Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cook Willow Health & Rehabilitation Center, Inc. during CMS and state inspections, most recent first.
A resident with intact cognition and significant visual impairment was threatened by a roommate, who had dementia and mental health diagnoses, when the roommate placed a plastic knife to the resident’s neck after the resident called out for assistance. Following the incident, the DON instructed an LPN to move the victim rather than the aggressor, and the resident was relocated to a room at the end of a corridor four rooms away, with no alternate route of access, requiring the resident to pass the aggressor’s room to reach common areas. The resident reported feeling they had no real choice but to move and later expressed anger and ongoing nervousness about the situation. Interviews and census review showed that private rooms on another unit had been available for the aggressor, and facility leadership acknowledged that the victim was not offered the option to remain in the original room, despite resident rights policies guaranteeing notice and choice regarding roommate changes.
Food storage and dishwashing documentation were deficient when multiple partially used dry, refrigerated, and frozen food items were found without dates or labels after opening, including pasta, meats, fish, and seafood. In addition, the dishwasher temperature log had repeated missing entries for meal periods even though the machine itself was observed reaching proper wash and rinse temps, and the FSD acknowledged the incomplete documentation.
A resident with cognitive impairment and physical limitations reported being inappropriately touched by staff during a shower. The allegation was relayed to the ADON, who did not report or investigate the claim, and the DON was not informed. The facility failed to notify the State Agency and did not follow its own abuse reporting policy.
A resident with dementia and a recent cerebral infarction, who was alert and required moderate assistance, reported being inappropriately touched by staff during a shower. The allegation was relayed to the ADON, but no investigation was conducted or documented, as the reporting staff member expressed doubt about the event and requested no further questioning. The DON was unaware of the incident, and facility policy requiring prompt investigation of abuse allegations was not followed.
A resident with dementia and an elopement risk repeatedly removed a wanderguard bracelet used to help prevent exiting outside. Nursing notes documented the device was off and later refused, but the care plan was not revised to reflect the repeated removals or the resident’s stated method of removing it with nail clippers.
A resident with multiple serious diagnoses, including COPD, CHF, and anemia, died after being found not breathing and without a heartbeat. The RN pronounced death, but the record did not include a complete RNP assessment because it omitted blood pressure and pupillary response, despite facility policy requiring documentation of absent pulse, respirations, BP, heart sounds, fixed and dilated pupils, and the time of assessment.
A resident with weakness, gait instability, and a history of falls was ordered to be transferred with assist of 2 staff and a RW, but an NA transferred the resident alone without using the care card, gait belt, or RW. The resident fell during the transfer and sustained a head hematoma, facial swelling, bruising, and pain, requiring ambulance transfer to the ED for trauma evaluation. Staff interviews confirmed the transfer did not follow the resident’s care plan or physician’s order.
A resident receiving hospice services had no written nursing or SW visit notes in the chart, only a visit log listing staff name, discipline, and visit type. Hospice staff documented in their own system and shared information verbally, but the facility did not have the hospice care plan or written details of what was provided and the resident’s response.
Urinary Catheter Drainage Bag Touched Floor: A resident with an indwelling urinary catheter had the drainage bag attached to the back of a wheelchair and observed touching the floor on multiple occasions. RN, NA, and the ICN all stated the bag should not touch the floor, and the facility policy prohibited the collection bag or tubing from touching the floor or other contaminated objects such as chair wheels.
Failure to Notify Ombudsman of Discharges and Transfers: The facility did not send required discharge and transfer notices to the Ombudsman for 3 sampled residents. One resident had repeated hospital transfers and readmissions for UTI, sepsis, MI, and respiratory issues; another was severely cognitively impaired and transferred by ambulance after garbled speech and inability to follow commands; and a third, admitted for rehab with Parkinson’s disease and a clavicle fracture, was discharged home. Staff interviews confirmed the notifications were not being completed as required by policy.
