Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Willowbrooke Ct Skilled Care Ctr At Bayleigh Chase during CMS and state inspections, most recent first.
The facility failed to protect residents from abuse, with incidents involving physical assault by a GNA and inadequate investigations into allegations of abuse. Staff did not report incidents immediately, and the facility did not ensure all staff had required abuse training. Additionally, the administration dismissed allegations without thorough investigation, contributing to the facility's inability to protect residents.
A facility failed to conduct a root cause analysis for a resident with Alzheimer's Dementia who experienced multiple falls, one resulting in a hip fracture. Despite being identified as a high fall risk, the resident's care plan lacked updated interventions to prevent further falls. The facility's Fall Reduction and Management Policy was not fully adhered to, as confirmed by the DON, who noted that only monitoring was listed as an intervention and the Root Cause of Fall section was not completed.
The facility did not conduct annual performance reviews for GNAs, as required, since 2011. The DON, who joined in 2020, confirmed that evaluations were not performed for GNAs, only for the ADON. This oversight affects the facility's ability to provide targeted in-service education.
The facility failed to consistently monitor and document meal temperatures before serving, as required by policy. The Dietary Manager, new to the position, had not reviewed temperature logs until recently and was unaware that staff were not temping all food items. This oversight potentially affected all residents consuming food from the kitchen, except one resident who was NPO.
The QA committee at the facility failed to conduct a thorough Performance Improvement Project (PIP) as required by their QAPI program. The DON admitted that the PIP for increasing pressure ulcers was limited to collecting information and filling out a form, without tracking outcomes or conducting a root cause analysis. The Administrator acknowledged the lack of proper documentation, which hindered the ability to demonstrate the facility's efforts.
The facility administration failed to ensure effective oversight, resulting in incomplete investigations of injuries and abuse. The DON provided inadequate reports for residents with unwitnessed falls, lacking assessments and care plan updates. An abuse allegation was mishandled, with the alleged perpetrator not suspended and police not notified. Additionally, an LPN did not report an abuse incident immediately, and the facility could not verify required abuse training for agency staff.
The facility failed to ensure all nursing staff, including agency staff, received training on abuse reporting procedures. An LPN witnessed a GNA physically abusing a resident but delayed reporting the incident, allowing the GNA to continue working. The facility did not verify the LPN's abuse training, relying on the agency for documentation.
The facility failed to report several incidents of alleged abuse, neglect, or injuries of unknown origin to the OHCQ within the required timeframe. This included cases of unwitnessed falls, bruises, and abuse allegations that were not reported to local law enforcement or the state agency promptly. The facility's policy requires immediate reporting of such incidents, but this was not adhered to, and investigations were not conducted thoroughly.
The facility failed to thoroughly investigate multiple allegations of abuse and injuries of unknown origin, and did not protect residents from further harm. Incidents included unwitnessed falls resulting in fractures, unreported physical abuse, and dismissed verbal abuse allegations. Investigations were incomplete, lacking interviews with all relevant staff and residents, and failed to implement preventive measures.
The facility failed to administer and document pain medication for two residents with reported pain. One resident with severe cognitive impairment was found with hip pain, but the MAR did not reflect the administration of Tylenol as documented. Another resident with dementia and gait abnormalities experienced arm pain after a fall, but further doses of Tylenol were not recorded despite ongoing pain complaints and a physician's order. These issues were discussed with the facility's DON and NHA.
A facility failed to maintain accurate medical records for a resident who alleged abuse by an employee. The incident was reported, but the resident's medical records lacked documentation of the abuse allegation, assessment of injury, mental status, physician notification, or measures taken. Despite 17 nursing progress notes during the relevant period, none addressed the abuse incident.
A resident with a history of a left femur fracture and neuropathy did not have their lidocaine patches removed as per physician's orders, despite documentation indicating otherwise. The patches were found still on the resident during an observation, and the discrepancy was confirmed by the DON. The facility's policy on medication administration was not followed.
Failure to Protect Residents from Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving staff and residents. In one case, a Geriatric Nursing Assistant (GNA) physically assaulted a resident by choking and punching them, which was witnessed by other staff members. Despite the severity of the incident, the abuse was not reported immediately, allowing the GNA to continue working for an additional 12 hours before being suspended. The facility also failed to ensure that all staff had the required abuse training, particularly agency staff, and did not conduct a Root Cause Analysis or involve the Quality Assessment Performance Improvement (QAPI) committee in addressing the incident. In another incident, a resident alleged that they were slapped by a staff member after a verbal altercation. The facility's investigation was inadequate, as it did not include statements from all staff who worked during the time of the alleged incident, and the police were not notified. Additionally, a staff member failed to report an allegation of abuse immediately, and the facility did not act on this information when it was brought to their attention. A third incident involved a resident alleging verbal and mental abuse by a GNA, who was not suspended during the investigation. The facility's administration dismissed the allegations without conducting a thorough investigation, relying on assumptions rather than interviewing the resident or staff. This lack of immediate action and failure to follow proper procedures contributed to the facility's inability to protect residents from abuse and neglect.
