Cook Willow Health & Rehabilitation Center, Inc.
COOK WILLOW HEALTH & REHABILITATION CENTER, INC. in PLYMOUTH, CT — inspection on April 29, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
following the 4/3/26 altercation and although Resident #2 was the aggressor, she only had vacant
new room. Resident #1 agreed so she thought it was fine.
The DON identified it did not occur to her
by Resident #2's room to access the remainder of the facility.Interview with the Director of Social Services on 4/29/26 at 1:27 PM identified Resident #1 should have remained in his/her room after the 4/3/26 altercation and the aggressor (Resident #2) should have been moved to a different room.
She reported she understood why Resident #1 was frustrated with the room change.Re-interview with the DON on 4/29/26 at 1:45 PM identified Resident #1 should have been offered to remain in his/her original room and Resident #2 should have had the room change since the facility had two (2) private rooms on a different unit available at the time.
Additionally, she reported she should have ensured the residents rooms were located on separate units.
Review of the facility census dated 4/3/26 identified there were three (3) private rooms available on the East (short-term) unit that Resident #2 could have been moved to, which would have allowed Resident #1 to remain in his/her original room following the altercation.
Review of the Abuse, Definitions and Procedure for Suspected Abuse policy dated 11/2021 directed, in part, the procedure for incidents of resident-to-resident abuse includes: the charge nurse and supervisor assess the victim of abuse for injury/harm, initiate proper treatment and investigate the incident to determine etiology and precipitating factors.
Using this information, interventions are put into place to prevent further incidents and mitigate any negative consequences for the victim of such abuse.
The plan of care for both the victim and the abuser is updated to reflect these interventions and a nurse's note is written.
Review of the Residents' [NAME] of Rights policy (undated) directed, in part, you have the right to notice before your roommate is changed, you have the right to be treated equally with other residents in receiving care and services and regarding transfer and discharge regardless of the source of payment for your care and you have the right to be free from verbal, sexual, physical or mental abuse, corporal punishment or involuntary seclusion.Although requested, a facility policy for room transfer following a resident-to-resident altercation was not available.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.