Inspection Reports for Brockford Inn

The survey included a complaint investigation component. The complaint was substantiated as the facility failed to provide the required pureed bread or substitute for residents #4 and #7 during the lunch meal on 08/05/25.

The facility failed to provide a food substitution for 2 residents who were ordered a therapeutic pureed diet during the lunch meal on August 5, 2025. Specifically, residents #4 and #7 did not receive pureed bread or a pureed bread alternative as required.

The facility was found to have unresolved deficiencies including lack of an emergency release switch for electromagnetic locks on the assisted living unit, failure to submit required construction plans for a generator installation, and failure to maintain fire safety systems as evidenced by a missing sprinkler head escutcheon in room 201.

The complaint investigation included an allegation that Staff B, a Personal Care Aide, twisted Resident #2's finger during incontinence care. Resident #2 reported the incident and had a bruised finger. The facility failed to report this allegation to the Health Care Personnel Registry as required.

The facility was found to have multiple deficiencies including pest control issues with roaches in resident rooms, failure to complete Health Care Personnel Registry (HCPR) checks upon hire for staff, lack of therapeutic diet menus for residents with physician-ordered diets, medication administration errors including missed or incorrect medications for several residents, and failure to report an allegation of abuse to the HCPR.

The complaint investigation was triggered by concerns regarding residents' clothing not being returned after laundering and medication administration errors, specifically oxygen administration and medication record accuracy.

The facility failed to ensure residents' rights related to clothing items not returned after laundering for 7 residents, and failed to administer medications as ordered for 1 of 5 sampled residents related to oxygen administration. Additionally, the facility failed to ensure accuracy of Medication Administration Records for 2 of 5 sampled residents regarding oxygen and antidepressant medication dosages.

The facility failed to administer medication as ordered for one resident related to insulin and failed to ensure medication administration records were accurate for two residents related to pain and dizziness medications.

The complaint investigation was triggered by concerns about infection control and resident safety during the COVID-19 pandemic. The local health department was involved and conducted testing revealing multiple positive cases among residents and staff.

The facility failed to ensure recommendations and guidance established by the CDC, NCDHHS, and local health department were implemented and maintained to protect residents during the COVID-19 pandemic. Deficiencies included inadequate screening of visitors and staff, improper use of PPE by staff, poor infection control practices including hand hygiene, and failure to isolate COVID-19 positive residents effectively.

Complaint investigation was initiated by the Caldwell County Department of Social Services on February 7, 2020 related to missed dialysis treatments during a quarantine.

The facility failed to ensure referral and follow-up for 3 of 3 sampled residents (#5, #6, and #8) who did not receive dialysis treatments due to the facility being quarantined during an outbreak of illness, resulting in two residents being hospitalized (#5 and #6) and one resident (#6) dying. Documentation and notification failures regarding missed dialysis treatments were also noted.

The survey identified multiple deficiencies including lack of current sanitation and fire safety inspection reports, unsafe exterior exit paths, damaged walls, improper storage and handling of medical oxygen cylinders, inadequate fire safety rehearsals documentation, compromised fire-rated walls and ceilings, and improper storage near fire sprinkler heads.

The facility failed to administer medications as ordered by a licensed prescribing practitioner for 2 of 5 sampled residents related to not administering hydrochlorothiazide and Tylenol. Additionally, the Medication Administration Records (MARs) were found to be inaccurate for these residents.

Complaint investigation was part of the visit conducted August 29-31, 2017.

The facility failed to assure proper table service with non-disposable place settings including knives, failed to ensure menu substitutions were of equal nutritional value and properly documented, and failed to administer medications according to licensed practitioner orders, including improper insulin administration and missed Vitamin B12 doses.

The facility was found to have multiple deficiencies including unsafe and unmaintained exterior stairs and handrails, failure to maintain and service emergency light units, inaccessible emergency release switch for electromagnetically locked doors, and lack of fire protection in penetrations of fire rated roof/ceiling assemblies.

Two complaint investigations were initiated by the County Department of Social Services on February 16-17, 2016. The follow-up survey and complaint investigation were conducted in March 2016. The complaints involved failure to assure proper referrals for a resident with disrobing behaviors and failure to treat a resident with dignity during incontinence care.

The facility failed to assure referrals were made to the primary care provider to meet the routine and acute health care needs for one resident with disrobing behaviors. Additionally, the facility failed to ensure a resident was treated with respect, consideration, and dignity when checking for incontinence, including inappropriate staff behavior and lack of proper documentation and reporting of resident behaviors.

The complaint investigation was initiated by Caldwell County Department of Social Services on November 6, 2015, related to allegations of verbal abuse and injury of unknown source.

The facility failed to provide window coverings for resident privacy in 5 of 15 rooms on the Special Care Unit. The Administrator failed to ensure total operation compliance related to management, Health Care Personnel Registry, and resident rights. The facility did not investigate allegations of injury of unknown source (shoulder dislocation) for one resident and failed to report verbal abuse by a staff member to the Health Care Personnel Registry. Staff verbal abuse of residents was also documented.

The complaint investigation was initiated by Caldwell County Department of Social Services on September 10, 2015, related to supervision, medication administration, injury of unknown source, and staff impairment.

The facility failed to assure proper supervision of a resident with confusion related to a urinary tract infection, failed to administer medications as ordered including crushing time-released medications, failed to investigate an injury of unknown source (hip fracture) for a resident, had an impaired staff member on duty, and failed to report to the Health Care Personnel Registry. The Administrator failed to assure total operation compliance with management, personal care, medication administration, and resident rights.

Multiple deficiencies were identified including hazardous latching hardware that could trap individuals, failure of staff to know emergency release switch locations, compromised fire-rated walls and ceilings with unsealed penetrations, fire/smoke barrier doors not latching properly, holes in draft stop walls, malfunctioning exit signs, improper storage near fire sprinkler heads, corridor doors not fitting properly, and plumbing fixtures lacking vacuum breakers.

The visit included a complaint investigation related to falls and supervision in the Special Care Unit.

The facility failed to provide adequate supervision and interventions for 4 of 6 residents in the Special Care Unit, resulting in serious injuries including fractures and death. Additionally, the facility failed to treat residents with dignity and respect and did not ensure adequate care and services related to fall prevention.