Willowbrooke CT Skilled Care: Staff Assault Failures - MD
The assault at Willowbrooke CT Skilled Care Center at Bayleigh Chase was witnessed by a licensed practical nurse and another nursing assistant, according to federal inspection records. Neither reported it immediately as required by facility policy and federal regulations.
The LPN who witnessed the attack waited until the next evening to call the Director of Nursing. The other nursing assistant present said she didn't report it because she assumed the LPN had.
"She did not report the incident because she thought LPN#3 reported it," the nursing assistant wrote in her statement to investigators.
When federal inspectors interviewed the nursing assistant on January 14, 2025, she "repeatedly indicated she was unable to recall details of the incident." She couldn't remember why she thought the LPN would report it, couldn't recall who the LPN called, and said the phone call "could have been about anything."
The facility never contacted police about the assault, despite policy requiring immediate notification to law enforcement for crimes or allegations of crimes.
This was one of multiple failures to properly investigate and report abuse allegations uncovered during a January 2025 federal inspection. Inspectors found the facility failed to protect seven residents from abuse, with staff repeatedly failing to follow mandatory reporting procedures.
In another case from October 2022, a resident told his daughter that a staff member "smacked him/her on the mouth" after he called the employee a derogatory name. The resident had actually mentioned being "slapped twice on the face" to a nursing assistant three days earlier, but that worker "forgot to report it," according to inspection records.
The facility reported this incident to the state but never contacted local law enforcement, as required when abuse allegations involve assault.
During a January 9, 2025 interview, the Director of Nursing confirmed police weren't notified and acknowledged she was aware the nursing assistant had failed to report the resident's abuse allegation when it was first made.
The inspection also revealed inadequate investigations of suspicious injuries. Resident #902, who has dementia, was found bleeding from the forehead with "a black and blue bump already formed" after an unwitnessed fall on July 12, 2023. The resident complained of shoulder and elbow pain and had difficulty moving without grimacing.
An X-ray revealed a nondisplaced elbow fracture requiring hospital treatment. But investigators found no interviews beyond the single nursing assistant assigned to care for the resident that day. The facility implemented no new interventions to prevent future falls.
Another resident with dementia, #903, suffered a hip fracture in an unwitnessed fall on May 10, 2024. A CT scan revealed a left intra trochanteric fracture. The investigation identified concerns with a faulty bed alarm that may have contributed to the fall, but there was "no further documentation of interventions or audits" to ensure the problem was fixed.
Resident #904, who has dementia and Parkinson's disease, was found on the floor May 30, 2023 with a hematoma on the forehead and blood on the mouth and nose. Hospital evaluation revealed a left orbital floor fracture, a mild fracture of the left anterior maxillary wall, and a left subdural hematoma — a potentially life-threatening collection of blood between the brain and skull.
The facility's investigation "failed to include any interviews with staff or residents from the day of the incident." Administrators simply assumed the resident fell from a chair and hit his face, causing the multiple fractures.
During the review of that incident, inspectors discovered another unwitnessed fall with fracture involving the same resident on March 15, 2023 that was never properly investigated.
Current residents also reported ongoing problems. Resident #45, who has major depressive disorder and mild cognitive impairment, told inspectors during a January 7, 2025 interview that a nursing assistant "hated him/her" and had called the resident an expletive.
"S/he said s/he reported it to the Director of Nursing who told R45 that it was unacceptable behavior," inspection records state. The nursing assistant remained employed at the facility.
The resident said the worker provided poor care during showers, not washing or drying properly, and would "gang up" with another assistant to talk about the resident in hallways. "S/he said they said they were not going to do the right thing."
When the Director of Nursing was interviewed January 8, 2025, she admitted she had discussed the resident's allegations with the administrator but "that was as far as it's gone." She said they hadn't reported it to the state and she was "waiting to discuss it with Regional Clinical Nurse."
The administrator told inspectors he consulted with the Director of Nursing and medical director and "decided there was no validity to the allegation" partly because the resident claimed a nursing assistant had killed her dog, and another worker mentioned by the resident "has not worked here for a long time."
He confirmed the allegations weren't reported to the state and that he "did not interview the resident or any staff before making this conclusion."
Facility policy requires anyone who witnesses or suspects abuse to "immediately report the incident to their department supervisor," who must then notify administrators within two hours for incidents involving abuse or serious injury, or within 24 hours for other incidents. The policy specifically states that "criminal acts include, but are not limited to, assault, sexual assault, and theft of resident property."
The pattern of delayed reporting, inadequate investigations, and failure to contact law enforcement left vulnerable residents at continued risk. Federal inspectors found that staff who witnessed the April 2022 assault continued working at the facility, with no evidence of additional training or monitoring to prevent future incidents.
The inspection covered 12 residents reviewed for abuse allegations, with additional unreported incidents discovered during individual medical record reviews that the facility had never identified.
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.
Additional Resources
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Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
WILLOWBROOKE CT SKILLED CARE CTR AT BAYLEIGH CHASE in EASTON, MD was cited for violations during a health inspection on January 17, 2025.
Neither reported it immediately as required by facility policy and federal regulations.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at WILLOWBROOKE CT SKILLED CARE CTR AT BAYLEIGH CHASE?
- Neither reported it immediately as required by facility policy and federal regulations.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in EASTON, MD, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from WILLOWBROOKE CT SKILLED CARE CTR AT BAYLEIGH CHASE or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 215137.
- Has this facility had violations before?
- To check WILLOWBROOKE CT SKILLED CARE CTR AT BAYLEIGH CHASE's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.