Bradford Hills Nursing: Wound Care Skipped Repeatedly - PA
Inspectors who visited Bradford Hills Nursing & Rehabilitation Center on May 27, 2026, found that staff had failed to document — and in the facility's own accounting, failed to complete — physician-ordered wound care for at least three residents over the course of May.
The problems were not isolated to a single resident or a single lapse.
A physician had ordered Nystatin cream applied to Resident 2's abdomen every day shift and every night shift for wound care, starting January 21, 2026. When inspectors reviewed that resident's treatment administration record for May, they found the treatment had gone undocumented on three of the 26 days they examined. May 10. May 18. May 19. On each of those days, the record was blank.
Resident 3's situation was more complicated, and in some ways more troubling. That resident had a wound on the left ischium, the curved bone that forms the base of the pelvis, a location that bears the body's weight during sitting and is particularly vulnerable to breakdown. A physician order in place starting April 28 instructed staff to cleanse the wound with normal saline, pat it dry, apply Silvasorb gel to the base of the wound, apply zinc oxide around the wound's edges, and secure everything with a bordered gauze dressing, every day shift. The order ran until May 4. Of the four days it was active and reviewed by inspectors, staff failed to complete the treatment on one of them. May 3 was blank.
A new order took effect May 4, expanding the same wound care regimen to both day and night shifts. Inspectors reviewed 23 days under that order. Two were blank. May 20. May 21. Back-to-back days with no documented treatment on a wound that required twice-daily attention.
Silvasorb gel is used to treat partial and full thickness wounds. The distinction matters: full thickness wounds extend through the skin's outer layers entirely. The inspection report does not specify the depth of Resident 3's wound, but the ordered treatment protocol, saline cleansing, antimicrobial gel, zinc oxide barrier, secured dressing, reflects the kind of regimen typically associated with a wound that required consistent, careful attention.
The inspection report does not describe what Resident 3's wound looked like by the time inspectors arrived. It does not say whether the missed treatments caused visible deterioration. What it records is the absence of documentation, and under the facility's own system, an undocumented treatment is an uncompleted one.
The same citation was issued to Bradford Hills less than six months earlier. Inspectors had flagged the same failure, under the same regulatory provision governing quality of care, on December 12, 2025. The May 2026 inspection listed that prior citation explicitly, marking the wound care failures as a repeat violation.
The findings were reviewed with the Nursing Home Administrator and the Director of Nursing on the afternoon of May 27, 2026.
There is nothing in the inspection report about what either administrator said.
What the record shows is a pattern that repeated itself across residents and across weeks. A doctor writes an order. The order specifies what to do, when to do it, and for whom. The shift comes. The shift goes. The line on the form stays empty.
For Resident 3, whose wound sat at the base of the pelvis and required cleaning and dressing twice a day, two of those empty lines fell on consecutive days.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bradford Hills Nursing & Rehabilitation Center from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 13, 2026 · Our methodology
BRADFORD HILLS NURSING & REHABILITATION CENTER in TROY, PA was cited for violations during a health inspection on May 27, 2026.
The problems were not isolated to a single resident or a single lapse.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.