Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Litchfield Woods during CMS and state inspections, most recent first.
Unaccounted Morphine During Shift Count: A cognitively intact resident with chronic pain was prescribed PRN Morphine, but a shift narcotic count found 15 mL missing. The controlled substance record showed two doses documented, while the MAR/TAR lacked matching entries, and the resident stated only one dose was received. Staff could not explain the discrepancy, and the DON determined the missing Morphine was misappropriated.
Incomplete controlled substance documentation: A resident with chronic pain had an active PRN Morphine order, but two doses were not documented in the MAR/TAR. The narcotic count was 15 mL short at shift change, and the controlled substance record included a count correction to 100 mL with no explanation for the variance. RN documentation was missing, and the DON confirmed the MAR/TAR did not reflect the administrations.
Failure to Follow Transfer Assistance Order Resulted in Fall and Fracture: A resident with dementia, left-sided hemiplegia/hemiparesis, weakness, and high fall risk was ordered assist of 1 for transfers with a FWW/RW. During a transfer from a wheelchair to a shower chair, an NA took one hand off the resident to move the wheelchair, leaving the resident without full support; the resident leaned left and fell to the floor. Follow-up imaging showed a non-displaced fracture of the right humeral neck/proximal humerus.
Food was served with poor palatability and inconsistent temperatures. Residents reported cold, tasteless, undercooked, overcooked, and small-portioned meals, while surveyors observed plated meals on ceramic plates without a warming system. A test tray showed baked fish below the required hot-hold/cook temp, and the DDS acknowledged the temp was low. Surveyors also observed dry pork and polenta, overly seasoned fish and mashed potatoes, and mushy string beans, while the DDS stated recipes were not routinely followed and some items had no formal recipe.
Failure to Monitor Refrigerator and Dishwasher Temps: Staff did not identify or report repeated out-of-range temps in 3 kitchenette refrigerators/freezers, despite logs showing multiple abnormal readings and resident food items stored inside. Staff also failed to recognize low dishwasher wash/rinse temps during a cycle, and dietary aides continued processing dishes without checking the machine temps.
PASRR Level 2 evaluation was not completed for a resident after a new post-admission diagnosis of major depression. The resident also had PTSD and anxiety disorder, with the MDS documenting depression, PTSD, and anxiety while PASRR 2/SMI was coded as No. The SW stated the resident had a negative Level 1 PASRR and later developed major depressive disorder, but no Level 2 referral was made when the change occurred, despite facility policy requiring a new Level 2 screen for a significant change in status.
The facility failed to ensure snacks were available and offered as needed. Residents reported that snacks were limited to items like saltines and graham crackers, were not offered anymore, and often had to be requested. Surveyors observed kitchenette appliances with lock mechanisms and signs restricting access, while staff said snacks were kept behind the nurse's station or in the clean utility room and were only distributed when time allowed or when residents called for them.
A resident with dementia, hemiplegia, and significant assistance needs fell during a shower transfer when staff lost control of the transfer and the resident was lowered to the floor. Nursing notes and the REF did not document RP notification, and interviews showed the RP did not recall being notified of the fall and later confirmed no call was received until days later about the resident’s fracture. The DNS, LPN, and RN stated it was their responsibility to notify the RP, and facility policy required verbal notification and documentation.
Portable oxygen E-tanks were not safely stored for three residents who required oxygen therapy. One resident’s care plan did not identify oxygen use despite documentation of 2 LPM via NC, and a freestanding tank was seen by the doorway without a stand. Another resident with COPD had a tank standing upright on the floor leaning against a chair and wall, and an aide said tanks were left that way when not in use. A third resident using a wheelchair also had a freestanding tank observed next to the chair without a holder before it was later seen secured on the wheelchair.
Medication administration errors exceeded the 5% threshold, with an observed rate of 6.9%. An RN prepared bethanechol for a resident after breakfast even though the label said to give it on an empty stomach, and also administered the wrong OTC cough medication by confusing guaifenesin ER with a guaifenesin/dextromethorphan ER product. The resident had multiple chronic conditions, including CKD, respiratory failure, diabetes, and COPD.
Failure to Assist Resident With Dental Follow-Up: A resident with COPD, depression, anxiety, and dysphagia had broken and missing teeth and was seen by a dentist, who recommended extractions and dentures. After the dentist later said the resident was not a good candidate for dentures because of a dry mouth, nursing gave the resident the dentist’s contact information and told the resident to call for options, but did not assist with arranging the requested follow-up or second opinion. The resident still wanted dentures, and no follow-up appointment had been made at the time of survey.
