Eastcastle PL Bradford Ter Conv CTR

In the surveyor’s words

From the most serious findings on record at Eastcastle PL Bradford Ter Conv CTR, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 18, 2026

  Based 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. […]

• Actual harm, isolatedF686May 19, 2022

  Based on observation, interview, and record review the Facility did not provide necessary treatment and services to prevent development of a pressure injury and promote healing for 1 (R4) of 3 Residents with pressure injuries. On 2/8/22 R4's significant change minimum data set indicated R4 was at risk for the development of pressure injuries. R4's plan of care for pressure injuries was not revised to include individualized interventions to prevent developing pressure injuries based upon assessment. On 3/6/22 nursing noted R4 developed a pea sized area on the sacrum and was called a stage 2. The area was not comprehensively assessed on this date. On 3/8/22 the Facility assessed the area and staged it as a stage 2 pressure injury despite the area being assessed to have 60% slough present. […]

• No harm, potential for more than minimal, widespreadF886May 19, 2022

  Based on interview and record review the facility did not ensure they completed COVID-19 testing of staff according to Center for Disease Control (CDC) recommendations for 1 of 3 staff with approved non-medical exception for the COVID-19 vaccination. There is no documentation Staff-L, who has a non-medical COVID-19 vaccination exemption, is being tested for COVID-19 according to CDC county transmission rates. This has the potential to affect all 35 Residents at the facility. Findings include: On 5/18/22, this Surveyor reviewed the facility policy titled Resident and Staff Testing Intervals for COVID-19, undated, which documents: Staff not up to date (COVID-19 vaccination) must routine test at a minimum according to CDC county transmission rate. 1. […]

• No harm, potential for more than minimal, patternF812Feb 18, 2026

  Based 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.Findings include:The facility policy and procedure Hospitality Department-Attendance, Conduct, and Safety Policy dated 9/12/2025 documents: The purpose of this policy is to give a hospitality employees clear direction regarding attendance, time-off requests, food handling, glove usage guidelines, kitchen safety, and grooming standards. […]

• No harm, potential for more than minimal, patternF700May 19, 2022

  Based on observation, interview, and record review the facility did not have an updated comprehensive assessment for repositioning/assist bars for 10 (R18, R234, R1, R17, R2, R23, R6, R9, R15 & R25) of 10 Residents observed with repositioning/assist bars. Further, the facility did not have evidence of the Interdisciplinary Team (IDT) involvement, no documentation of repositioning/assist bars being reviewed at care conference, and repositioning/assist bars were not documented on their Minimum Data Set (MDS) or comprehensive care plan. *R18, R234, R1, R17, R2, R23, R6, R9, R15, and R25 did not have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . […]