Inspection Report Summary
Most inspections at this facility found no deficiencies, including the most recent complaint investigation on October 10, 2025, which was clean. However, earlier in September 2025, inspectors identified issues related to resident rights and property misappropriation, though no serious harm occurred and the staff member involved was terminated. Past deficiencies have included resident safety concerns such as failure to prevent falls and timely family notification, infection control lapses, medication and dietary monitoring problems, and documentation errors. Several complaint investigations were substantiated, but many others found no violations. The facility’s record shows improvement over time, with recent reports showing fewer and less severe deficiencies compared to earlier years.
Deficiencies (last 8 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a October 2025 inspection.
Census over time
| Name | Title | Context |
|---|---|---|
| Nathan Moffie | Administrator | Personnel contacted during the inspection |
| Sofia Calamita | DON | Personnel contacted during the inspection |
| Name | Title | Context |
|---|---|---|
| Nathan Moffie | Administrator | Personnel contacted during inspection |
| Description |
|---|
| Failure to notify Resident #1's family on the same day of the resident's fall. |
| Failure to ensure removal of Resident #2's jewelry, leading to misappropriation by a staff member. |
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the plan of correction letter |
| Director of Nursing | Interviewed during investigation and responsible for ensuring compliance with plan of correction |
| Description |
|---|
| Resident Rights/Exercise of Rights not fully upheld |
| Room/Roommate Change notification and documentation issues |
| Treatment/Services to Prevent/Heal Pressure Ulcers deficiencies |
| Pharmacy Services/Procedure/Pharmacist/Records issues |
| Labeling and Storage of Drugs and Biologicals deficiencies |
| Food Procurement, Storage, Preparation, and Sanitary issues |
| Infection Prevention and Control deficiencies |
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for ensuring compliance with the plan of correction | |
| Administrator | Responsible for ensuring compliance with the plan of correction and performing audits | |
| Infection Control Nurse | Performs audits related to infection control and skin assessments | |
| Dietary Service Manager | Performs audits related to food storage and labeling |
| Name | Title | Context |
|---|---|---|
| Brittany Buckridge | Signature of FLIS staff and report submitter |
| Name | Title | Context |
|---|---|---|
| Nathan Moffie | Administrator | Personnel contacted during the inspection |
| Name | Title | Context |
|---|---|---|
| Nathan Moffie | Administrator | Personnel contacted during inspection. |
| Sofia Calamita | Director of Nursing | Personnel contacted during inspection. |
| Description |
|---|
| Failure to ensure a resident with confusion and identified fall risk was not left unattended in the bathroom, resulting in a fall and injury. |
| Name | Title | Context |
|---|---|---|
| Sofia Calamita | RN DNS | Signed the plan of correction letter. |
| Maureen Golas-Markure | Supervising Nurse Consultant | Recipient of the plan of correction and author of the complaint investigation letter. |
| Nathan Moffie | Administrator | Administrator of The Guilford House, recipient of the complaint investigation and plan of correction letters. |
| LPN #1 | Interviewed regarding the incident involving Resident #2 and bathroom supervision. |
| Description |
|---|
| Failure to ensure the resident was free from mistreatment, specifically verbal abuse by a nursing assistant who made derogatory comments to a resident. |
| Name | Title | Context |
|---|---|---|
| Sofia Calamita | RN DNS | Signed the plan of correction letter as the submitter. |
| Maureen Golas Markure | Supervising Nurse Consultant | Facility Licensing and Investigations Section, recipient of the plan of correction. |
| Nathan Moffie | Administrator | Facility administrator addressed in the notice and plan of correction. |
| Name | Title | Context |
|---|---|---|
| Sofia Calamita | Director of Nursing | Notified of correction of all violations during monitoring visit |
| Melissa Talamini | Nurse Consultant | Conducted desk audit and monitoring inspection |
| Name | Title | Context |
|---|---|---|
| Nathan Moffie | Administrator | Signed the plan of correction and responsible for ensuring implementation of the POC |
| Name | Title | Context |
|---|---|---|
| Nathan Motte | Personnel contacted during inspection | |
| Adam Cole | Owner | Personnel contacted during inspection |
| Jennifer Green | DNS | Personnel contacted during inspection |
| Name | Title | Context |
|---|---|---|
| Nathan Mote | Personnel contacted during inspection | |
| Adam Cal Mote | Owner | Personnel contacted during inspection |
| Jennifer Green | DNS | Personnel contacted during inspection |
| Description |
|---|
| Failure to ensure adequate space was provided to safely accommodate a resident's personal recliner, impacting CPR performance. |
| Failure to follow professional standards of practice to ensure CPR was provided on a hard, firm surface and failure to ensure staff had current CPR certifications. |