Failure to Provide Quarterly Patient Trust Fund Statements: A cognitively intact resident with CHF, DM, and anxiety disorder did not receive a quarterly trust account statement even though funds were held by the facility. The AR assistant stated quarterly statements were required and she was responsible for sending them, but she could not produce a log or tracking sheet, and record review showed only a small number of eligible trust accounts received statements while many others did not.
The facility stored multiple wheelchairs and a geri-recliner in resident lounge areas that were actively used for puzzles and visits, with the equipment cluttering the rooms and blocking access to furniture. The facility also failed to return and launder residents’ personal clothing and linens appropriately, with repeated reports of missing items, bleached clothing, stained or odorous sheets, overflowing laundry bins, and limited working washers and dryers. Staff and resident interviews confirmed that residents often lacked clean clothes, and one resident with dementia had multiple missing personal items with no documented resolution.
Failure to Resolve Grievances for Missing Personal Items: A resident with dementia and severe cognitive impairment had multiple personal items go missing, including clothing, shoes, a comforter set, and a blanket. The resident’s representative reported the losses to SW, but there was no documentation of the grievance or follow-up, and the ED stated permanent-marker labeling was not reliable while the laundry area contained multiple bags of unidentified items.
An LPN in a long-term care facility administered medications intended for another resident due to failing to verify the resident's identity, resulting in a medication error. The resident, who had chronic conditions, was transferred to the hospital but did not suffer significant adverse effects. The LPN was overwhelmed and working an unfamiliar shift, contributing to the error.
Multiple residents experienced misappropriation of their controlled medications, including missing doses, incomplete documentation, and discrepancies between medication records and resident reports. An LPN was consistently involved in these incidents, with audits revealing unrecovered quantities of Oxycodone and Percocet, and residents often reporting not receiving the narcotics as documented. The facility's medication handling and documentation processes were not properly followed, resulting in the loss and wrongful use of resident medications.
The facility did not timely report multiple incidents of missing Oxycodone and related documentation for four residents to the State Agency, despite internal audits revealing unrecovered narcotics and discrepancies in medication administration. Leadership believed reporting to the DEA was sufficient, contrary to facility policy requiring immediate notification of all alleged violations to the State Agency.
Two residents with cognitive impairment and pain management needs received narcotic medications that were documented on proof of use sheets but not consistently recorded in the MAR by an LPN. This failure to accurately document medication administration was identified during a facility investigation and was not in accordance with facility policy requiring complete medical records.
Unaccounted Morphine During Shift Count
Penalty
Summary
The facility failed to ensure a cognitively intact resident was free from misappropriation of property and that controlled substances were properly accounted for and safeguarded. The resident had diagnoses including intervertebral disc degeneration and chronic pain syndrome, and the care plan included pain medication therapy with physician-ordered Morphine Sulfate oral solution 20 mg/5 mL every 4 hours as needed for pain. The resident’s MDS indicated a BIMS score of 15/15 and recent opioid use. During a change-of-shift narcotic count, staff identified that the resident’s Morphine bottle was 15 mL short. The controlled substance record showed two PRN doses were documented by an RN, with the remaining volume expected to be 115 mL after the doses, but the shift count was documented as 100 mL with no explanation for the discrepancy. The MAR/TAR did not contain documentation for the two PRN Morphine administrations that were recorded on the controlled substance disposition record. The resident stated that one of the two doses was not received. Interviews showed the off-going and oncoming nurses were responsible for jointly verifying controlled substance counts at shift change. One RN stated she may not have thoroughly verified the Morphine volume and could not explain the 15 mL discrepancy, while another RN reported the discrepancy was identified during the count and was immediately reported. The DON stated the facility determined that 15 mL of the resident’s Morphine was unaccounted for and considered it misappropriation. The facility policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent.
