Plymouth, CT

Cook Willow Health & Rehabilitation Center, Inc.

5-star overall rating with 4-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

81 Hillside Avenue, Plymouth, CT

(860) 283-8208

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

60

Certified beds

Average residents

50

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1991-11-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.95

Registered nurse staffing

LPN hours / resident day

0.68

Licensed practical nurse staffing

Aide hours / resident day

2.53

Nurse aide staffing

Weekend hours

3.47

Weekend nurse staffing

RN turnover

25%

Annual RN turnover

Total nurse turnover

46%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 0.8
2.1
1.3 pts better
1.9
1.1 pts better
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 0
1.5
1.5 pts better
1.8
1.8 pts better
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 100.0%
87.5%
12.5 pts better
93.4%
6.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100.0%
93.5%
6.5 pts better
95.5%
4.5 pts better
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 3.5%
3.4%
0.1 pts worse
3.3%
0.2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 6.5%
17.1%
10.6 pts better
11.4%
4.9 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 5.5%
6.4%
0.9 pts better
5.4%
0.1 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 23.1%
17.3%
5.8 pts worse
19.6%
3.5 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 11.8%
19.4%
7.6 pts better
16.7%
4.9 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained 0.0%
0.0%
About the same
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened 17.0%
18.1%
1.1 pts better
16.3%
0.7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 10.7%
18.4%
7.7 pts better
14.9%
4.2 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
0.9%
0.9 pts better
1.0%
1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 2.5%
1.7%
0.8 pts worse
1.7%
0.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 24.8%
24.8%
About the same
19.8%
5 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 1.0%
4.4%
3.4 pts better
5.1%
4.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 100.0%
70.5%
29.5 pts better
81.7%
18.3 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 0.0%
11.1%
11.1 pts better
12.0%
12 pts better
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 1.8%
1.5%
0.3 pts worse
1.6%
0.2 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 100.0%
69.7%
30.3 pts better
79.7%
20.3 pts better
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 18.3%
25.0%
6.7 pts better
23.9%
5.6 pts better
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-12 · Fire 2025-09-12

9 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2024-02-06 · Fire 2024-02-06

10 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2021-11-22 · Fire 2021-11-22

3 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

3 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-09-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-12-16

D · Potential for more than minimal harm 2025-09-12

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-12-16

E · Potential for more than minimal harm 2024-02-06

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-02-17

D · Potential for more than minimal harm 2024-02-06

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-02-17

E · Potential for more than minimal harm 2021-11-22

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2022-02-23

D · Potential for more than minimal harm 2021-11-22

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-02-23

D · Potential for more than minimal harm 2021-11-22

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2022-02-23

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-09-12

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-10-22

D · Potential for more than minimal harm 2025-09-12

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-10-22

D · Potential for more than minimal harm 2025-09-12

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-10-22

D · Potential for more than minimal harm 2025-09-12

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-10-22

D · Potential for more than minimal harm 2025-09-12

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-10-22

D · Potential for more than minimal harm 2025-09-12

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-10-22

D · Potential for more than minimal harm 2025-09-12

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2025-10-22

D · Potential for more than minimal harm 2025-09-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-10-22

C · Minimal harm 2025-09-12

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-10-22

F · Potential for more than minimal harm 2024-02-06

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-03-19

D · Potential for more than minimal harm 2024-02-06

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-03-19

D · Potential for more than minimal harm 2024-02-06

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-03-19

D · Potential for more than minimal harm 2024-02-06

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-03-19

D · Potential for more than minimal harm 2024-02-06

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-03-19

D · Potential for more than minimal harm 2024-02-06

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-03-19

D · Potential for more than minimal harm 2024-02-06

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2024-03-19

B · Minimal harm 2024-02-06

F570 · Resident Rights Deficiencies

Health

Assure the security of all personal funds of residents deposited with the facility.

Corrected 2024-03-19

B · Minimal harm 2024-02-06

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-03-19

B · Minimal harm 2024-02-06

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-03-19

D · Potential for more than minimal harm 2021-11-22

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2021-12-29

D · Potential for more than minimal harm 2021-11-22

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2021-12-29

B · Minimal harm 2021-11-22

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2021-12-29

Penalties and ownership

What sits behind the stars

Ownership

Macdonald, Susan

5% Or Greater Direct Ownership Interest · Individual

100% 1 facilities 1975-07-01
Le Clair, Jennesa

Operational/Managerial Control · Individual

0% 1 facilities 1989-03-18
Le Clair, Jennesa

Corporate Officer · Individual

0% 1 facilities 1989-03-18
Macdonald, Susan

Operational/Managerial Control · Individual

0% 1 facilities 1975-07-01
Macdonald, Susan

Corporate Director · Individual

0% 1 facilities 1975-07-01
Macdonald, Susan

Corporate Officer · Individual

0% 1 facilities 1975-07-01
Macdonald, Walter

Corporate Officer · Individual

0% 1 facilities 1990-01-15
Oh, Jong Gil

Operational/Managerial Control · Individual

0% 2 facilities 2007-05-01

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Health
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Staffing
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Fines
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3-star overall rating with 3-star inspections with $29,950 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

Overall
3 / 5
Health
3 / 5
Staffing
2 / 5
Fines
$29,950

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