Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wolcott Hall Nursing Center Inc during CMS and state inspections, most recent first.
A resident with depression, anxiety, CHF, a heel pressure ulcer, a history of falls, memory recall deficits, and dependence in multiple ADLs exited the facility unsupervised after observing the front entrance operations from a library area near the door. Although nursing evaluations had not identified this resident as an elopement risk and there was no prior exit-seeking behavior, there was no staff assigned to the front desk, and staff were informally expected—but not guided by written policy—to monitor visitors entering and exiting and to remain until the door relocked. On a weekend day, an unidentified staff member buzzed a delivery driver out; the resident reported placing a foot in the door, entering the vestibule, waiting for the driver to leave, and then going out the main door. The resident was later found across the street in a parking lot by a passerby, who alerted staff, revealing that the resident had been outside for an unknown period without supervision.
A resident with multiple chronic conditions and severely impaired cognition experienced consistently low fluid intake for two weeks. Dehydration evaluations were not completed as required after consecutive days of low intake, and when an evaluation was done on a weekend showing signs of dehydration, the LPN did not immediately notify the provider. The provider was not informed until the next business day, and the resident was later hospitalized for dehydration requiring IV fluids.
A resident with dementia and total care needs sustained a burn to the right knee after an instant hot pack was applied directly to the skin without a protective barrier, in violation of manufacturer instructions. Staff interviews revealed a lack of training and protocol regarding hot pack use, and the facility did not have a written policy or documented education for staff on this procedure. The injury required wound care and changes in treatment as the wound progressed.
The facility did not maintain an accurate and consistent system for recording and reconciling controlled substances. The DNS was unable to demonstrate regular narcotic audits, and CSDR sheets were inconsistently handled, with some records from previous years unreconciled and confusion among staff about proper procedures. This resulted in discrepancies between recorded and actual controlled medications, contrary to facility policy.
A resident with respiratory conditions received oxygen therapy at varying flow rates without a physician order, as documented in nursing and therapy records. Staff interviews confirmed that an order is required, but none was present in the clinical record, and the facility's policy mandates physician authorization prior to oxygen administration.
An LPN was observed accessing a medication cart without a key and leaving it out of sight while administering medications to two residents. The cart's locking mechanism could be opened without a key, and the LPN did not consistently secure the cart as required by facility policy. Interviews with staff revealed inconsistent understanding of when the cart should be locked.
Two residents who had consented to receive the pneumococcal vaccine did not receive it as required, with no documentation of administration or refusal in their clinical records. Nursing staff cited competing priorities and the need to verify immunization history as reasons for the delay, despite facility policy requiring timely administration and documentation.
A resident with multiple psychiatric diagnoses and severe cognitive impairment did not have the consultant pharmacist's medication regimen review recommendation included in their clinical record, despite facility policy requiring such documentation. The pharmacist had recommended discontinuing an unused as-needed Melatonin order, but the recommendation was not filed as required.
A resident's missing wedding ring was not documented as a grievance by the facility, despite the Administrator being notified and initiating a search. The facility's Grievance Log lacked a concern form for the incident, and the Administrator could not provide documentation of the grievance process. The ring was later found with the resident's family, but this was not documented until the survey day.
Unsupervised Resident Elopement Through Unmonitored Front Entrance
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an unsupervised exit by a resident. The resident had diagnoses including depression, anxiety, congestive heart failure, a heel pressure ulcer, a history of falls, and some memory recall deficits. A recent significant change MDS showed the resident required substantial assistance with toileting hygiene, was dependent for bathing, dressing, and personal hygiene, and used a walker and/or wheelchair for mobility. Despite these needs, a nursing evaluation identified the resident as not at risk for elopement, and there were no prior documented exit-seeking behaviors. On the day of the incident, the resident was last seen by staff in the library near the front door around lunchtime. There was no staff member assigned to the front lobby reception desk on weekends, and staff were responsible for letting visitors in and out of the building. At some point after the last observation, a delivery driver was buzzed out of the facility by an unidentified staff member, and the resident followed. According to the resident’s later statements to the DON, social worker, and a housekeeper, the resident had been watching families come and go, observing the door light and timing how long it stayed green before relocking. The resident reported waiting until a delivery driver was buzzed out, placing a foot in the door, entering the vestibule between the locked interior door and the main exterior door, waiting for the driver to leave the parking lot, and then exiting through the second door. The resident was discovered outside the facility only when a passerby came to the front door and reported seeing an elderly person in a wheelchair across the street in a business parking lot. Staff, including an NA and an LPN, then went outside and brought the resident back into the building. The exact time the resident exited the facility was not known, and staff could only confirm that the resident had last been seen at approximately 12:20 PM and was found outside around 2:00–2:15 PM. Interviews with the DON, RN supervisor, administrator, and other staff confirmed that no staff member admitted to buzzing the delivery driver out, that the front desk was not staffed on weekends, and that although there was an expectation that staff would remain at the door until it closed and relocked and ensure no resident exited, this expectation was not supported by a written policy and was not effectively implemented, allowing the resident to leave the building unattended.