| Facility policy failed to direct staff CPR certifications and lacked a policy on the size of furniture a resident can have in their room. |
| Name | Title | Context |
|---|---|---|
| Nathan Moffie | Administrator | Named as facility administrator and recipient of the notice letter. |
| Jennifer Green | Director of Nursing | Named as Director of Nursing contacted during inspection. |
| Connie Vumback | Survey Team Leader | Survey team leader conducting the inspection. |
| Maureen Golas-Markure | Supervising Nurse Consultant | Supervisor and signatory of the notice letter. |
| LPN #1 | Nurse involved in CPR and documentation during resident emergency. | |
| LPN #2 | Nurse involved in CPR and documentation during resident emergency. | |
| RN #1 | Supervisor | Nurse supervisor present during CPR and interviewed. |
| Person #1 | CPR Trainer | CPR Trainer for the facility interviewed on 10/20/2022. |
| MD #1 | Medical Doctor interviewed regarding CPR standards. |
| Description | Severity |
|---|---|
| Tag F 558 classified as 'D' with disputed severity classification. | D |
| Tag F 678 classified as 'G' with disputed severity classification regarding scope and severity. | G |
| Name | Title | Context |
|---|---|---|
| Jennifer Green | Director of Nursing | Named in relation to the complaint investigation and plan of correction. |
| Connie Vumback | RN, Survey Team Leader | Conducted the inspection and submitted the report. |
| Maureen Golas-Markure | Supervisor | Supervisor of the survey team. |
| Nathan Moffie | Administrator | Personnel contacted during the inspection. |
| Name | Title | Context |
|---|---|---|
| Janet Rosato | RN | Representative of the FLIS who conducted the desk audit review and submitted the report. |
| Jennifer Greene | DNS | Personnel contacted during the inspection. |
| Name | Title | Context |
|---|---|---|
| Nathan Moffie | Administrator | Personnel contacted during inspection |
| Jennifer Green | Director of Nursing Services | Personnel contacted during inspection |
| Description |
|---|
| Failure to ensure the responsible party was notified or reminded of the date of Resident #1's care plan meeting. |
| Failure to notify the physician when Resident #1's minimum fluid requirements were not met for seventy-two hours consecutively. |
| Failure to monitor Resident #1's consumption of nutritional supplements after weight loss was identified. |
| Failure to document a complete assessment after Resident #1 sustained an unwitnessed fall. |
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the important notice letter regarding the complaint investigation. |
| Nathan Moffie | Administrator | Recipient of the notice letter. |
| Social Worker #1 | Interviewed regarding care plan meeting notification to Resident #1's responsible party. | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan meeting notice and fluid intake notification procedures. |
| Advanced Practice Registered Nurse #1 | APRN | Interviewed regarding notification of fluid intake goals and nutritional supplement monitoring. |
| Description |
|---|
| Lack of proper signage identifying COVID-19 positive units and required precautions at unit entrances. |
| Biohazard trash container not properly covered with isolation gowns hanging over the side. |
| Residents exposed to COVID-19 positive staff members were not placed on precautions as required. |
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Named as the author of the notice and contact for questions regarding violations. |
| Jennifer Green | DNS | Signed the plan of correction submitted in response to the COVID-19 focused survey. |
| Director of Nurses | Interviewed during the survey; provided information on COVID-19 positive residents and staff. |
| Description |
|---|
| Lack of signage identifying COVID-19 positive units and precautions to be taken upon entry. |
| Biohazard labeled trash disposal container was not properly covered and isolation gowns were hanging over the side. |
| Residents exposed to COVID-19 positive staff members were not placed on precautions initially. |
| Failure to screen visitors for travel history during the inspection on September 1, 2020. |
| Name | Title | Context |
|---|---|---|
| Jennifer Green | Director of Nursing (DNS) | Interviewed regarding COVID-19 cases and infection control practices; submitted plan of correction. |
| Karen Gworek | Supervising Nurse Consultant | Issued the notice of violation and instructions for plan of correction. |
| Cher Michaud | Supervising Nurse Consultant | Issued notice of violation related to September 1, 2020 inspection and plan of correction. |
| Description |
|---|
| Failure to screen for a visitor's travel history during the visitor screening and documentation process. |
| Name | Title | Context |
|---|---|---|
| Cher Michaud | Supervising Nurse Consultant | Author of the notice and contact for questions regarding violations |
| Jennifer Green | Director of Nurses (DNS) | Interviewed regarding visitor screening documentation and submitted the plan of correction |
| Nathan Moffie | Administrator | Recipient of the inspection notice |
| Description | Severity |
|---|---|
| Failure to ensure appropriate closure of a fire door to prevent an accident; fire door was propped open with a binder. | SS=D |
| Name | Title | Context |
|---|---|---|
| Maintenance Worker #1 | Identified as having propped open the fire door and received immediate in-service training | |
