Brockford Inn

The facility failed to ensure proper referral and follow-up to meet the acute health care needs for six residents. Specifically, the facility did not adequately address medical needs related to facial injuries from assaults, changes in behavior, alleged sexual assaults, and unwitnessed falls.

The facility failed to ensure proper referral and follow-up to meet the acute health care needs for six sampled residents. These needs included managing a facial injury from an assault, a change in behavior, an alleged sexual assault, and an unwitnessed fall.

The facility failed to provide appropriate food substitutions for residents on therapeutic pureed diets. Specifically, during lunch service on 08/05/25, a resident required a pureed diet did not receive pureed bread or a pureed bread alternative as part of their meal.

The facility failed to provide appropriate food substitutions for two residents on a therapeutic pureed diet. Specifically, during lunch service, the residents did not receive pureed bread or a nutritional substitute as required by the menu. The cook admitted to forgetting the bread and failing to provide an equivalent substitute.

The facility failed to maintain an environment free of hazards related to roaches in Assisted Living resident rooms. Observations and interviews confirmed the presence of roaches in resident rooms and hallways, with residents reporting roaches climbing walls and entering beds.

The facility failed to maintain a clean and orderly environment free of hazards, as evidenced by the presence of cockroaches in resident rooms. Observations and interviews confirmed roaches were visible on walls and moving near beds, causing distress to residents.

The facility failed to ensure all residents' care and services were met regarding clothing items not being returned after laundering. Interviews with seven residents revealed missing items including socks, underwear, pants, and shirts, with some residents having to go without underwear. Staff were aware of the missing items, but the clothing was not consistently returned to the residents.

The facility failed to administer medication as ordered by a licensed prescribing practitioner for one resident. Specifically, the facility ran out of Humalog insulin, resulting in several days where the medication was unavailable and doses were missed. This failure was documented in the resident's electronic medication administration record between April 14 and April 18, 2021.