Above 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 Havencare At Filosa during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, multiple comorbidities, a history of falls, and impaired mobility was placed on bed and chair alarms every shift per care plan and MD order, with alarms observed in active use. Although the care plan cited fall risk and poor safety awareness and the DON stated alarms were used because the resident did not use the call bell and tried to get up alone, the clinical record lacked a comprehensive assessment or fall risk documentation to support alarm use, did not describe individualized parameters or effectiveness, and did not show that alternatives or less restrictive interventions were tried or that alarm use was evaluated as a potential restraint, contrary to the facility’s own chair/bed alarm policy.
A resident with cognitive impairments and dysphagia experienced significant weight loss due to the facility's failure to document the consumption of nutritional supplements. Despite care plan interventions, the resident's weight decreased substantially over several months. Interviews revealed that the supplement intake was not recorded on the EMAR, hindering effective dietary evaluation and contributing to the resident's weight decline.
A facility failed to provide a privacy covering for a resident's urinary collection bag, which was observed resting on the floor with urine visible. The resident, who was severely cognitively impaired, required assistance for transfers and toileting hygiene. Staff interviews confirmed that facility policy required collection bags to be off the floor and covered, but documentation of this policy was not provided.
A resident with dementia and Alzheimer's experienced increased restlessness due to a medication transcription error. An APRN ordered Trazodone 75 mg, but an LPN misinterpreted it as 25 mg, leading to behavioral disturbances. The error was discovered when another APRN noted the resident's increased restlessness and recommended a dosage increase.
A resident with cognitive impairment and mobility dependence developed a new pressure ulcer due to the facility's failure to set an alternating pressure mattress (APM) according to physician's orders. The APM was incorrectly set at 200 pounds instead of the prescribed 165 pounds, despite staff signing off on the correct setting. This oversight contributed to the development of a deep tissue injury, highlighting a lapse in following the care plan and facility policy.
A resident with Alzheimer's and hand contractures was not consistently provided with prescribed hand rolls or palm guards, as observed over several days. Despite orders for these devices to manage contractures, the resident was often found without them, and there was insufficient documentation of refusals. The resident showed signs of discomfort during care, indicating a deficiency in following the treatment plan.
A resident with an indwelling urinary catheter was observed with the urinary drainage collection bag resting on the floor, contrary to facility policy. Despite interventions in the care plan, staff interviews revealed a misunderstanding of infection control protocols, as the collection bag was seen dragging on the floor while the resident was in a wheelchair.
The facility failed to maintain a homelike environment for residents, as observed in 9 out of 13 rooms on the second floor with dressers missing front pieces. Despite being reported to maintenance, the issue persisted for at least six months, and the Maintenance Director was unaware of the problem. Environmental Round logs did not include furniture checks or repair records.
A Covid-19 vaccine was improperly stored unrefrigerated in a medication cart, contrary to CDC guidelines. An LPN confirmed the error and discarded the vaccine. A pharmacist noted the vaccine should be refrigerated until use. The facility's policy requires refrigerated medications to be stored at specific temperatures, aligning with CDC and manufacturer guidelines.
Lack of Assessment-Based Care Planning for Bed and Chair Alarm Use
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a resident-specific, assessment-based care plan for the use of bed and chair alarms. Resident #1 had dementia with a BIMS score of 7/15 indicating severe cognitive impairment, atrial fibrillation, osteoporosis, multiple rib fractures, depression, a history of falls, and required partial to moderate assistance with ambulation and transfers. A quarterly MDS indicated no bed or chair alarms in use, while the resident’s care plan identified forgetfulness, poor safety awareness, and fall risk related to deconditioning, unsteady gait, and impaired mobility after a recent fall with rib fractures. The care plan directed use of bed and chair alarms per family request, along with other fall-prevention interventions, and a physician order later directed bed and chair alarms every shift. On observation, the resident was found sitting on the bed with an active bed alarm and a chair alarm present on the recliner, and the DON confirmed that bed and chair alarms were used at all times for this high fall-risk resident, who did not use the call bell and attempted to get out of bed alone. However, record review did not identify any comprehensive assessment or fall risk documentation addressing the clinical need, effectiveness, or individualized parameters for alarm use. There was no documentation explaining the rationale for alarms, any alternatives or less restrictive interventions trialed, or any assessment of whether the alarms constituted a restraint. The DON acknowledged that an assessment for alarm use had not been completed and could not provide documentation that less restrictive measures were attempted, despite the facility’s own Chair/Bed Alarm Policy describing alarms as alternatives to restraints and tools to alert staff when residents attempt to stand alone.
