet for Resident #3, indicated a [AGE] year-old male, with a readmission date of 07/27/2025 with diagnoses including hypertension (high blood pressure) and anxiety disorder. Record review of Resident #3's Quarterly MDS dated [DATE] indicated a BIMS of 14 indicating cognition intact. Diagnoses included high blood pressure and anxiety disorder. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to be treated with respect and dignity for 1 of 6 residents reviewed for resident rights. (Resident #1) The facility failed to ensure CNA C did not put her fingers in Resident #1's face. This failure could cause the resident to be distressed and could cause residents to feel disrespected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of residents (Resident #1) reviewed for resident abuse. The facility failed to ensure Resident #1 was free from abuse when CNA C put her fingers in Resident #1's face. This failure could cause the residents at risk of disrespect, mental anguish, and/or emotional distress.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Resident #2) reviewed for pressure injury. The facility failed to ensure the Treatment Nurse measured and adequately documented Resident #2's wound in the EMR when it was initially found on 05/15/2025. These failures could place residents at risk for deterioration of wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 4 residents (Resident #1) reviewed for resident rights. The facility did not have a DNR order when Resident #1 provided a copy of his Advanced Directive upon admission. The facility did not provide emergency medical technician and hospital personnel with any information relating to Resident #1's known existing advance directive. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 20 residents reviewed for range of motion. (Resident #66) The facility did not ensure Resident #66's palm guard (device used as a barrier between fingers and palmar skin to prevent injury to the palm from severe finger flexion contracture) was placed in her hands bilaterally, after therapy assessed the resident's needs and referred the resident to restorative care. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who entered the facility with an indwelling catheter were assessed for removal of the catheter as soon as possible and restore continence to the extent possible for 1 of 2 residents reviewed for urinary catheters. (Resident #275) The facility failed to attempt bladder retraining and discontinuation of an indwelling urinary catheter (a tube which is inserted into the bladder, through the urethra and remains in place to drain urine) for Resident #275 whose clinical condition did not necessitate catheterization. This failure could place residents with a urinary catheter at increased risk of dependence on a urinary catheter and urinary tract infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 20 residents reviewed for respiratory care and services. (Resident #66) *The facility failed to administer the correct dose of oxygen to Resident #66. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs to each resident for 1 of 7 residents reviewed for medications. (Resident #175) The facility failed to ensure Resident #175 was not administered a saline IV flush before administration of an IV antibiotic and an IV saline and an IV heparin flush after medication administration (SASH-saline administer, saline heparin) without a physician's order. This deficient practice could place residents at risk of consuming unprescribed medications, harm, and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 1 of 9 dietary staff (Dietary Staff B) reviewed for competencies. The facility failed to ensure Dietary Staff B had a current Food Handlers Certificate while working in the facility's kitchen. This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff.

Inspectors wroteResident #51 FTag Initiation Based on interview and record review, the facility failed to ensure that the residents and/or representatives had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the residents and/or representatives for 5 (Resident #23, #28, #38, #42 and #51) of 16 residents reviewed for care planning. The facility failed to ensure the IDT, Resident #23, Resident #28, and Resident #38 and RP of Resident #38, Resident #42 and the RP of Resident #42, Resident #51 and RP of Resident #51 were involved in the review of the comprehensive assessment and were able to discuss their individualized care needs for services to include their need for medical and nursing care, medications, therapy, psychological and dietary needs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote resident self-determination through support of resident choice for 1 of 22 residents reviewed for resident rights. (Resident #19) The facility did not assist Resident #19 out of bed when he requested. This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 3 of 22 residents reviewed for ADLs (Resident #17, Resident #19, and Resident #219). The facility failed to provide scheduled baths/showers for Resident #17 and Resident #19. The facility failed to trim and clean Resident #219 nails. These failures could place residents who required assistance from staff for personal hygiene at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation and interview, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 22 residents reviewed for resident rights. (Resident #19) The facility failed to close the blinds to the outside window while providing incontinent care to Resident #19. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 22 residents (Resident #225) reviewed for reasonable accommodations. The facility failed to provide an appropriately sized bedside commode for Resident #225. This failure could place residents at risk for unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate MDS assessment was completed for 1 of 14 residents reviewed for MDS accuracy. (Resident # 51 and #43) 1. The facility failed to accurately document Resident #51's and Resident #43's wander/elopement alarm usage. These failures could place residents at risk for not receiving needed care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 3 residents reviewed for new admissions (Resident #225). The facility failed to ensure Resident #225 completed her baseline care plan within 48 hours of admission and was provided a written summary. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder and entered the facility with an indwelling catheter was assessed for removal of the catheter as soon as possible for 1 of 2 residents (Resident #226) reviewed for catheter use. The facility failed to remove Resident #226's indwelling catheter after admission due to no appropriate diagnosis of use. This failure placed resident at risk for urinary tract infection (is an infection in any part of your urinary system, which includes your kidneys, bladder, ureters, and urethra) and inappropriate treatment and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 22 residents reviewed for respiratory care. (Resident #22, Resident #60). The facility failed to ensure Resident #22's nebulizer mask and tubing was properly stored and dated per the facility's policy. The facility failed to assist Resident #60 with putting on and taking off her Bipap machine (a form of non-invasive ventilation that providers might use if you can breathe on your own but are not getting enough oxygen or cannot get rid of carbon dioxide). These failures could place residents at risk of respiratory complications or respiratory infection.

Inspectors wroteBased on record review, interview and observation the facility failed to ensure 1 of 22 residents reviewed for psychotropic medications were given the meds to treat a specific condition. The facility failed to have an appropriate diagnosis or indication of use for Resident #38's Risperdal (antipsychotic). This failure could put residents at risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on interview, and record review the facility failed to provide specialized rehabilitative services for 1 of 22 residents reviewed for specialized rehabilitative services. (Resident #62) The facility failed to ensure Resident #62 received occupational therapy and as per physician orders after being readmitted to the facility. This failure could place residents with orders for therapy at risk of not meeting their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 22 residents (Residents #19 and Resident #223) reviewed for infection control practices. The facility to ensure the WCN performed a sterile dressing change on Resident #223. The facility failed to ensure CNA D changed gloves and practiced good hand hygiene during incontinent care provided to Resident #19. These failures placed residents at risk for cross contamination and infection.