Failure to Timely Complete Dehydration Evaluations and Notify Provider
Penalty
Summary
A deficiency occurred when the facility failed to complete dehydration evaluations in accordance with its own policy and did not notify the provider in a timely manner regarding a resident's fluid status. The resident in question had multiple diagnoses, including adjustment disorder with depressed mood, peripheral vascular disease, and congestive heart failure, and was identified as having severely impaired cognition. Clinical records showed the resident consistently had poor food and fluid intake, with daily fluid consumption falling below the minimum required amount for fourteen consecutive days. Dehydration evaluations were only completed intermittently, despite the resident's ongoing inadequate fluid intake. According to facility policy, a dehydration evaluation should have been performed after three consecutive days of insufficient fluid intake, but there was a delay in completing the evaluation after such a period. Additionally, when a dehydration evaluation was performed on a weekend and revealed signs of dehydration, the responsible LPN did not immediately notify the provider, instead placing the evaluation in the APRN binder for later review. This resulted in a delay in provider notification until the next business day. The resident subsequently exhibited increased lethargy, mental status changes, and further decline in intake, prompting a transfer to the hospital, where dehydration was confirmed and IV fluids were administered. Interviews with staff confirmed that the facility's practice was to notify providers immediately if dehydration was suspected on weekends, but this protocol was not followed. The facility was unable to provide a specific dehydration evaluation policy, though related protocols directed staff to ensure adequate hydration and timely provider notification.
Resident Burn Injury Due to Improper Hot Pack Application
Penalty
Summary
A resident with diagnoses including dementia, ulcerative colitis, liver cancer, brain cancer, and colon cancer, who was totally dependent on staff for transfers and bed mobility, sustained a burn injury to the right outer knee due to the improper application of an instant hot pack. The resident's care plan noted memory impairment and impaired decision-making, requiring staff to use simple communication and provide reminders. The resident was unable to self-apply a hot pack due to total care needs, and the hot pack was found applied directly to the skin without a protective barrier, contrary to manufacturer instructions. Staff interviews revealed that nurse aides and nurses had access to the hot packs, but there was no documented training or protocol regarding their use. The nurse aide who discovered the injury reported not having applied the hot pack and was unaware of any protocol or training related to hot pack application. The Director of Nursing confirmed that only licensed nurses were permitted to apply hot packs and that staff should follow manufacturer guidance, but acknowledged the absence of a written policy or documented staff education on this matter. Medical documentation showed the resident initially sustained a first-degree burn, which later developed slough in the wound bed, requiring a change in treatment. The wound specialist noted that the development of slough was part of the normal healing process for burns. The facility's lack of a written protocol, staff education, and failure to ensure proper application of the hot pack led to the resident's injury.
Failure to Maintain Accurate Controlled Substance Records and Reconciliation
Penalty
Summary
The facility failed to establish and maintain a comprehensive system for recording the receipt and disposition of all controlled medications, resulting in an inability to accurately reconcile these medications. Observations revealed that the Controlled Substance Disposition Records (CSDR) were not consistently reconciled, with some records from the previous year remaining unaccounted for and lacking documentation of medication destruction. The binder containing these records did not include current audit sheets, and the last narcotic audit was not recent. The Director of Nursing Services (DNS) was responsible for narcotic reconciliation but did not utilize the provided audit sign-off sheets, instead signing the CSDR sheets directly. Audits, which were supposed to occur twice monthly, were not performed regularly, and the DNS could not demonstrate consistent reconciliation practices. Interviews with nursing staff indicated confusion and inconsistency regarding the handling of CSDR sheets, particularly when residents were discharged or medications were discontinued. White CSDR sheets were sometimes sent to the records department without being reconciled with the yellow sheets, and the DNS was not always informed of their whereabouts. During an attempted reconciliation, the DNS found discrepancies between the number of controlled medications recorded and those present in the medication cart, with some records and medications located in different areas of the facility. Facility policy required double-locking and counting of narcotics per protocol, as well as reconciliation upon admission, transfer, and discharge, but these procedures were not consistently followed.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, asthma, COPD, and dyspnea was admitted to the facility and received oxygen therapy without a corresponding physician order. The resident was documented as using oxygen at various flow rates, including 2 liters per minute in the hospital and up to 5 liters per minute in the facility, as noted in nursing and therapy records. Despite ongoing administration of oxygen and multiple nursing notes indicating its use, there was no physician order in the clinical record specifying the use or flow rate of oxygen for this resident. Interviews with nursing staff and facility leadership confirmed that a physician's order is required for oxygen therapy, but none was found in the resident's record. The admission nurse acknowledged that the oxygen order was not included in the admission paperwork, and the facility's policy on nasal cannula oxygen administration requires verification of a physician's order prior to starting therapy. Additionally, the Director of Nursing Services stated there was no policy for monitoring residents on continuous oxygen therapy.