Incomplete Controlled Substance Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate record for a resident with intervertebral disc degeneration and chronic pain syndrome who had an active order for Morphine Sulfate oral solution 20 mg/5 mL every 4 hours as needed for pain. The quarterly MDS identified the resident as cognitively intact with a BIMS score of 15/15 and as having received opioids in the prior 7 days. The resident care plan addressed pain medication therapy and directed administration of analgesic medications as ordered by the physician. A Facility Reportable Event identified an allegation of misappropriation involving the resident’s Morphine, with 15 mL missing from the bottle while the order remained active. During the change-of-shift narcotic count, the facility noted the liquid Morphine was 15 mL short. The controlled substance record showed RN #1 documented two PRN doses as given, with the remaining volume decreasing from 125 mL to 115 mL, but the record also contained a later count correction showing 100 mL remaining with no explanation for the 15 mL variance. Review of the MAR/TAR showed no documentation of the 1:35 AM and 6:30 AM Morphine administrations. RN #1 stated she did not document the doses during the busy overnight shift and did not return to complete the charting. The DON confirmed the two PRN Morphine administrations were not documented in the MAR/TAR, and the facility investigation identified a suspected nurse who denied the allegation.
Failure to Follow Transfer Assistance Order Resulted in Resident Fall and Fracture
Penalty
Summary
The facility failed to provide transfer assistance according to the physician’s order for a resident with dementia, left-sided hemiplegia and hemiparesis, generalized weakness, and a history of fall risk. The resident’s care card and care plan identified the resident as an assist of 1 for transfers with a rolling walker/four wheeled walker, and the physician’s order directed transfers with an assist of 1 and a FWW. The resident was also identified as severely cognitively impaired and as requiring substantial to maximal assistance with transfers on the MDS assessment. On 1/30/25, the resident was being transferred from a wheelchair to a shower chair in the shower room when the NA lowered the resident to the floor. The NA stated he was standing behind the resident holding the resident by the waist, then took his right hand off the resident to move the wheelchair out of the way while continuing to hold the resident with only his left hand. The resident then began to lean to the left and fell onto the floor. Facility documentation and staff statements identified that the NA did not maintain both hands on the resident during the transfer, despite the resident’s transfer status requiring assist of 1. After the fall, the resident was evaluated for pain and bruising, and imaging later identified a non-displaced fracture of the right humeral neck/proximal humerus. Staff interviews confirmed that the NA should have kept both hands on the resident during the transfer and that he did not follow the resident’s transfer procedure. The facility policy reviewed stated that each resident’s ADL assistance program is developed and implemented based on the individual’s evaluation to encourage the highest level of function.
Food Served at Improper Temperatures and Poor Quality
Penalty
Summary
Food and drink were not consistently served in a palatable, attractive, and safe temperature state. Residents reported that food was undercooked or overcooked, cold at times, tasteless, terrible, and served in small portions. During lunch service, surveyors observed meals being portioned from a steam table onto ceramic plates without a warming device, with clear plastic covers that had a circular hole in the center, and the facility’s Director of Dining Services stated that no plate warmer or insulated cover system was used. The facility used a point-of-service steam table system, with food placed into the steam table before meal service began. During a test tray observation, the herb baked fish measured below the required hot-hold and cooking temperatures, with temperatures recorded at 127.9 degrees Fahrenheit by the surveyor and 126 degrees Fahrenheit by the DDS. The DDS acknowledged that the fish temperature was low and stated that hot food should be held at or above 135 degrees Fahrenheit and fish should be cooked to 145 degrees Fahrenheit. Facility documentation showed the fish was placed into the steam table at 140 degrees Fahrenheit and 137 degrees Fahrenheit, which was below the acceptable internal cooking temperature identified in the dining services training materials. Food quality concerns were also observed. The herbed pork and polenta appeared visibly dry, the baked fish was heavily seasoned with an excessively thick layer of seasoning, the mashed potatoes used for shepherd’s pie were described as excessively seasoned, and the string beans were described as mushy. The DDS stated recipes were not routinely followed, there was no formal policy to follow recipes, and not all food items had a recipe available. A cook stated that when recipes were unavailable, she used internet recipes or asked the DDS, and she described an error in seasoning the fish that resulted in too much seasoning being applied.
