Windsor Locks, Connecticut — State regulators have ordered a Connecticut nursing home to close after an Alzheimer’s patient wandered outside in the middle of the night and died in the cold — and a state investigation found the facility failed her at almost every turn.
The Connecticut Department of Social Services issued the closure order against Bickford Health Care Center in Windsor Locks this week, requiring all 36 residents to be transferred to other facilities by April 10. The move comes after Margaret “Peggy” Healey, 93, left the building undetected in the early morning hours of February 8 and spent more than three hours outside in freezing temperatures before being found unresponsive in the snow.
A Series of Failures
According to state investigators, Healey exited through a rear employee entrance at 1:50 a.m. That door was designed to stay closed and locked — but detectives found it was routinely left propped open, and the keypad access code was printed and posted nearby.
Staff didn’t notice she was missing until 4:45 a.m., nearly three hours later. When they found her lying in the snow about 40 feet from the building just after 5:00 a.m., they wheeled her back inside and attempted to warm her with blankets. Police weren’t called until 6:23 a.m. — four and a half hours after Healey was last seen on surveillance video leaving the building. She was pronounced dead at 6:46 a.m.
The Connecticut Department of Public Health’s investigation found that Healey had a WanderGuard alert device — the kind worn like a bracelet that’s supposed to trigger an alarm if a resident approaches an unsecured exit. But the employee entrance she used wasn’t equipped with the alert system sensors.
“The facility’s change in condition policy directed that 911 should be called immediately if a resident is unresponsive,” DPH wrote in its order. State regulators found the facility failed to follow its own protocol.
What Investigators Found
The DPH report documented a cascade of regulatory violations:
- Failed to notify police within 15 minutes of Healey going missing, as required by state law
- Failed to call 911 promptly when Healey was found unresponsive outside in sub-freezing temperatures
- Failed to ensure physician notification of a resident’s change in condition
- Healey’s medical file had no documentation of her wandering behaviors or planned interventions
- Three emergency exit doors were not properly maintained and failed to fully close, latch, or sound alarms when opened
- No written agreements for laboratory or radiology services
- No documentation of 24-hour physician coverage for emergency care
The DSS order concluded that “the health, safety, and welfare of patients” at the facility was “jeopardized.”
State Response
DSS Commissioner Andrea Barton Reeves appointed Katharine Sacks as temporary manager to oversee the resident transfer process. “This order reflects our commitment to ensuring that the individuals who call Bickford home are moved to safe, appropriate settings as quickly and compassionately as possible,” Reeves said in a statement.
DPH Commissioner Manisha Juthani added that the investigation “make clear that the residents of Bickford Health Care Center deserved better.”
It’s not the first time a state crackdown has followed a resident death uncovered through investigation — a similar accountability moment played out when a nursing home was found responsible for a staff failure that resulted in a covered-up resident death.
Bickford had a prior history of safety violations before Healey’s death, according to industry reports. The facility had owed more than $100,000 in back taxes as recently as last year.
Families of the remaining 36 residents are now scrambling to find placement at other facilities before the April 10 deadline.
