Willowbrooke CT: Abuse Investigation Failures - MD

Licensed Practical Nurse #3 witnessed the entire assault on Resident #905 at Willowbrooke CT Skilled Care Center at Bayleigh Chase. She watched Geriatric Nursing Assistant #7 pull the resident's hair, rush at him and strike him. Then she said nothing for nearly 19 hours.

The LPN finally reported the abuse at 6:03 PM the next day, according to facility time records reviewed by federal inspectors in January. By then, GNA #7 had finished her overnight shift, returned that afternoon, and worked three more hours — all while caring for other vulnerable residents.

Director of Nursing confirmed that GNA #7 "was not sent off duty on 4/25/22 immediately after the incident." When asked why, she said GNA #6, who witnessed part of the assault, "did not report the incident and LPN #3 was an agency staff member and did not report it immediately."

The facility's own policy requires immediate removal of suspected abusers pending investigation. They failed to follow it.

This was one of multiple abuse cases where Willowbrooke CT botched investigations, according to the January 17 federal inspection that found the facility in immediate jeopardy for failing to protect residents from abuse.

In another incident from October 2022, Resident #901 — a person with severe cognitive impairment — told his daughter that a staff member had smacked him on the mouth after he called her a name. The resident had actually reported being slapped twice in the face two days earlier, but GNA #10 "forgot to report it."

Twenty-six nursing staff worked on Resident #901's unit during the three-day period when the abuse allegedly occurred. Investigators obtained written statements from only five of them. They never interviewed dietary workers, housekeeping staff, activities personnel, maintenance workers or laundry staff who might have witnessed something.

"She wasn't sure why she didn't get more staff statements," the Director of Nursing admitted when inspectors questioned the incomplete investigation.

The facility never expanded their inquiry after learning about the earlier slapping incident from GNA #10's statement.

When inspectors discovered a new abuse allegation during their visit, administrators made the same mistakes. Resident #45 accused GNA #1 of calling him an expletive and retaliating against him for complaints. The Director of Nursing had heard about some allegations but said "this was the first time she heard that R45 alleged that GNA1 called him/her an (expletive)."

The Administrator and Director of Nursing discussed the allegations but never interviewed the resident or any staff. They decided the claims lacked validity because the resident mentioned a dog that didn't exist and referenced a staff member who no longer worked there.

"He said this was not reported to the state and that he did not interview the resident or any staff before making this conclusion," inspectors wrote. The Administrator explained they "decide if it's valid before they report it to the state."

The accused staff member was never suspended.

These investigation failures extended beyond abuse cases. When Resident #24 showed up with a 6x4 bruise on the left side of her face and a puffy eye, staff documented it as an "injury of unknown origin" but never completed a proper assessment.

"A complete skin assessment was not done. The entire body should have been assessed since it was an injury of unknown origin," the Director of Nursing acknowledged. "No other residents were interviewed or staff. This was an incomplete investigation."

The facility's systemic problems went deeper than botched abuse investigations. Resident #52, a man with severe cognitive impairment from Alzheimer's disease, fell 11 times between October 2023 and July 2024. The final fall fractured his left hip, requiring surgery.

Each time he fell, staff filled out incident reports but never completed the "Root Cause of Fall" section that might have identified prevention strategies. For nearly 10 months after his first fall, the only new intervention added to his care plan was encouraging exercise. A call bell pad wasn't installed until December 2024 — five months after his hip fracture.

"It could have brought more ideas for effective fall prevention interventions," the Director of Nursing admitted when confronted with the blank root cause sections.

Pain management failures compounded resident suffering. When Resident #903 fell in the bathroom and complained of hip pain rated as a "6," nursing notes claimed Tylenol was given at 9:50 PM. The medication administration record showed no Tylenol was actually provided.

Resident #902 broke his elbow in a fall. For four consecutive days, progress notes stated he "had complaints of pain on the left arm and was given routine Tylenol." The medication records showed he received Tylenol only once during that period. The progress notes "all repeated the same information verbatim" — suggesting staff copied previous entries rather than documenting actual care.

Staff oversight had collapsed entirely. The Director of Nursing admitted she hadn't conducted performance evaluations for nursing assistants since taking the job in 2020. When asked who was responsible for evaluating other nursing staff, she stated flatly: "They're not done."

GNA #7's personnel file contained performance reviews from 2009 and 2011, but nothing since. Federal regulations require annual evaluations to identify training needs and ensure competent care.

The facility also failed to verify that agency staff received required abuse training. When LPN #3 — the witness who delayed reporting the assault for 19 hours — was questioned about her training, the Director of Nursing said: "She was an agency staff. We don't have her abuse training."

The agency provided licenses and background checks, she explained, "but we don't get their abuse training."

Medical record keeping was equally deficient. When Resident #901 alleged being slapped in the mouth, staff wrote 17 progress notes over the following nine days. Not one mentioned the abuse allegation, any assessment for injuries, notification of the physician, or protective measures implemented.

The Director of Nursing had identified that significant incidents "should be documented in a narrative note in the progress note section." Her staff ignored this requirement entirely.

These failures created immediate danger for residents, according to state regulators who determined the facility posed immediate jeopardy on January 13. The combination of substantiated abuse from 2022 and the new allegation during the survey triggered the most serious enforcement action possible.

Resident #52 continues requiring assistance with transfers and mobility after his hip surgery. His care plan still lists the same goal from September 2023: "I will be free of minor injuries." That goal remains unmet after 11 falls and a major fracture that required surgical intervention.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Willowbrooke Ct Skilled Care Ctr At Bayleigh Chase from 2025-01-17 including all violations, facility responses, and corrective action plans.

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