Inspection Reports for
The Greens at Cannondale

The complaint was substantiated. NA #1 was witnessed by NA #2 yelling and swearing at Resident #1 during care on 8/19/2025. The facility investigated, interviewed staff and the resident, and terminated NA #1 for verbal abuse.

The facility failed to ensure a resident was free from verbal abuse by a nursing assistant who was witnessed yelling and swearing at the resident. The nursing assistant was terminated following the investigation.

The complaint investigation found substantiated resident-to-resident abuse on 3/16/2025 where Resident #2 assaulted Resident #1 causing a nasal fracture. Resident #2 also exhibited combative behavior towards staff. The facility implemented increased monitoring and psychotropic medication adjustments.

The facility failed to protect a resident from abuse by another resident, resulting in a nasal fracture. Resident #2 exhibited escalating aggressive behaviors, including assaulting Resident #1 and staff, leading to hospital transfers and increased monitoring.

Complaint #42974 triggered the investigation. The complaint was substantiated based on findings of client injury and safety lapses.

The agency failed to identify and evaluate an injury of unknown origin and failed to ensure the safety of a client in the locked Memory Care unit. The investigation found lapses in monitoring and notification related to the client's injuries and safety.

The facility had multiple deficiencies including failure to notify physicians and representatives of new wounds and medication unavailability, inadequate abuse prevention and neglect, failure to provide scheduled showers and weight monitoring, incomplete wound care and assessments, medication management issues, expired sanitizer test strips and improper sanitizer levels, improper infection control practices, and lack of annual staff competency evaluations.

The investigation was triggered by a complaint regarding a medication error where Resident #1 was administered morphine at ten times the prescribed dose on three occasions. The complaint was substantiated with findings of Immediate Jeopardy due to medication errors and failure to timely notify the physician.

The facility failed to ensure timely reporting of a significant medication error to the physician and failed to follow the five rights of medication administration, resulting in Resident #1 receiving 50 mg morphine doses instead of the ordered 5 mg. Additionally, the clinical record was incomplete with missing vital signs documentation after the medication error.

The complaint investigation found that Resident #1 was transferred by a nurse aide without the required assistance of two staff members as per physician's order. The resident sustained a laceration to the right lower leg. The facility's investigation confirmed the nurse aide did not follow the transfer order. Interviews with involved staff were unsuccessful.

The facility failed to ensure that Resident #1 was transferred with the required assistance of two staff members as ordered by the physician, leading to a 5 cm laceration on the resident's right lower leg. Interviews revealed that the nurse aide transferred the resident without assistance, contrary to the physician's order.

The facility failed to timely follow physician orders for wound care treatments, failed to measure a pressure ulcer upon resident readmission, lacked a physician's order for a pressure relieving device upon resident return from hospitalization, and did not ensure nursing staff had documented education on wound vac care.

The complaint investigation was substantiated. Resident #1 fell while being transferred without the required mechanical lift and staff assistance, sustaining a hematoma and traumatic intracranial hemorrhage requiring hospital admission. The nurse aide did not follow physician orders or care plan.

The facility failed to use a mechanical lift and adequate staff assistance during Resident #1's transfer, resulting in a fall causing a head injury and hospital admission. The nurse aide did not follow physician orders or the care plan, and the facility's fall prevention policy was not properly implemented.

The complaint involved an allegation of staff to resident abuse substantiated by witness reports and facility investigation. The resident had no injury or emotional distress. The allegation was substantiated and LPN #1's employment was terminated.

The facility substantiated the allegation that LPN #1 physically abused Resident #1 by striking the resident's leg after the resident kicked the nurse. LPN #1 was removed from the unit and terminated following the investigation.

The facility failed to administer medication according to physician orders for one resident, resulting in a medication error. Additionally, multiple medication carts were found to be unclean and contained loose pills, with inadequate labeling and unclear cleaning responsibilities.

The complaint investigation included allegations of resident-to-resident abuse, failure to notify the Ombudsman of hospital transfers, inadequate code status documentation, delayed hospital transfer after falls, medication errors, lack of RN assessments for skin tears, improper end-of-life documentation, inadequate pressure ulcer care, and failure to administer pneumococcal vaccines.

The facility failed to protect residents from physical abuse by other residents, failed to notify the Ombudsman of hospital transfers, did not verify or document code status upon admission, delayed hospital transfer after a fall with injury, failed to transcribe medication orders correctly, lacked RN assessment for skin tears, did not have proper documentation for RN pronouncement of death, did not maintain specialty air mattress settings per orders, and failed to administer or offer pneumococcal vaccines as required.

The facility was found deficient in multiple areas including incomplete fall risk assessments, failure to follow physician orders for medication administration, improper food labeling, inadequate infection control related to catheter care, and failure to implement pneumococcal vaccination policies.

A violation was identified related to failure of Assisted Living Services Agency (ALSA) staff to provide necessary safety checks every two hours for a client at high risk for falls, resulting in a fall with injury. Documentation failed to indicate completion of required safety checks and safe care provision.

Violations of Connecticut State Agencies regulations and General Statutes were identified related to failure to develop a written agreement between the assisted living services agency (ALSA) and the home care agency, and failure to ensure ALSA special care unit disclosures were signed by responsible parties. The facility submitted a Plan of Correction addressing these issues.

Violations of Connecticut state statutes and regulations were identified during the inspection, including deficiencies in personnel file documentation, medication administration, and clinical competency evaluations. A plan of correction was submitted to address these deficiencies.