Removal Plan
- Resident #45 was interviewed by the social worker regarding his/her abuse claim. The facility reported the incident to the state. A 5-day investigation was completed and submitted. The conclusion was that alleged abuse could not be substantiated. GNA #1 was removed from resident #45's care. All residents in GNA #1's group were interviewed by the social worker with no concerns identified.
- All other residents in WillowBrooke Court will be interviewed by nursing and the social worker to ensure there is no suspected abuse or neglect.
- Training on Abuse, Neglect, Reporting & Investigation was conducted by the Regional Clinical Director to the Director of Nursing (DON) & Assistant Director of Nursing (ADON). All team members currently working were educated on Abuse & Neglect Policy and protocol focusing on report abuse as soon as possible, obtaining witness statements, suspension pending investigation, Acts policy and state regulations on Abuse & Neglect, & who the abuse coordinator of the community is by nursing management (DON/ADON). The rest of the team members working in WillowBrooke Court will complete training by nursing management (DON/ADON). For those team members not on the schedule to work the training will be conducted by the DON and ADON by phone.
- The management team (NHA, DON, & ADON) will round twice a week to randomly interview 5% of the current residents on different shifts and different times regarding the quality of their care and monitor team members' interaction with residents. Any issues identified will be corrected immediately. Any concern from the resident will be reported per regulation requirement. Any alleged team member will be suspended immediately pending investigation.
- Random interviews by the NHA, DON, & ADON will be audited until 100% compliance is achieved and findings will be discussed in monthly QAPI.
Failure to Conduct Root Cause Analysis for Resident Falls
Penalty
Summary
The facility failed to conduct a root cause analysis and thorough investigation for a resident who experienced multiple falls, one of which resulted in a left hip fracture requiring surgery. The resident, diagnosed with Alzheimer's Dementia, had severe cognitive impairment and was identified as a high fall risk. Despite this, the facility did not implement new interventions to prevent further falls between September 2023 and July 2024, even after the resident experienced 11 falls. The resident's care plan identified them as a fall risk due to deconditioning, gait/balance problems, incontinence, and unawareness of safety needs. However, the interventions listed in the care plan were not updated with new strategies to address the ongoing fall risk. The facility's Fall Reduction and Management Policy aimed to identify and mitigate fall risks, but the lack of new interventions and failure to complete the Root Cause of Fall section in the Fall Incident Reports indicated a gap in adherence to this policy. The Director of Nursing confirmed that the Fall Intervention Form only included monitoring as an intervention and acknowledged that the Root Cause of Fall section was not completed. This oversight potentially limited the facility's ability to develop effective fall prevention strategies, as no new interventions were identified or implemented following the resident's falls.
Failure to Conduct Regular Performance Reviews for GNAs
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) received a performance review at least once every 12 months, which has the potential to affect all residents. This deficiency was identified during a review of staff records and interviews with facility staff. Specifically, the employee file of one GNA was reviewed, revealing no performance reviews since 2011. The Director of Nursing (DON), who joined the facility in 2020, admitted to not conducting evaluations for GNAs, only for the Assistant Director of Nursing (ADON). The lack of performance reviews prevents the facility from providing regular in-service education based on these evaluations.
Failure to Monitor and Document Meal Temperatures
Penalty
Summary
The facility failed to ensure that meal temperatures were consistently taken and documented before each meal was served, which is a critical step in maintaining food safety standards. The Dietary Manager (DM) reviewed the food temperature logs and found that from January 1 to January 9, temperatures were not documented for all three meals or all hot food items prepared for each meal. The DM, who had been in the position for four months, admitted to not reviewing the temperature logs until the week of the survey and was unaware that staff were not temping all food items prepared for each meal. During interviews, both the DM and the Director of Nursing (DON) expressed their expectations that food should be served at the correct temperature and that staff should ensure this is done in a timely manner. The facility's policy on food temperatures, revised in January 2013, states that food temperatures should be obtained and recorded prior to meal service, and any inappropriate temperatures should be corrected. However, the lack of consistent documentation and monitoring of food temperatures indicates a failure to adhere to this policy, potentially affecting all residents consuming food from the kitchen, except for one resident who was nothing by mouth (NPO).
