Guilford House, The

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of four (4) sampled residents (Resident #1) who were at risk for falls, the facility failed to ensure Resident #1's family was notified on the same day when the resident sustained a fall.

The findings include:Resident #1's diagnoses included heart failure, muscle weakness, difficulty in walking and cellulitis.

The admission record dated 6/7/25 identified family members were Resident #1's emergency contact.

The admission nurse's note dated 6/7/25 at 6:10 PM identified Resident #1 was admitted to the facility from the hospital at 5:00 PM.

The note indicated Resident #1 was alert, forgetful, anxious, calling out occasionally wanting to go home and redirected to place and time.

The nurse's note dated 6/8/24 at 2:07 AM identified Resident #1 was found lying on his/her side next to his/her bed.

The note identified Resident #1 appeared confused pupils were equal, round, and reactive to light, there was no internal or external rotation or lengthening or shortening of all extremities, and no new skin redness or open areas.

The note identified the provider was notified and a new order was obtained to perform safety checks for three (3) days every two (2) hours.

The note identified Resident #1's family needed an update in the morning.

Review of the clinical record from 6/8/25 through 6/14/25 failed to reflect documentation Resident #1's family was updated regarding the 6/8/25 fall.

The facility Accident and Investigation dated 6/8/25 identified the physician was notified on 6/8/25 at 2:20 AM of the fall however Resident #1's family was not notified regarding the fall until 6/14/24, six (6) days later.

Interview and clinical record review with the Director of Nursing (DON) on 9/22/25 at 12:06 PM identified Resident #1's family should have been notified at the time of the fall.

Review of the facility policy titled Fall-Unwitnessed directed, in part, notify family and provider of occurrence and re-notify if any changes.

Review of the facility policy titled Resident's Change in Condition, directed, in part, any changes in condition must be reported to the family/responsible party along with any new orders from the provider.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/22/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Guilford House, The

109 West Lake Avenue Guilford, CT 06437

SUMMARY STATEMENT OF DEFICIENCIES