The April 25, 2022 assault at Willowbrooke CT Skilled Care Center at Bayleigh Chase was witnessed by two staff members, but neither reported it immediately. The aide, identified as GNA#7, clocked out at 7:51 AM on April 26 and returned at 2:57 PM for another shift before the Director of Nursing finally ordered her off duty at 6:03 PM.
"When she came in to work the next day, she was made aware of the incident," the Director of Nursing told federal inspectors during a January 9 interview. She confirmed that GNA#7 was not removed immediately after the assault because the witnesses — LPN#3, an agency worker, and GNA#6 — did not report it right away.
The facility's failure to protect residents extended beyond delayed responses to witnessed abuse. Inspectors found a pattern of incomplete investigations that left vulnerable residents at risk.
Resident #901, who has severe cognitive impairment, told his daughter that a staff member smacked him on the mouth after he called her a name. But when investigators reviewed written statements, they discovered another unreported assault buried in one aide's account.
GNA#10 revealed that Resident #901 had told her on October 28, 2022 that he was slapped twice on the face during the day by someone in the TV room. She forgot to report it.
The facility never expanded their investigation after learning about this earlier abuse allegation.
Twenty-six nursing staff worked on Resident #901's unit during the three-day period when the assaults allegedly occurred. Investigators obtained written statements from only five of them. No statements were collected from activities staff, maintenance workers, laundry personnel, dietary employees or housekeeping staff who might have witnessed something useful.
Another case revealed how administrators dismissed resident complaints without investigation. Resident #45, who has depression and mild cognitive impairment, told inspectors that GNA#1 called him an expletive and retaliated against him for making reports to administration.
The resident said GNA#1 and GNA#2 would "gang up on him" and talk about him in the hallway. He believed GNA#1 killed his dog and ignored her job duties.
When inspectors reported these allegations to administrators on January 7, the Director of Nursing said she was aware of the dog allegation but had never heard about the expletive. The administrator later told inspectors he consulted with the Director of Nursing and the Medical Director and decided there was "no validity to the allegation" based on the fact that the resident never had a dog at the facility.
He made this determination without interviewing the resident or any staff members. The allegations were never reported to the state, and the accused staff member was not suspended.
"After an allegation is made they decide if it's valid before they report it to the state," the administrator explained. "If they investigate they will interview the resident and any staff that was identified."
But he did not investigate.
The facility also botched the investigation of an unexplained facial injury. Resident #24, who has severe cognitive impairment with a mental status score of zero out of fifteen, developed a 6x4 inch bruise on the left side of her face by her eye. Her left eye was puffy when staff discovered the injury during shift change on August 22, 2024.
The Director of Nursing who completed the investigation admitted to inspectors that "a complete skin assessment was not done" even though it was classified as an injury of unknown origin. "The entire body should have been assessed," she acknowledged.
She did not know if the resident had hit her head. No other residents were interviewed. No staff who worked the night shift were questioned.
"This was an incomplete investigation," she told inspectors.
Beyond abuse investigations, the facility failed residents in basic medical care. Resident #27, who was cognitively intact and suffered from nerve pain after a hip fracture, had doctor's orders for two lidocaine patches to be applied each morning and removed at bedtime.
On January 8, RN#6 documented in the medication record that she had removed the patches. But when RN#4 came to give morning medications the next day, both patches were still stuck to the resident's hip and leg. There were no dates or initials indicating when they had been applied.
The Director of Nursing agreed that RN#6 "should not have documented the removal of the patches until after she had removed them."
The most devastating failure involved Resident #52, a man with Alzheimer's dementia who fell eleven times between October 2023 and July 2024. The final fall on July 1 fractured his left hip and required surgery.
Fall after fall, the pattern was identical. He would attempt transfers without calling for help, end up on the floor, sometimes with skin tears. Staff would find him kneeling on fall mats, lying in the bathroom, sitting by his recliner.
On January 1, 2024, he was found lying on his back in his bathroom beside his wheelchair after trying to transfer to the toilet. He got a skin tear on his left forearm.
Three days later, he fell twice in one day. The first time, staff found him on the floor next to his bed with his head at the footboard and a skin tear on his lower left leg. Hours later, he was discovered lying on his left side in front of his recliner.
The facility's Fall Incident Reports were filled out after each tumble, documenting his diagnoses, medications, mental status and room conditions. But under the "Fall Huddle Investigation Worksheet," staff listed no new interventions other than monitoring. The "Root Cause of Fall" section remained blank for every single fall.
From September 22, 2023 until July 9, 2024 — nearly ten months and seven falls later — no new interventions were added to his care plan to prevent further falls.
On July 1, he was found lying on his back in his bathroom beside his wheelchair again, this time with a skin tear on his left forearm. Later that day, he complained of pain in his upper left leg. An X-ray revealed the hip fracture that required surgery.
"The Root Cause of Fall section had not been completed, and it could have brought more ideas for effective fall prevention interventions," the Director of Nursing admitted to inspectors.
The facility's quality assurance program proved equally hollow. When asked about a Performance Improvement Project on increasing pressure ulcers, the Director of Nursing described a one-person effort: "I collected the information from the IP and filled out the form and that was our PIP."
There was no committee, no root cause analysis, no action plans or outcome measurements.
The administrator acknowledged the documentation failures: "We are doing the work but are not documenting the work. We do not have the proof to show you."
Meanwhile, the facility failed to ensure safe food temperatures, with staff not documenting temperatures for all meals or food items from January 1 through January 9, 2025. The Dietary Manager, four months into her position, said she only became aware that week that staff were not checking all food temperatures before serving residents.
The inspection violations paint a picture of systematic failures in the most basic responsibilities of nursing home care: protecting vulnerable residents from harm, investigating suspicious injuries, preventing falls, and ensuring proper medical treatment. Resident #52 continues to live with the consequences of his fractured hip, while the facility's administrators continue to struggle with what they acknowledge is inadequate documentation of resident safety efforts.
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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