Failure to Honor Resident Room Choice After Resident-to-Resident Threat
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose whether to remain in their room and to receive appropriate notice before a room change following a resident‑to‑resident altercation. One resident with intact cognition, muscle weakness, type II diabetes mellitus, and absolute glaucoma was dependent on staff for bed mobility and required assistance with transfers and ambulation. This resident ambulated independently with a rolling walker in the room and throughout the facility and enjoyed walking out of the room, socializing with friends, and going to the dining room for meals. Another resident, who had Alzheimer’s disease, major depressive disorder with psychotic symptoms, generalized anxiety disorder, and moderately impaired cognition, had a care plan identifying poor impulse control, lack of safety awareness, potential for manipulative behaviors, and a history of making accusatory statements, with interventions including the use of plastic utensils and staff support for coping and behavior. On the date of the incident, the cognitively intact resident reported that the dinner cart was outside the room and began calling out “hello” for help. The roommate became aggravated, approached the resident’s side of the room, told the resident to use the call bell, and then placed a plastic knife to the resident’s neck and moved it across. The victim reported that the roommate cursed, called names, and threatened that if the resident did not “shut up” it would be worse next time. Staff documentation and interviews confirmed that the victim was removed from the room to the hallway, assessed with no acute injury noted, and that the aggressor was placed on one‑to‑one observation and sent to the ED for evaluation. The victim was described as calm but slightly anxious and later expressed being upset and worried about the aggressor returning. Following the altercation, the DON directed staff to move the victim to a different room, despite the aggressor being the one who initiated the threatening behavior. The LPN asked the victim if they were agreeable to the move and proceeded with the room change without offering the option to remain in the original room. The new room was located at the end of a hallway four rooms away from the aggressor’s room, with no alternate route of exit or access, requiring the victim to routinely pass the aggressor’s room to reach common areas and the dining room. The victim later reported feeling they had no real choice but to move in order to feel safe, expressed anger that the aggressor ended up with a private room, and continued to feel nervous about having to walk past the aggressor’s room. Interviews with facility leadership acknowledged that the victim should have been offered the choice to remain in the original room, that the aggressor should have been moved instead, and that private rooms on another unit had been available at the time. The facility’s Residents’ Bill of Rights policy stated that residents have the right to notice before a roommate is changed, to be treated equally with other residents, and to be free from abuse, but there was no specific policy available for room transfers following resident‑to‑resident altercations.
Food Storage Labeling and Dishwasher Temperature Logging Deficiencies
Penalty
Summary
The facility failed to ensure perishable food items were dated when opened and stored in accordance with its food storage policy. During a tour of the Dietary Department, multiple items in the dry storage area were found without labels or dates after opening, including partially used bags of acini pasta, penne pasta, ziti pasta, split peas, and bread crumbs. In the walk-in cooler, partially used genoa salami, Virginia ham, and cooked rare roast beef were also observed without dates. In the walk-in freezer, partially used corn, sliced pepperoni, and clams were not labeled or dated, and 13 fish cakes wrapped in clear plastic wrap and a clear bag containing 6 seasoned white fish fillets had no date or expiration information because they had been removed from the original packaging. The facility also failed to consistently document dishwasher temperatures as required. Observation of the dishwashing process showed the machine reached appropriate wash and rinse temperatures, but review of the Dishwashing Temps Daily Log showed repeated missing entries for breakfast, lunch, and dinner across multiple dates. The Food Service Director acknowledged awareness of the missing documentation and stated there should not have been any missing entries on the log. The facility policy required dietary staff to date perishable food items upon opening and to check and log dishwasher temperatures at least once per meal period or shift.
Failure to Timely Report and Investigate Alleged Resident Mistreatment
Penalty
Summary
Staff failed to report and investigate an allegation of mistreatment involving a resident with diagnoses of cerebral infarction, dementia, and anxiety disorder. The resident, who was alert and oriented with a BIMS score of 14/15 and required moderate assistance for showers, reported to a staff member that they were inappropriately touched by another staff member during a shower. The staff member relayed the allegation to the ADON, but the ADON did not report or investigate the allegation, citing the reporting staff's disbelief in the event and a request not to discuss the matter further with the resident. The facility did not submit a reportable event to the State Agency as required, and the DON was not made aware of the allegation until later. Facility policy and the DON both require that all abuse allegations be reported immediately, investigated promptly, and reported to the State Agency within two hours of discovery. The failure to report and investigate the allegation in a timely manner, as well as the lack of notification to the State Agency, constituted a deficiency in the facility's handling of suspected abuse.
Failure to Investigate Alleged Mistreatment in a Timely Manner
Penalty
Summary
The facility failed to ensure a timely investigation of an allegation of mistreatment involving a resident diagnosed with cerebral infarction, dementia, and anxiety disorder. The resident, who was alert and oriented with a BIMS score of 14/15 and required moderate assistance for showers, reported to a staff member that they had been inappropriately touched by another staff member during a shower. This allegation was communicated to the ADON, but the facility was unable to provide documentation that an investigation was conducted regarding the reported mistreatment. The ADON stated that the allegation was not investigated or reported because the reporting staff member did not believe the event had occurred and requested that the resident not be questioned further. The DON was not aware of the allegation and confirmed that all such reports should be investigated according to facility policy, which requires thorough investigation of any abuse allegations within 72 hours. The lack of documentation and failure to investigate the reported incident constituted a deficiency in the facility's response to alleged violations.