Failure to Document Nutritional Supplement Intake Leads to Resident Weight Loss
Penalty
Summary
The facility failed to document the percentage of nutritional supplements consumed by a resident, leading to significant weight loss. The resident, who had a history of left-sided hemiplegia, hemiparesis, dysphagia, and dementia, experienced a notable decrease in weight over several months. Despite interventions outlined in the resident's care plan, such as providing large portions and juice supplements, the facility did not track the consumption of these supplements. The resident's weight dropped from 129.3 pounds to 107 pounds over a period of less than six months, indicating a 17.2% weight loss. Interviews with the dietitian and LPN revealed that the consumption of the house juice supplement was not documented on the Electronic Medication Administration Record (EMAR), as required by the facility's policy. The dietitian noted that without tracking the supplement intake, it was challenging to evaluate the resident's dietary needs effectively. The LPN confirmed that the resident typically consumed only a portion of the supplement, further contributing to the weight loss. The lack of documentation and monitoring of supplement intake was a significant factor in the resident's continued weight decline.
Failure to Provide Privacy Covering for Urinary Collection Bag
Penalty
Summary
The facility failed to provide a privacy covering for the urinary collection bag of a resident with an indwelling urinary catheter. The resident, who was severely cognitively impaired and required assistance for transfers and toileting hygiene, was observed on two separate occasions with the urinary collection bag resting on the floor and urine visible, without a privacy bag covering. These observations were made while the resident was in bed, with the collection bag visible from the hallway. Interviews with facility staff, including a Registered Nurse and the Infection Control Nurse, confirmed that the facility's policy required urinary collection bags to be off the floor and covered with a privacy bag. Despite this policy, the facility was unable to provide documentation of the policy when requested. The deficiency was identified during a survey, and the lack of adherence to the facility's policy was noted as a failure to honor the resident's right to a dignified existence and privacy.
Medication Transcription Error Leads to Increased Resident Restlessness
Penalty
Summary
The facility failed to accurately transcribe a medication order for a resident diagnosed with vascular dementia, unspecified psychosis, and Alzheimer's disease. The resident, who was severely cognitively impaired, was prescribed Trazodone to manage behavioral disturbances. An Advanced Practice Registered Nurse (APRN) ordered an increase in Trazodone from 50 mg to 75 mg at bedtime. However, the order was incorrectly transcribed into the electronic chart as 25 mg by a Licensed Practical Nurse (LPN) who misinterpreted the handwritten order. As a result of the transcription error, the resident experienced increased restlessness and behavioral disturbances, including removing incontinence briefs and urinating on the bed and floor multiple times during the night. The resident's restlessness persisted despite staff attempts to redirect with food and conversation. The error was identified when another APRN noted the increased restlessness and recommended increasing the Trazodone dosage, unaware of the original order for 75 mg. Interviews revealed that the psychiatric APRN communicated medication changes on paper, which led to the transcription error by the LPN who no longer worked at the facility.
Failure to Set APM Correctly Leads to Pressure Ulcer
Penalty
Summary
The facility failed to ensure that an alternating pressure mattress (APM) for a resident was set according to the physician's orders, which contributed to the development of a new pressure ulcer. The resident, who was moderately cognitively impaired and dependent on staff for mobility, had a physician's order for an APM with a weight setting of 165 pounds. However, observations revealed that the APM was set at 200 pounds, contrary to the physician's directive. This discrepancy was noted despite staff signing off on the correct setting, indicating a failure in following the prescribed care plan. The resident was at risk for skin breakdown due to decreased mobility and incontinence, and a new deep tissue injury was identified on the coccyx, possibly linked to the incorrect APM setting. Interviews with nursing staff revealed that the charge nurse was responsible for checking the APM settings each shift, but the required checks were not adequately performed. The facility's policy required that the APM be checked for placement and inflation each shift, but this protocol was not followed, leading to the deficiency.