Medication Cart Not Properly Secured During Administration
Penalty
Summary
Surveyors observed that a medication administration cart was not properly secured during medication passes. Specifically, an LPN was able to access the medication cart drawers without using a key by simply pulling the lock out with her fingers. On two separate occasions, the LPN prepared medications for residents, pushed the lock in on the cart, and then entered residents' rooms, closing the privacy curtain and leaving the cart out of her line of sight. Despite the lock being engaged, the LPN was able to open the cart without a key upon returning. Interviews revealed that the LPN believed the cart did not need to be secured with a key if it was in the resident's doorway and she was in the room. The DNS stated that the cart must be locked when the nurse walks away, but also indicated that if the cart was visible and the nurse was close by, it might be acceptable not to use the key. The DNS also acknowledged that the locks would be checked, as they should not be accessible without a key when in the locked position. Facility policy requires medication carts to be locked when not visible to the nurse or qualified staff.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to ensure that the pneumococcal vaccine was administered to two residents as requested and consented to upon admission. For one resident with diagnoses including dementia, diabetes, anemia, and atrial fibrillation, the responsible party provided consent for the pneumococcal vaccine, but clinical records showed no evidence that the vaccine was administered or refused. The Infection Preventionist (IP) nurse acknowledged responsibility for vaccine administration but cited competing priorities such as managing COVID-19 and gastrointestinal outbreaks, and the need to verify historical immunization records, as reasons for the delay. Another resident, admitted with dementia, COPD, and pulmonary fibrosis, also had consent forms signed by the responsible party for the pneumococcal vaccine, but clinical records did not show that the vaccine was given. The responsible party believed the vaccine had been administered after consent was provided, but later learned it had not been given. Interviews with nursing staff confirmed that the process requires consent, a physician's order, and administration by nursing staff, but the vaccine was not administered as required. Facility policy states that residents should be offered the vaccine upon admission, with documentation of administration, refusal, or historical vaccination, but this was not followed for the two residents.
Pharmacy Medication Review Recommendations Not Maintained in Clinical Record
Penalty
Summary
The facility failed to ensure that monthly pharmacy medication regimen review recommendations were included in the clinical record for one resident reviewed for unnecessary medication. Specifically, a resident with diagnoses of anxiety disorder, bipolar disorder, and dementia, who was severely cognitively impaired and utilized antipsychotic and antidepressant medications, did not have the consultant pharmacist's recommendation documented in their clinical record. The pharmacist's review identified that the resident's as-needed order for Melatonin had not been used in the previous 90 days and recommended discontinuation due to lack of use. Interviews with facility staff revealed that the standard process is for pharmacist recommendations to be faxed to the facility, reviewed, and then placed in both the provider book and the resident's physical clinical record. However, in this instance, the Director of Nursing Services (DNS) was unable to explain why the recommendation was not included in the resident's record. The facility's policy requires that copies of consultant pharmacist reports be maintained as part of the resident's permanent record, but this was not followed in this case.
Failure to Document Grievance for Missing Item
Penalty
Summary
The facility failed to initiate a grievance concern for a missing item belonging to a resident diagnosed with dementia, anxiety, agitation, and depression. On January 10, 2023, the Administrator was notified of the resident's misplaced wedding ring and indicated that a concern form would be initiated. The Administrator communicated with the resident's family member about the missing ring and began a search. However, the facility's Grievance Log did not document the completion of a grievance concern form for the missing ring on that date. During an interview and clinical record review on July 3, 2024, the Administrator could not provide documentation showing that a grievance concern form was completed when the ring was reported missing. The Administrator noted that the facility was without a social worker at the time, which contributed to the oversight. Although the ring was eventually found to be with the resident's family member, there was no documentation to confirm this resolution until the day of the survey. The facility's grievance policy requires that each concern form includes the concern, resolution, and the person responsible for resolving it, but this process was not followed in this instance.
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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 Torrington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Havencare At Litchfield Woods | 0.7 mi | ★★★★★ | 5 | 0 |
| Torrington Center For Nursing & Rehabilitation Llc | 1 mi | ★★★★★ | 1 | 0 |
| Havencare At Valerie Manor | 2.8 mi | ★★★★★ | 20 | 0 |
| Cook Willow Health & Rehabilitation Center, Inc. | 10.4 mi | ★★★★★ | 14 | 0 |
| Cherry Brook Health Care Center | 10.8 mi | ★★★★★ | 5 | 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 July 2026) and official state health department websites.