| Licensed Practical Nurse #1 | Reported the fire door was propped open during the tour |
| Description |
|---|
| Failure to ensure appropriate closure of a fire door to prevent an accident; fire door was propped open in the medical record/PPE storage area. |
| Name | Title | Context |
|---|---|---|
| Lisa A. DiLorenzo | Supervising Nurse Consultant | Signed the notice letter and is the contact for questions regarding violations |
| Jennifer Green | RN DNS | Submitted the plan of correction letter |
| Description |
|---|
| Failure to ensure appropriate closure of a fire door to prevent an accident; fire door was propped open with a kardex three ring binder. |
| Name | Title | Context |
|---|---|---|
| Nathan Moffie | Administrator | Named in relation to review of facility policy and plan of correction |
| Lisa A. DiLorenzo | Supervising Nurse Consultant | Author of the notice and contact for questions regarding violations |
| Description |
|---|
| Failure to provide care and services in a dignified manner to Resident #106. |
| Failure to notify responsible parties of changes in treatment for Residents #8 and #256. |
| Failure to follow resident ambulation and exercise programs for Resident #26. |
| Failure to monitor and identify unnecessary medications for Resident #256. |
| Failure to ensure physician follow-up when Resident #306 refused blood work. |
| Failure to consistently monitor food item temperatures to ensure safety and palatability. |
| Failure to ensure resident food preferences were honored and therapeutic diets provided. |
| Failure to ensure Facility Assessment included necessary competencies and staff training. |
| Failure to provide consistent infection prevention and control documentation and surveillance. |
| Failure to ensure residents were offered and/or immunized for Pneumococcal Conjugate Vaccine (PCV13). |
| Name | Title | Context |
|---|---|---|
| Jennifer Green | Director of Nursing Services (DNS), RN | Personnel contacted during inspection and submitted plan of correction. |
| Connie Greene | Supervising Nurse Consultant, RN, BSN, MS | Author of the notice letter and complaint investigation correspondence. |
| J. Overbye | DPH Nurse Consultant, RN, MSN | Report submitted by this nurse consultant for the desk audit. |
| Calvin Moffie | Administrator | Facility administrator named in the notice letter. |
| Description |
|---|
| Facility failed to provide care and/or services in a dignified manner to Resident #106. |
| Facility failed to notify responsible party of changes and specific bloodwork requirements for sampled residents. |
| Facility failed to follow restorative services plan for Resident #26, including ambulation and exercise program. |
| Facility failed to ensure medication monitoring and identification of necessary administration for Resident #256. |
| Facility failed to ensure physician follow-up when Resident #306 refused blood work ordered by physician. |
| Facility failed to consistently monitor and record food item temperatures to ensure food safety. |
| Facility failed to ensure resident food preferences were honored and therapeutic diets provided. |
| Facility failed to ensure Facility Assessment included staff competencies and level of care needed for residents. |
| Facility failed to consistently provide evidence/documentation of infection prevention and control program. |
| Facility failed to ensure residents were offered and/or immunized for Pneumococcal Conjugate Vaccine (PCV13). |
| Name | Title | Context |
|---|---|---|
| Connie Greene | Supervising Nurse Consultant | Signed the initial notice letter and involved in instructions regarding deficiencies |
| Jennifer Green | RN DNS | Signed the Plan of Correction submission letters and responsible for compliance |
| Calvin Moffie | Administrator | Facility administrator addressed in the notice letter |
| Description |
|---|
| Facility failed to ensure a comfortable homelike environment for Resident #23, including placing mattress on floor without bedframe and failing to request a waiver for this placement. |
| Facility failed to make prompt efforts to resolve Resident #26's grievance regarding rude nurse aide behavior. |
| Facility failed to immediately report allegations of abuse involving Residents #36 and #164 and failed to remove alleged staff member from schedule promptly. |
| Facility failed to develop a comprehensive care plan related to monitoring dialysis access site for Resident #2. |
| Facility failed to provide treatment as ordered and failed to reassess Resident #2 following persistent agitation and failed to monitor dialysis access site properly. |
| Facility failed to ensure refrigerator did not contain undated and expired items, including multiple expired sauces and open undated food items. |
| Facility failed to ensure complete intravenous (IV) therapy log documentation for discontinuation and outcome of IV therapy. |
| Name | Title | Context |
|---|---|---|
| Jennifer Green | DNS | Named as personnel contacted during inspection and referenced in findings regarding resident care and environment. |
| Calvin Moffie | Administrator | Named as personnel contacted during inspection and recipient of violation letter. |
| Norma Schuberth | Supervising Nurse Consultant | Signed the complaint investigation and violation letter. |
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