Inadequate Performance Improvement Project Documentation
Penalty
Summary
The Quality Assurance (QA) committee at the facility failed to conduct a comprehensive Performance Improvement Project (PIP) that included continuous improvement of processes, measured outcomes, developed and implemented action plans, and conducted a root cause analysis. This deficiency was identified through interviews and a review of facility documentation. The facility's Quality Assurance, Performance Improvement (QAPI) and Compliance Program document, dated October 2022, outlined the purpose of QAPI as a proactive, systematic, interdisciplinary, comprehensive, and data-driven approach to improve the quality of life, care, and services for residents. However, the QA committee did not adhere to these guidelines, as evidenced by the lack of thorough documentation and analysis in their PIP efforts. During an interview, the Director of Nursing (DON) revealed that each department could fill out a form to report areas of concern or improvement, and residents could report concerns through the Resident Council or to any nurse or employee. The Infection Preventionist (IP) identified an issue with increasing pressure ulcers, prompting a PIP. However, the DON admitted that the PIP consisted merely of collecting information from the IP and filling out a form, without tracking outcomes, developing and implementing action plans, conducting a root cause analysis, or measuring the success of actions. The Administrator acknowledged that while work was being done, it was not being documented properly, resulting in a lack of proof to demonstrate the facility's efforts.
Facility Fails to Investigate and Address Abuse and Injuries
Penalty
Summary
The facility administration failed to provide effective oversight to ensure resources were used effectively to meet the health and safety needs of residents. This was evidenced by the lack of a system to complete investigations related to injuries of unknown origin, failure to address abuse, and failure to ensure all staff received required training for abuse. The Director of Nursing (DON) provided incomplete investigation reports for incidents involving residents with unwitnessed falls resulting in fractures. These reports lacked essential information such as resident assessments, witness statements, and care plan updates. The DON admitted to not conducting root cause analyses for incidents and only discussing them without proper documentation. The facility did not report or investigate several incidents involving residents with falls and injuries of unknown origin. Additionally, a staff member identified in an abuse allegation was not suspended upon notification, and the facility failed to conduct thorough investigations into these incidents. The DON and Nursing Home Administrator (NHA) were unable to identify who was responsible for the final review of investigations prior to submission. An abuse allegation against a GNA was not handled appropriately, as the alleged perpetrator was not suspended and continued working on the same unit. The facility also failed to notify the police of a previous abuse allegation and did not expand the investigation to include all potential witnesses. Furthermore, an LPN witnessed an abuse incident but did not report it immediately, and the facility could not verify the required abuse training for this agency staff member.
Failure to Ensure Abuse Training for Agency Staff
Penalty
Summary
The facility failed to ensure that all nursing staff received training on abuse, including procedures for reporting incidents of abuse, neglect, exploitation, and misappropriation of resident property. This deficiency was identified during the review of a facility-reported incident involving a resident who was physically abused by a Geriatric Nursing Assistant (GNA). The incident was witnessed by an LPN, who did not report it until nearly 19 hours later, allowing the GNA to continue providing care to residents during that time. The Director of Nursing confirmed that the LPN, who was an agency staff member, had not received the required abuse training from the facility, as the facility relied on the agency to provide necessary documentation, excluding abuse training verification.
Failure to Timely Report Abuse and Neglect Incidents
Penalty
Summary
The facility administration failed to report several incidents of alleged abuse, neglect, or injuries of unknown origin to the Office of Health Care Quality (OHCQ) within the required timeframe. This deficiency was evident in multiple cases, including a resident with Alzheimer's and osteoporosis who experienced an unwitnessed fall resulting in a fracture, which was reported to the OHCQ approximately 10 hours after the incident. Another resident with breast cancer, dysphagia, and dementia had multiple documented injuries of unknown origin that were not reported to the OHCQ, including bruises and an unwitnessed fall. In another case, a resident with dementia and Parkinson's disease was found on the floor with a fracture, but the incident was not reported to the OHCQ. Additionally, an allegation of abuse involving a resident being slapped by an employee was not reported to local law enforcement, and the facility's investigation revealed that staff failed to report the incident immediately. Furthermore, a resident reported being physically abused by a Geriatric Nursing Assistant, but the incident was not reported to the OHCQ or local law enforcement in a timely manner. The facility's policy requires immediate reporting of suspected abuse, neglect, or crimes to the appropriate authorities, but this was not adhered to in several instances. The Director of Nursing and the Administrator were aware of the allegations but failed to report them to the state agency or conduct thorough investigations. In one case, the Administrator concluded there was no validity to an allegation without interviewing the resident or staff involved. These failures to report and investigate incidents in a timely manner highlight significant deficiencies in the facility's handling of abuse and neglect allegations.