Care Plan Not Revised After Repeated Wanderguard Removal
Penalty
Summary
The facility failed to revise the care plan for a resident with Alzheimer's dementia, a history of viral hepatitis, and a seizure disorder after the resident repeatedly removed a wanderguard bracelet used to help prevent exiting through doorways outside. The resident was identified as moderately cognitively impaired and independent with ADLs, and the care plan already listed elopement as a concern with interventions including wanderguard checks, diversional activities, psychiatric consults as needed, and medication for anxiety as needed. Nursing documentation on 6/25/25 noted the wanderguard was not in place and the resident said it had to be removed because the ankle swelled; the note documented that a new bracelet was applied but did not identify how the resident removed it. Later nursing notes on 7/21/25 documented that the resident continued to refuse wanderguard replacement after multiple attempts, stating the device was no longer needed, and a follow-up note recorded that the bracelet was reapplied after education. The resident told the surveyor that the wanderguard had been removed more than once and that nail clippers were used because the resident did not want to wear it. The ADNS and RN stated the care plan should have been revised after the removals and that they were unaware how the resident was removing the bracelet; the ADNS also stated the care plan was not revised to include the removals and new interventions. The resident's elopement assessments continued to identify the resident as an elopement risk.
Incomplete RN Pronouncement Assessment at Time of Death
Penalty
Summary
The facility failed to ensure a comprehensive assessment was completed at the time of death for a resident with hemophagocytic lymph histiocytosis, COPD, atrial fibrillation, diastolic CHF, and anemia. The resident’s admission MDS identified the resident as cognitively intact, dependent on staff for all transfers and personal care, and requiring set-up assistance for eating. The care plan noted altered respiratory status and difficulty breathing related to a right lower infiltrate, with interventions including bronchodilator inhaled agents and monitoring for effectiveness and side effects. A physician’s order later directed DNR, DNI, DNH, RNP, and comfort measures only. Nursing documentation stated the resident was found not breathing and without a heartbeat, and the RN pronounced death, but the assessment did not include a lack of blood pressure or pupillary response. The next of kin and funeral home were notified. The DON and ADNS reviewed the record and confirmed the RNP assessment was not comprehensive because it did not include absence of blood pressure. The facility policy required the RN to document absence of pulse, respirations, blood pressure, heart sounds, pupillary response fixed and dilated, and the time of the assessment, and the RN stated he was aware of the policy but his note failed to include blood pressure.
Failure to Follow Transfer Assistance Orders Resulted in Resident Fall and Head Injury
Penalty
Summary
The facility failed to provide transfer assistance according to the physician’s order and the resident’s care plan for a resident with a history of non-traumatic subarachnoid hemorrhage, muscle weakness, difficulty walking, unsteadiness on feet, and repeated falls. The resident’s MDS and care conference documentation identified the resident as cognitively intact and requiring assistance of 2 staff with a rolling walker for transfers, with additional documentation that a pivot assist device could be used only for transfers off the toilet. The resident care plan and nurse aide care card also identified the resident as an assist of 2 for transfers with a rolling walker. During a transfer from bed to wheelchair, an NA transferred the resident alone instead of using 2 staff as directed. The NA stated she did not reference the kardex/NA care card and believed the resident was a stand-pivot assist of 1. She also stated she did not use a gait belt or the rolling walker during the transfer. The resident fell during the transfer and struck the head on the floor, resulting in a large raised hematoma to the left forehead, facial swelling, bruising, and complaints of pain. The resident was sent by ambulance to the hospital emergency department for trauma evaluation. Facility documentation and staff interviews confirmed the resident was supposed to be transferred with 2 staff and a rolling walker, and that the NA did not follow the plan of care. The DNS stated the NA transferred the resident alone and that this caused the fall and injuries. The charge nurse reported finding the resident on the floor with only the NA in the room and stated the NA should not have transferred the resident by herself. The PT also stated the resident’s leg weakness made transfer with only 1 staff unsafe and that 2 staff should have assisted with the transfer.
