Inspection Reports for
The Guilford House

The investigation substantiated that Resident #1's family was not notified timely of a fall, and that Resident #2's rings were misappropriated by Nurse Aide #1, who was terminated and had a warrant issued for arrest.

The facility failed to notify Resident #1's family on the same day of a fall, notifying them six days later, violating facility policy. Additionally, the facility substantiated misappropriation of Resident #2's rings by a staff member, who was terminated and had a warrant issued for arrest.

Complaint #130244, #577252. The investigation substantiated that Resident #1's family was not notified timely of a fall and that Resident #2's jewelry was misappropriated by a staff member who was subsequently terminated.

Two violations were identified: first, the facility failed to notify Resident #1's family on the same day of a fall incident; second, the facility failed to ensure removal of Resident #2's jewelry, resulting in misappropriation by a staff member. Both residents did not suffer serious harm.

The plan outlines corrective actions for multiple deficiencies related to resident rights, room changes, pressure ulcer prevention, pharmacy services, medication storage, food sanitation, and infection control. No residents suffered serious harm related to these matters.

The complaint investigation found that Resident #1 fell while attempting to transfer without assistance, resulting in a subdural hematoma and eventual death. Interviews revealed staff failed to hear alarms or calls for help, and a nursing assistant assigned to the resident was missing from the unit at the time of the fall. The Director of Nursing Services confirmed expectations for staff to report when leaving assignments and noted the nursing assistant was no longer employed due to other concerns.

The facility failed to provide adequate supervision to Resident #1, who had a history of falls and cognitive impairment, leading to a fall with head injury and subsequent hospitalization. Staff did not respond promptly to alarms or calls for assistance, and a nursing assistant assigned to the resident was unaccounted for at the time of the fall.

The visit was complaint-related under Complaint CT numbers 25709 and 25779. The complaint was substantiated as violations were identified during the investigation.

The facility was found noncompliant with regulations related to resident safety, specifically failing to ensure a resident with confusion and fall risk was not left unattended in the bathroom, resulting in a fall and injury. The facility lacked a policy regarding leaving residents unattended in the bathroom.

The complaint investigation substantiated that NA #1 spoke inappropriately to Resident #1 using derogatory and foul language. The facility immediately removed NA #1 from work and notified local police, physician, DNS, and responsible party.

The facility substantiated that NA #1 made inappropriate verbal comments to Resident #1, which constituted verbal abuse. The facility took immediate action by removing NA #1 from work and requesting the nursing agency not to send NA #1 back to the facility.

The visit was complaint-related, investigating allegations of verbal abuse by staff. The facility investigation substantiated that NA #1 spoke inappropriately to Resident #1 and should not have made the comment. The facility removed NA #1 from work and requested the nursing agency not to send NA #1 back.

The investigation found that a nursing assistant (NA #1) made an inappropriate verbal comment to a resident, constituting verbal abuse. The facility took immediate action by removing NA #1 from work and requested the nursing agency not to send NA #1 back. The facility substantiated the verbal abuse allegation and implemented corrective measures.

The facility was found deficient in multiple areas including failure to notify the Ombudsman and resident representatives of transfers, failure to provide bed hold notifications, inadequate monitoring and intervention for significant weight loss, improper storage and labeling of respiratory equipment, lack of emergency dialysis equipment at bedside, missing annual performance evaluations for nurse aides, expired medications in storage, failure to honor resident food preferences, improper food storage and labeling, incomplete updates to resident care plans after falls, lapses in infection control practices including improper PPE use and hand hygiene, and failure to enforce smoking policy on facility grounds.

The complaint investigation substantiated that Resident #2 was a victim of medication misappropriation involving tampered blister packs containing incorrect medications. The investigation also found failures in medication security and reconciliation for Resident #1, resulting in a medication discrepancy and an opioid overdose.

The facility failed to ensure Resident #2 was free from misappropriation of prescribed controlled medication, resulting in administration of incorrect medications. Additionally, the facility failed to properly secure and reconcile controlled substances for Resident #1, leading to a discrepancy in medication counts and an opioid overdose event.

Complaint Investigation #33090 was substantiated with deficiencies cited related to CPR procedures and facility policies.

Deficiencies were cited related to failure to ensure adequate space for a resident's personal recliner, failure to follow professional standards for CPR including staff CPR certification, and failure to have a policy on furniture size in resident rooms. The facility failed to ensure proper CPR procedures and equipment use during a resident emergency.