Inadequate Investigations and Resident Protection Failures
Penalty
Summary
The facility staff failed to thoroughly investigate allegations of abuse and injuries of unknown origin, and failed to protect residents from further abuse. This was evident in several cases, including Resident #902, who experienced an unwitnessed fall resulting in a nondisplaced elbow fracture. The investigation into this incident was inadequate, as it only included an interview with the GNA assigned to the resident and lacked new interventions to prevent future falls. Resident #903 also suffered from an unwitnessed fall, resulting in a hip fracture. The investigation was limited to interviews with the nurse and GNA caring for the resident, and there was no documentation of corrective actions regarding a faulty bed alarm that may have contributed to the fall. Similarly, Resident #904 experienced multiple unwitnessed falls, with one resulting in a subdural hematoma and facial fractures. The investigation did not include interviews with staff or residents, and assumptions were made about the cause of the falls without thorough investigation. In another case, Resident #901 reported being slapped by an employee, but the facility's investigation was insufficient, as it did not expand to include all potential witnesses. Additionally, GNA#7 was not immediately removed from duty after being accused of physically abusing Resident #905, and the facility failed to conduct a comprehensive investigation into the incident. Furthermore, the facility did not adequately investigate an injury of unknown origin for R24, and R45's allegations of verbal abuse by a GNA were dismissed without proper investigation or reporting to the state.
Failure to Administer and Document Pain Management
Penalty
Summary
The facility failed to administer and document pain medication for residents with reported pain, as evidenced by the cases of two residents. Resident #903, who had severe cognitive impairment and was diagnosed with unspecified dementia and abnormalities of gait, was found on the bathroom floor with complaints of left hip pain. Although nursing staff documented that Tylenol was administered for the pain, the medication administration record (MAR) did not reflect this, despite the resident's pain being documented as a '6' prior to hospital transfer. Similarly, Resident #902, also diagnosed with unspecified dementia and abnormalities of gait, was found with a swollen arm and pain after a fall. Although the MAR indicated that Tylenol was administered initially, no further doses were recorded despite ongoing complaints of pain and a physician's order for medication every six hours as needed. Additionally, on a separate occasion, Resident #902 complained of leg pain and had a bruise, but no pain medication was documented as administered until several hours later. These deficiencies were discussed with the facility's Director of Nursing (DON) and Nursing Home Administrator (NHA).
Failure to Document Abuse Allegation and Assessment
Penalty
Summary
The facility staff failed to maintain complete and accurate medical records for a resident involved in an abuse allegation. The incident involved a resident who reported to their daughter that an employee had physically assaulted them after being called a derogatory name. The Director of Nursing (DON) reported the incident to the state agency and initiated an investigation. However, a review of the resident's medical records revealed that there was no documentation of the abuse allegation, no assessment specific to the allegation, and no record of any evidence of injury, the resident's mental status, physician notification, or measures implemented in response to the incident. This lack of documentation was evident despite the presence of 17 nursing progress notes within the relevant timeframe, none of which addressed the abuse allegation or related assessments.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that physician's orders for a resident's medication were followed, specifically regarding the removal of lidocaine patches. The resident, who was cognitively intact and had a history of a left femur fracture and neuropathy, was prescribed two lidocaine patches to be applied in the morning and removed at bedtime. However, during an observation, it was found that the patches had not been removed as per the physician's orders, despite documentation indicating otherwise. The incident involved a registered nurse who documented the removal of the patches without actually performing the task. This was confirmed during interviews with the nurse and the Director of Nursing, who acknowledged the discrepancy between the documentation and the actual practice. The facility's policy on medication administration and management, which requires accurate documentation of medication administration, was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 222 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Easton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pines Nursing And Rehab | 0.3 mi | ★★★★★ | 90 | 0 |
| Mallard Bay Nursing And Rehab | 13 mi | ★★★★★ | 44 | 0 |
| Autumn Lake Healthcare At Chesapeake Woods | 13 mi | ★★★★★ | 26 | 1 |
| Caroline Nursing And Rehab | 15.4 mi | ★★★★★ | 5 | 0 |
| Denton Nursing And Rehab | 16.7 mi | ★★★★★ | 36 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Willowbrooke Ct Skilled Care Ctr At Bayleigh Chase.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.