Wolcott Hall Nursing Center, Inc

In the surveyor’s words

From the most serious findings on record at Wolcott Hall Nursing Center, Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Dec 8, 2022

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of five residents (Resident #1) reviewed for advanced directives, the facility failed to ensure staff addressed Resident #1's Advanced Directive choices (full code vs. do not resuscitate) upon readmission in accordance with facility policy. This resulted in contradictory information in the medical record which cause confusion when R #1 was found without a pulse and respirations and staff did not initiate Cardiopulmonary Resuscitation (CPR) timely resulting in a finding of Immediate Jeopardy. The finding includes: Resident #1's diagnoses included diabetes, gangrene, major depressive disorder, anxiety, and acquired absence of left leg above knee. […]

• Actual harm, isolatedF689Feb 8, 2025

  Based on record review and interviews for one of three sampled residents (Resident #42) reviewed for accidents, the facility failed to ensure the resident was free from injury resulting from an instant hot pack. The findings include: Resident #42's diagnoses included dementia, ulcerative colitis, liver cancer, brain cancer, and colon cancer. The quarterly MDS assessment dated [DATE] identified Resident #42 had intact cognition (BIMS of 15), was totally dependent on staff for transfers, toileting, hygiene, and dressing, and utilized a manual wheelchair for mobility. The Resident Care Plan (RCP) dated 11/15/24 identified Resident #42 had a recall, memory impairment and impaired decision making related to dementia. […]

• No harm, potential for more than minimal, patternF584Aug 12, 2026

  Based on observation, review of facility documentation, job descriptions, and interviews for 2 of 2 units, the facility failed to ensure the environment was clean, maintained in good repair and homelike manner, and the facility failed to ensure that electrical/television wiring was maintained in a safe and orderly manner. The findings include:Review of the infection control surveillance safety rounds log identified the last infection control quarterly round were completed on 3/31/26 and on 6/30/26.Observation during the initial tour on 8/10/26 at 8:40 AM through 9:30 AM, and on 8/12/26 at 10:40 AM through 11:00 AM with the Maintenance Supervisor/Housekeeping Supervisor and RN #1 (Infection Preventionist) identified the following:a. […]

• No harm, potential for more than minimal, patternF657Aug 12, 2026

  Based on review of the clinical record, facility policy, and interviews for 3 of 3 residents (Resident #6, 25 and 44) reviewed for care planning, the facility failed to ensure the residents and/or resident representatives were invited to and given the opportunity to participate in their quarterly care plan meetings, and for 1 of 2 residents (Resident #50) reviewed for pain management, the facility failed to ensure the comprehensive care plan was revised following an amputation. The findings include: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses that included dementia, history of falling, and muscle weakness. The care plan dated 10/24/25 identified Resident #6 needed staff assistance with ADLs. Interventions included advanced directives per MD orders. […]

• No harm, potential for more than minimal, patternF755Feb 8, 2025

  Based on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to establish a system of records of receipt and disposition of all controlled medications in sufficient detail to enable an accurate reconciliation and failed to have a system in place to keep an accurate accounting of controlled medications. The findings include: Observation on [DATE] at 11:35 AM identified the DNS office contained a binder that held the yellow Controlled Substance Disposition Records (CSDR), the CSDR sheets were organized alphabetically. Additionally, some of the yellow CSDR sheets were from 2023 and had not yet been reconciled with the white CSDR nor were the medications identified as having been destructed. […]