Complaint Investigation #33090 was conducted to determine compliance with 42 CFR Part 483 requirements. Deficiencies were cited. The facility disputed the severity classifications of tags F 558 and F 678 but did not dispute the actual F tags. The investigation included review of EMS run sheet and interviews clarifying chest compression procedures and staff actions during an emergency.

Deficiencies were cited as a result of the complaint investigation survey. The facility disputed the severity classifications of certain tags but did not dispute the actual deficiencies. The report includes detailed narrative clarifying events related to chest compressions and CPR procedures during an emergency.

The facility failed to ensure regular resident council meetings, ongoing resident rights education, accessible ombudsman information, grievance education, proper IV therapy documentation, and consistent COVID-19 mask use in the kitchen. Deficiencies were noted in sanitizing procedures and resident awareness of survey reports and grievance processes.

Complaint investigation survey conducted following complaint #28794. The report does not explicitly state substantiation status.

The report details multiple violations related to failure in notifying responsible parties about care plan meetings, failure to notify physicians when fluid requirements were not met, failure to monitor nutritional supplement consumption, and failure to document a complete assessment after an unwitnessed fall. The facility was required to submit a plan of correction addressing these issues.

The survey identified multiple infection control deficiencies related to COVID-19, including inadequate signage at COVID-19 units, improper disposal of PPE, and failure to place residents exposed to COVID-19 positive staff on precautions. The facility had 19 COVID-19 positive residents and 27 staff members tested positive as of the inspection date.

The survey identified violations related to infection control practices, including inadequate signage for COVID-19 units, improper handling of biohazard disposal, and failure to place exposed residents on precautions. The facility had 19 COVID-19 positive residents and 27 staff members tested positive. Corrective actions were planned and implemented promptly.

The facility failed to screen visitors for travel history during the visitor screening and documentation process on 9/1/20. The Director of Nurses acknowledged the form did not include a travel history question and was unable to confirm if visitors had provided travel information.

Deficiencies were identified unrelated to COVID-19, including failure to ensure appropriate closure of a fire door to prevent accidents. The fire door was found propped open, which is against facility policy and fire safety regulations.

The facility failed to ensure appropriate closure of a fire door to prevent an accident. Observations and interviews revealed that the fire door to the medical record/PPE storage area was propped open, which is against facility policy and safety regulations.

The facility was found to have a violation related to fire safety where a fire door in the medical record/PPE storage area was propped open, which is against facility policy and safety regulations.

Complaint investigation #CT#24355 was conducted with violations identified at the time of inspection. The complaint involved allegations of mistreatment and failure to provide dignified care to Resident #106, which was not substantiated. Other findings related to notification failures, medication monitoring, infection control, and dietary issues were documented.

Violations #1 through #4 were identified as being corrected at the time of the desk audit, and no violations were identified during this inspection. The report includes detailed findings from prior complaint investigations and renewal inspections, with multiple violations related to resident care, notification, medication monitoring, infection control, and dietary services.

The facility was found deficient in multiple areas including failure to provide dignified care to a resident, failure to notify responsible parties of treatment changes, failure to follow restorative ambulation plans, failure to monitor and document medication necessity and laboratory testing, inconsistent food temperature monitoring, failure to provide therapeutic diets as ordered, incomplete facility-wide competency assessments, inadequate infection surveillance documentation, and failure to properly offer and document pneumococcal vaccinations.

Complaint #24355 was investigated. The facility did not substantiate abuse regarding a resident's allegation of mistreatment by a nurse aide, but deficiencies were identified in care and dignity.

The report details multiple violations of Connecticut State Agencies regulations related to dignity and care of residents, notification of changes to responsible parties, restorative services, medication monitoring, infection control, food preparation, dietary services, and staff competency. The plan of correction outlines measures to address these deficiencies and ensure compliance.

Complaint investigation #23389 was conducted and violations were substantiated as violations of Connecticut State Agencies regulations and statutes were identified.

Violations of the Regulations of Connecticut State Agencies and General Statutes were identified, including failure to ensure a comfortable homelike environment, failure to make prompt efforts to resolve resident grievances, failure to immediately report allegations of abuse, failure to monitor dialysis access sites, and failure to ensure proper documentation and monitoring of medical and dietary items.