Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
14 residents
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 0
Oct 29, 2025
Visit Reason
Surveyors completed a complaint investigation at Eastcastle Place.
Findings
No deficiencies were identified and the complaint was unsubstantiated.
Complaint Details
The complaint was unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 15, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report suspected abuse, neglect, or theft, specifically concerning a missing narcotic pain medication for resident R1.
Findings
The facility did not report the missing morphine syringe for resident R1 to local law enforcement despite a thorough internal investigation. The investigation found no evidence of diversion or intentional misappropriation, but the police were not notified as required by policy.
Complaint Details
The complaint investigation found that the facility did not ensure that incidents reviewed for an allegation of misappropriation were reported to local law enforcement. Specifically, a missing morphine syringe for resident R1 was not reported to police despite reasonable suspicion of a crime. The facility conducted a thorough investigation including staff interviews, medication audits, and video review but did not notify law enforcement. The Nursing Home Administrator acknowledged the failure to notify police.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication syringes discrepancy: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN-E | Registered Nurse | Witnessed and counted morphine syringes on 6/25/25 |
| LPN-C | Licensed Practical Nurse | Witnessed morphine count and reported missing syringe |
| LPN-D | Licensed Practical Nurse | Counted morphine syringes and identified discrepancy |
| DON-B | Director of Nursing | Reviewed investigation and video footage regarding missing morphine |
| NHA-A | Nursing Home Administrator | Acknowledged failure to notify law enforcement about missing morphine |
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 0
Mar 21, 2025
Visit Reason
Surveyor conducted a verification visit and complaint investigation to assess previous deficiencies and the complaint.
Findings
The previous 2 deficiencies were corrected, no new deficiencies were identified, and the complaint was unsubstantiated.
Complaint Details
Complaint was unsubstantiated.
Report Facts
Revisit fee: 200
Inspection Report
Routine
Deficiencies: 4
Nov 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection prevention, and control practices at the nursing home.
Findings
The facility was found deficient in ensuring call lights were within reach for residents, specifically for resident R290, and in following proper infection control procedures including hand hygiene and use of personal protective equipment during wound care and incontinence care for residents R13, R22, and R290.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility did not ensure the call light was within reach for resident R290. | Level of Harm - Minimal harm or potential for actual harm |
| Staff did not follow infection control procedures including hand hygiene and sanitizing equipment during wound care for resident R13. | Level of Harm - Minimal harm or potential for actual harm |
| Staff did not follow enhanced barrier precautions during incontinence care for resident R290. | Level of Harm - Minimal harm or potential for actual harm |
| Staff did not change soiled gloves or perform hand hygiene prior to applying lotion during incontinence care for resident R22. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 12
Residents affected: 3
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA)-D | Observed assisting resident R290 into bed and performing incontinence care without donning gowns | |
| Certified Nursing Assistant (CNA)-E | Observed assisting resident R290 into bed and performing incontinence care without donning gowns | |
| Certified Nursing Assistant (CNA)-F | Observed performing incontinence care for resident R22 without changing gloves or hand hygiene before applying lotion | |
| Certified Nursing Assistant (CNA)-G | Assisted with incontinence care for resident R22 | |
| Certified Nursing Assistant (CNA)-H | Assisted with incontinence care for resident R22 | |
| Infection Preventionist (IP)-C | Observed performing wound care for resident R13 with improper hand hygiene and equipment sanitization | |
| Nursing Home Administrator (NHA)-A | Informed of concerns regarding deficiencies | |
| Director of Nursing (DON)-B | Informed of concerns regarding deficiencies |
Inspection Report
Routine
Census: 15
Deficiencies: 2
Sep 23, 2024
Visit Reason
On 09/23/2024, a standard licensing survey and two complaint investigations were conducted at Eastcastle Place, a community-based residential facility (CBRF) in Milwaukee, WI.
Findings
Two violations of Chapter DHS 83 were issued, both complaints were substantiated. One deficiency involved failure to report a serious injury incident to the Department, and the other involved violation of residents' privacy due to a video camera capturing resident movements in the hallway.
Complaint Details
Two complaints were investigated and both were substantiated. One complaint alleged a resident fall resulting in injury that was not reported. The other complaint related to privacy violations due to hallway video surveillance.