Hospice visits lacked written documentation and care plan communication
Penalty
Summary
The facility failed to ensure hospice provided nursing and social work documentation and communication regarding hospice visits for one sampled resident receiving hospice services. The resident was admitted in June 2018 with diagnoses including severe dementia with psychotic disturbances and Type 2 diabetes, and was receiving hospice services since October 2024. The quarterly MDS identified cognitive impairment, one-sided upper and lower extremity impairment, dependence for oral hygiene, toilet use, dressing, and personal hygiene, and hospice enrollment. The resident’s care plan included hospice visits, social service support for emotional needs, pastoral clergy for spiritual needs, maximum comfort, and cooperation with the hospice team to meet the resident’s needs. A physician order directed hospice services, comfort measures, DNR, do not hospitalize, and RN may pronounce death. Review of hospice documentation showed that nursing and social work visits were recorded only on a Visit Description Log listing the hospice employee name, discipline, and whether the visit was scheduled or unscheduled, but there were no notes describing what was provided or the resident’s response. There was also no copy of the hospice care plan in the clinical record. Interviews revealed the facility did not require hospice staff to leave written notes after visits, hospice staff documented in their own system but did not provide that documentation to the facility, and communication was occurring verbally rather than in writing. The SW and APRN were unaware hospice was not providing written documentation, and the DNS stated verbal communication was not sufficient and that written documentation of findings, recommendations, and the plan of care was needed.
Urinary Catheter Drainage Bag Touched Floor
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter drainage bag was not touching the floor for a resident admitted with diagnoses including obstructive uropathy and tubulo-interstitial nephritis. The quarterly MDS identified the resident as cognitively intact, totally dependent on staff for ADLs, and having an indwelling urinary catheter. The care plan identified the catheter as a concern and included interventions to change the bag as needed, keep it below the level of the bladder, document pain or discomfort, and monitor for signs of infection. A physician’s order directed monthly catheter changes, daily meatal hygiene, and catheter care once a shift. Observations showed the resident’s urinary catheter drainage bag attached to the back of the wheelchair and touching the floor on multiple occasions while the resident was seated in the wheelchair. RN #1 stated the drainage bag should not touch the floor because the floor was not a clean surface and said it was the NA’s responsibility to ensure it never touched the floor. NA #1 observed the bag touching the floor and stated it should not be touching the floor as it was an infection control issue. The Infection Preventionist also stated urinary drainage bags should not touch the floor and noted the bag’s placement on the wheelchair may have caused it to touch the floor. The facility policy directed that the collection bag and/or tubing are not allowed to touch the floor or other contaminated objects such as the wheels of chairs.
Failure to Notify Ombudsman of Resident Discharges and Transfers
Penalty
Summary
The facility failed to ensure the Ombudsman was notified of resident discharges and transfers for 3 of 3 closed records reviewed. Facility policy required that a copy of the discharge or transfer notice be sent to a representative of the Office of the State Long-Term Care Ombudsman, but the record review and staff interviews showed these notifications were not being completed for the sampled residents. Resident #2 had multiple hospital transfers and readmissions related to serious medical conditions, including UTI, sepsis, septic shock, atrial fibrillation, myocardial infarction, and pulmonary infiltrates. The resident was sent to the hospital on several occasions for respiratory distress, abdominal pain, a cystoscopy procedure, and later for nausea, cough, wheezing, shaking, diminished lung sounds, and fever. The record reflects repeated transfers and returns to the facility, but the report identifies no Ombudsman discharge or transfer notification for these events. Resident #53 was admitted with metabolic encephalopathy, cellulitis of the left lower limb, and acute osteomyelitis, and was severely cognitively impaired, dependent for toileting and transfers, and required substantial assistance with bed mobility. After developing difficulty speaking, garbled speech, and inability to follow commands, the resident was transferred by ambulance to the hospital. Resident #55 was admitted for short-term rehabilitation with Parkinson's disease with dyskinesia, a left clavicle fracture, and a history of falling, and was moderately cognitively impaired and dependent for transfers and toileting. The resident improved and was discharged home with a responsible party, but the facility record review and interviews showed the Ombudsman was not notified of these discharges and transfers.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Plymouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Bucks Hill | 5.4 mi | ★★★★★ | 0 | 0 |
| Ingraham Manor Rehab And Nursing | 5.8 mi | ★★★★★ | 6 | 1 |
| Pines At Bristol For Nursing & Rehabilitation, The | 6.1 mi | ★★★★★ | 3 | 0 |
| Waterbury Center For Nursing & Rehabilitation Llc | 6.4 mi | ★★★★★ | 1 | 0 |
| Apple Rehab Watertown | 6.6 mi | ★★★★★ | 14 | 0 |
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