Cook Willow Health & Rehab: Victim Moved After Attack - CT
The victim, identified in inspection records only as Resident #1, was directed out of her own room following a physical altercation on April 3, 2026. The aggressor, Resident #2, stayed put. Nobody, at the time, appears to have thought through what that meant for Resident #1 every time she needed to leave her new room: her path to the rest of the facility ran directly past the door of the person who had just attacked her.
A complaint inspection completed April 29, 2026 documented what happened and how the facility's own leadership came to explain it.
The Director of Nursing told inspectors she had made the call on the day of the altercation. She said she checked for available rooms and found only vacant private rooms on the short-term unit, so she contacted the Administrator, and together they decided Resident #2 would stay where she was. An LPN was directed to move Resident #1. The Director of Nursing said Resident #1 agreed to the move, so she considered it resolved.
She acknowledged to inspectors that it did not occur to her that Resident #1's new room was at the end of a hallway and that Resident #1 would have to walk past Resident #2's room to reach the rest of the building.
The Director of Social Services, interviewed the same afternoon, was more direct. She told inspectors Resident #1 should have remained in her original room and that the aggressor should have been the one moved. She said she understood why Resident #1 was frustrated.
The Director of Nursing, re-interviewed at 1:45 PM on April 29, walked back her earlier account. She acknowledged Resident #1 should have been offered the chance to stay in her original room. She said Resident #2 should have had the room change. She also said she should have ensured the two residents ended up on separate units entirely.
Then inspectors reviewed the facility's own census records from April 3, the day of the altercation. Those records showed three private rooms available on the East unit, which is the short-term unit where the incident occurred. Any one of those three rooms could have taken Resident #2. Resident #1 could have stayed where she was.
The Director of Nursing had told inspectors there were only rooms available on the short-term unit, which she used to explain why moving Resident #2 wasn't straightforward. The census showed three rooms available on that same unit. The constraint she described did not exist.
The facility's own abuse policy, dated November 2021, laid out what is supposed to happen after a resident-to-resident abuse incident. The charge nurse and supervisor are to assess the victim for injury or harm, initiate proper treatment, investigate the incident to determine what caused it and what factors led to it, and put interventions in place to prevent further incidents and protect the victim from negative consequences. Both the victim's and the aggressor's care plans are to be updated to reflect those interventions.
Inspectors asked for a facility policy specifically addressing room transfers following resident-to-resident altercations. No such policy was available.
The facility's Residents' Rights policy, though undated, states that residents have the right to notice before a roommate is changed, the right to be treated equally with other residents in receiving care and services, and the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
What the inspection report does not contain is any account of what Resident #1 experienced in the weeks between the altercation and the inspection. The assault happened April 3. Inspectors arrived April 29. For twenty-six days, the record is silent on whether Resident #1 encountered Resident #2 in that hallway, whether she asked to be moved back, whether she filed a complaint, or what the daily reality of that arrangement looked like for her.
What the record does contain is a Director of Nursing who, by her own admission on re-interview, recognized the decision was wrong, a Director of Social Services who said plainly that the victim should not have been moved, and a census document showing that the logistical problem the facility cited to justify the decision was not, in fact, a problem at the time.
The inspection cited violations at the level of minimal harm or potential for actual harm, with few residents affected. That classification reflects the regulatory framework inspectors apply. It does not describe what it is to be the person who was attacked and then handed a new room key and pointed toward the end of a hallway.
Cook Willow Health & Rehabilitation Center is a licensed nursing facility in Plymouth, Connecticut. The inspection was conducted in response to a complaint.
The aggressor kept her room. The victim kept walking past it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cook Willow Health & Rehabilitation Center, Inc. from 2026-04-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
COOK WILLOW HEALTH & REHABILITATION CENTER, INC. in PLYMOUTH, CT was cited for violations during a health inspection on April 29, 2026.
The victim, identified in inspection records only as Resident #1, was directed out of her own room following a physical altercation on April 3, 2026.
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.