Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cook Willow Health & Rehabilitation Center, Inc. during CMS and state inspections, most recent first.
A resident with intact cognition and significant visual impairment was threatened by a roommate, who had dementia and mental health diagnoses, when the roommate placed a plastic knife to the resident’s neck after the resident called out for assistance. Following the incident, the DON instructed an LPN to move the victim rather than the aggressor, and the resident was relocated to a room at the end of a corridor four rooms away, with no alternate route of access, requiring the resident to pass the aggressor’s room to reach common areas. The resident reported feeling they had no real choice but to move and later expressed anger and ongoing nervousness about the situation. Interviews and census review showed that private rooms on another unit had been available for the aggressor, and facility leadership acknowledged that the victim was not offered the option to remain in the original room, despite resident rights policies guaranteeing notice and choice regarding roommate changes.
A resident with cognitive impairment and physical limitations reported being inappropriately touched by staff during a shower. The allegation was relayed to the ADON, who did not report or investigate the claim, and the DON was not informed. The facility failed to notify the State Agency and did not follow its own abuse reporting policy.
A resident with dementia and a recent cerebral infarction, who was alert and required moderate assistance, reported being inappropriately touched by staff during a shower. The allegation was relayed to the ADON, but no investigation was conducted or documented, as the reporting staff member expressed doubt about the event and requested no further questioning. The DON was unaware of the incident, and facility policy requiring prompt investigation of abuse allegations was not followed.
Failure to Honor Resident Room Choice After Resident-to-Resident Threat
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose whether to remain in their room and to receive appropriate notice before a room change following a resident‑to‑resident altercation. One resident with intact cognition, muscle weakness, type II diabetes mellitus, and absolute glaucoma was dependent on staff for bed mobility and required assistance with transfers and ambulation. This resident ambulated independently with a rolling walker in the room and throughout the facility and enjoyed walking out of the room, socializing with friends, and going to the dining room for meals. Another resident, who had Alzheimer’s disease, major depressive disorder with psychotic symptoms, generalized anxiety disorder, and moderately impaired cognition, had a care plan identifying poor impulse control, lack of safety awareness, potential for manipulative behaviors, and a history of making accusatory statements, with interventions including the use of plastic utensils and staff support for coping and behavior. On the date of the incident, the cognitively intact resident reported that the dinner cart was outside the room and began calling out “hello” for help. The roommate became aggravated, approached the resident’s side of the room, told the resident to use the call bell, and then placed a plastic knife to the resident’s neck and moved it across. The victim reported that the roommate cursed, called names, and threatened that if the resident did not “shut up” it would be worse next time. Staff documentation and interviews confirmed that the victim was removed from the room to the hallway, assessed with no acute injury noted, and that the aggressor was placed on one‑to‑one observation and sent to the ED for evaluation. The victim was described as calm but slightly anxious and later expressed being upset and worried about the aggressor returning. Following the altercation, the DON directed staff to move the victim to a different room, despite the aggressor being the one who initiated the threatening behavior. The LPN asked the victim if they were agreeable to the move and proceeded with the room change without offering the option to remain in the original room. The new room was located at the end of a hallway four rooms away from the aggressor’s room, with no alternate route of exit or access, requiring the victim to routinely pass the aggressor’s room to reach common areas and the dining room. The victim later reported feeling they had no real choice but to move in order to feel safe, expressed anger that the aggressor ended up with a private room, and continued to feel nervous about having to walk past the aggressor’s room. Interviews with facility leadership acknowledged that the victim should have been offered the choice to remain in the original room, that the aggressor should have been moved instead, and that private rooms on another unit had been available at the time. The facility’s Residents’ Bill of Rights policy stated that residents have the right to notice before a roommate is changed, to be treated equally with other residents, and to be free from abuse, but there was no specific policy available for room transfers following resident‑to‑resident altercations.
Failure to Timely Report and Investigate Alleged Resident Mistreatment
Penalty
Summary
Staff failed to report and investigate an allegation of mistreatment involving a resident with diagnoses of cerebral infarction, dementia, and anxiety disorder. The resident, who was alert and oriented with a BIMS score of 14/15 and required moderate assistance for showers, reported to a staff member that they were inappropriately touched by another staff member during a shower. The staff member relayed the allegation to the ADON, but the ADON did not report or investigate the allegation, citing the reporting staff's disbelief in the event and a request not to discuss the matter further with the resident. The facility did not submit a reportable event to the State Agency as required, and the DON was not made aware of the allegation until later. Facility policy and the DON both require that all abuse allegations be reported immediately, investigated promptly, and reported to the State Agency within two hours of discovery. The failure to report and investigate the allegation in a timely manner, as well as the lack of notification to the State Agency, constituted a deficiency in the facility's handling of suspected abuse.
Failure to Investigate Alleged Mistreatment in a Timely Manner
Penalty
Summary
The facility failed to ensure a timely investigation of an allegation of mistreatment involving a resident diagnosed with cerebral infarction, dementia, and anxiety disorder. The resident, who was alert and oriented with a BIMS score of 14/15 and required moderate assistance for showers, reported to a staff member that they had been inappropriately touched by another staff member during a shower. This allegation was communicated to the ADON, but the facility was unable to provide documentation that an investigation was conducted regarding the reported mistreatment. The ADON stated that the allegation was not investigated or reported because the reporting staff member did not believe the event had occurred and requested that the resident not be questioned further. The DON was not aware of the allegation and confirmed that all such reports should be investigated according to facility policy, which requires thorough investigation of any abuse allegations within 72 hours. The lack of documentation and failure to investigate the reported incident constituted a deficiency in the facility's response to alleged violations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Plymouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Bucks Hill | 5.4 mi | — | 0 | 0 |
| Ingraham Manor Rehab And Nursing | 5.8 mi | — | 6 | 1 |
| Pines At Bristol For Nursing & Rehabilitation, The | 6.1 mi | — | 3 | 0 |
| Waterbury Center For Nursing & Rehabilitation Llc | 6.4 mi | — | 1 | 0 |
| Apple Rehab Watertown | 6.6 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.