Failure to Apply Prescribed Devices for Hand Contractures
Penalty
Summary
The facility failed to ensure that a device was applied for hand contractures for a resident diagnosed with Alzheimer's disease, poly osteoarthritis, abnormal posture, and contractures of both hands. The resident required maximal assistance with daily activities and had impaired range of motion in both upper extremities. A physician's order directed the application of a hand guard and a rolled cloth for contracture management, with specific instructions for removal during hand hygiene. However, observations revealed that the resident was frequently without the prescribed hand rolls or palm guard, and there was no documentation of resident refusals for the cloth hand rolls, except on one occasion. The occupational therapy notes indicated that the resident initially showed signs of pain when touched but tolerated minimal touching and the use of rolled gauze. Despite this, multiple observations over several days showed the resident without the prescribed devices, and the resident was observed grimacing and crying out during handwashing, indicating discomfort. Interviews and record reviews confirmed the lack of documentation for the application of the hand rolls, highlighting a deficiency in the facility's adherence to the prescribed treatment plan for managing the resident's contractures.
Infection Control Deficiency: Urinary Collection Bag on Floor
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident with an indwelling urinary catheter. Resident #566, who has diagnoses including retention of urine, benign prostatic hyperplasia, and Parkinson's disease, was observed on multiple occasions with the urinary drainage collection bag resting on the floor. The resident's care plan included interventions such as maintaining the foley catheter as ordered and providing education on catheter use. Despite these interventions, observations on two separate dates revealed the collection bag on the floor, which is against the facility's urinary catheter policy. Interviews with staff, including a registered nurse and nurse aides, confirmed that the facility policy requires the drainage bag to be kept off the floor. However, the infection control nurse indicated that if the collection bag was in a privacy bag, it was considered acceptable as the privacy bag acted as a barrier. This discrepancy in understanding and implementation of the policy contributed to the deficiency, as the urinary collection bag was observed dragging on the floor while the resident was in a wheelchair, indicating a failure to adhere to infection control protocols.
Deficiency in Maintaining Homelike Environment
Penalty
Summary
The facility failed to provide a homelike, clean environment for 9 out of 13 resident rooms on the second floor. During an initial facility tour, it was observed that several rooms had dressers missing the front piece, exposing clothing in the drawers. Interviews revealed that the issue had persisted for at least six months. A staff member had informed an LPN about the problem, who in turn reported it to maintenance using a call-in voicemail system. However, the Maintenance Director was unaware of the issue, and the Environmental Round logs did not include furniture checks or records of needed repairs.
Improper Storage of Covid-19 Vaccine
Penalty
Summary
The facility failed to ensure proper storage of a Covid-19 vaccine in accordance with CDC guidelines. During an observation on the 2nd floor medication cart, a Covid-19 vaccine labeled with a resident's name was found unrefrigerated. An LPN confirmed that the vaccine should have been refrigerated and subsequently discarded it. A pharmacist later confirmed that the vaccine should remain refrigerated until shortly before use to maintain its efficacy. Documentation showed the vaccine was received months earlier, but the LPN who received it could not recall its handling upon receipt. The facility's policy mandates that refrigerated medications be stored in a separate refrigerator with specific temperature requirements, and vaccines should comply with CDC guidelines and manufacturer specifications.
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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 Danbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Havencare At Hancock Hall | 0.2 mi | ★★★★★ | 0 | 0 |
| Saint John Paul Ii Center | 1.3 mi | ★★★★★ | 9 | 0 |
| Civita Care Center At Danbury | 1.7 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Glen Hill | 1.8 mi | ★★★★★ | 0 | 0 |
| Bethel Health Care Center | 4.3 mi | ★★★★★ | 0 | 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.