Deficiencies (2)
| Description |
|---|
| Failure to report an incident resulting in serious injury to the Department for a resident who fell on 08/22/2024 and required emergency room treatment. |
| Residents were recorded/filmed by a video camera mounted in the common hallway, violating residents' rights to privacy. |
Report Facts
Number of violations issued: 2
Resident census: 15
Date of resident fall incident: Aug 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator B | Administrator | Confirmed resident fall incident and acknowledged failure to report |
| Licensee A | Licensee | Acknowledged resident fall incident and privacy violation due to hallway camera |
Inspection Report
Enforcement
Deficiencies: 1
Sep 23, 2024
Visit Reason
A standard licensing survey and two complaint investigations were conducted to determine if Eastcastle Place was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #141X11) for violations related to the operation of the facility, including failure to protect residents' rights to physical and emotional privacy, specifically regarding the use of electronic monitoring in living areas and hallways.
Complaint Details
Two complaint investigations were conducted as part of the survey process; however, substantiation status is not explicitly stated.
Deficiencies (1)
| Description |
|---|
| Failure to protect and promote each resident's right to physical and emotional privacy by using electronic monitoring equipment in living areas and hallways. |
Report Facts
Inspection fee: 200
Compliance timeframe: 45
Appeal timeframe: 10
Posting duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MaryBeth Hoffman | Assisted Living Regional Director | Contact person for questions about the letter. |
| Kenneth Brotheridge | Assisted Living Director | Signed the enforcement notice letter. |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 31, 2023
Visit Reason
The document is an annual inspection report for Eastcastle PI Bradford Ter Conv Ctr conducted to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 22, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a survey completed on 06/22/2023 for Eastcastle PI Bradford Ter Conv Ctr.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Deficiencies: 14
May 19, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident rights, abuse reporting, transfer and discharge procedures, care planning, pressure ulcer care, respiratory care, hospice services, and COVID-19 testing.
Findings
The facility was found deficient in multiple areas including inaccurate documentation of residents' code status, failure to report and investigate allegations of neglect, lack of written transfer/discharge notices and bed hold policy notices, inadequate discharge planning, failure to provide scheduled showers, improper pressure ulcer care and staging, unsafe transfer practices, lack of assessments and orders for bed assistive devices, incomplete hospice service coordination, and failure to conduct required COVID-19 testing for exempt staff.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 13
Level of Harm - Actual harm: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Inaccurate documentation of resident code status with conflicting electronic and paper records for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report an allegation of neglect to the State Survey Agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to investigate an allegation of neglect for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide written transfer/discharge notices including appeal rights and ombudsman contact for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide written notification of bed hold policy to residents or representatives for two residents transferred to hospital. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement effective discharge planning for two residents including lack of documentation of discharge planning meetings and follow-up. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide scheduled showers to one resident without documented refusal. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for one resident including incorrect staging and incomplete wound assessments. | Level of Harm - Actual harm |
| Failure to transfer one resident using the prescribed Hoyer lift; instead an EZ stand lift was used contrary to care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure call light within reach and floor mats on both sides of bed for one resident at high risk for falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain oxygen therapy according to physician orders for one resident including discrepancies in oxygen liter flow documentation and settings. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to assess, obtain consent, and document risks and benefits for bed assistive devices including repositioning bars for multiple residents; lack of physician orders and care plan documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to effectively coordinate hospice services for two residents including missing physician orders, incomplete hospice documentation, and lack of communication between hospice and facility staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to perform COVID-19 testing on staff with approved non-medical vaccination exemption according to CDC recommendations based on county transmission rates. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Weight loss percentage: 16.3
Number of shifts worked: 18
Pressure injury size: 1.2
Pressure injury size: 0.6
Pressure injury size: 0.1
Braden score: 14
Morse fall risk score: 75
BIMS score: 6
BIMS score: 15
BIMS score: 3
BIMS score: 12
BIMS score: 0
BIMS score: 0
BIMS score: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN Manager-M | Registered Nurse Manager | Named in wound care and code status documentation findings. |
| RN-E | Registered Nurse | Named in code status documentation and oxygen therapy findings. |
| DON-B | Director of Nursing | Named in multiple findings including code status, neglect investigation, discharge planning, wound care, oxygen therapy, repositioning bars, and hospice coordination. |
| Administrator-A | Administrator | Named in multiple findings including neglect investigation, discharge planning, wound care, oxygen therapy, repositioning bars, and hospice coordination. |
| SW-C | Social Worker | Named in code status, discharge planning, and hospice coordination findings. |
| LPN-J | Licensed Practical Nurse | Named in neglect investigation findings. |
| CNA-P | Certified Nursing Assistant | Named in transfer and incontinence care findings. |
| CNA-Q | Certified Nursing Assistant | Named in transfer and incontinence care findings. |
| HSM-D | Health Services Manager | Named in code status, discharge planning, and hospice coordination findings. |
| RD-F | Dietician | Named in nutritional care and weight loss findings. |
| HRN-I | Hospice Registered Nurse | Named in hospice coordination findings. |
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