Failure to Monitor Refrigerator and Dishwasher Temperatures
Penalty
Summary
The facility failed to ensure that refrigerator and freezer temperatures in three resident kitchenette nourishment rooms were identified and reported when they were out of range. During a kitchen tour, the Director of Dining Services (DDS) stated that cooks completed the daily temperature logs for the kitchen refrigerators and the resident unit kitchenette refrigerators, and that the Infection Control Nurse also verified expiration dates. However, review of the nourishment room refrigerator/freezer logs showed repeated out-of-range temperatures in the first-floor, second-floor, and ground-floor units across June and July 2025, with the logs instructing staff to report all temperatures out of range. The DDS stated he was not made aware of the abnormal temperatures recorded on these logs, and one cook later stated she took low readings twice, adjusted the refrigerator dial herself, and did not notify anyone. Observations of the resident kitchenette refrigerators showed temperatures outside the acceptable range while resident food and beverages were stored inside. The first-floor refrigerator was observed at 38 degrees F with multiple resident-labeled and resident food items inside, and the second-floor refrigerator was observed at 30 degrees F with yogurt, thickened liquids, milk, juice, sandwiches, salad, and frozen items stored inside. The ground-floor log also showed multiple out-of-range temperatures and missing entries. One staff member stated she did nothing when she obtained out-of-range temperatures and was confused by the log instructions. The facility also failed to identify low temperatures during a dishwasher cycle. During observation, the dishwasher wash cycle measured 129 degrees F and the rinse cycle measured 143 degrees F, below the stated required temperatures of 160 degrees F and 180 degrees F. Two dietary aides continued processing dishes and plate covers without identifying the low temperatures or checking the cycle temperatures. The DDS stated the staff were not aware to monitor the temperatures during the cycle, and there was no written policy for checking dishwasher temperatures between wash cycles; the facility relied on verbal instruction and training.
PASRR Level 2 Evaluation Not Completed After New Major Depression Diagnosis
Penalty
Summary
The facility failed to ensure a Level 2 PASRR evaluation was completed after a resident developed a new post-admission diagnosis of major depression. Resident #78 had diagnoses that included major depression, PTSD, and anxiety disorder. The annual MDS identified the resident as cognitively intact and independent with toileting, transfers, and bed mobility, and also documented depression, PTSD, and anxiety disorder while coding PASRR 2/serious mental illness as 0 or No. The resident’s care plan identified risks for behavior problems, verbal outbursts, refusals of daily care, and trouble sleeping related to depression, PTSD, and anxiety, with psychotropic medication use and psychiatric follow-up as needed. The Director of Social Work stated that the resident had a negative Level 1 PASRR in January 2020 and was diagnosed with major depressive disorder while in the facility in August 2023, but a referral for Level 2 PASRR was not made at that time. The facility policy directed that a new Level 2 PASRR screen be completed when a resident experiences a significant change in status indicating a worsening PASRR condition or a previously unidentified PASRR condition.
Restricted Access to Snacks and Limited Snack Availability
Penalty
Summary
The facility failed to ensure adequate snacks were available and offered to residents in accordance with their needs, preferences, and requests. Resident interviews indicated that snacks were limited or unavailable, with one resident stating the facility took all snacks away and that saltines were the only option, another stating there were no snacks anymore, and another reporting snacks were not available unless asked for and that there were not many available. A resident council meeting also reflected concerns that graham crackers and saltines were the only available snacks, snacks were not offered anymore, and there were locks on the refrigerator. During the kitchen and unit observations, surveyors found signs of restricted access to snacks, including lock mechanisms attached to the refrigerator, freezer, and microwave in the first-floor kitchenette and a sign on the second-floor refrigerator stating soda was no longer kept in the fridge and to ask the RN. Staff reported that non-perishable snacks had been moved behind the nurse's station because some residents took multiple snacks, and that snack options had been reduced since a new company acquired the facility. The facility policy stated snacks would be made available at designated times and whenever requested, but staff interviews showed snacks were kept in areas not accessible to residents and were only distributed when staff were able or when residents used a call light to request them.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify the resident’s responsible party of a fall. Resident #72 had diagnoses including dementia, left-sided hemiplegia and hemiparesis, and a right proximal humerus fracture, and the annual MDS identified the resident as severely cognitively impaired and requiring assistance with bed mobility, toileting, and transfers. The care plan identified a risk for falls and directed assistance of one staff member with a rolling walker for transfers and toileting, along with help with ADLs. On 1/30/25, Resident #72 fell in the shower while being transferred from a wheelchair to a shower chair. Nursing documentation stated the resident lost balance and fell to the floor, and another note documented the resident was found on the bathroom floor and complained of left hip pain, with an x-ray ordered. The Reportable Event Form marked family notification as “No” and “self,” and neither nursing progress note documented that the responsible party was notified. Interviews with the resident’s responsible party and emergency contact indicated they did not recall being notified of the fall, and the responsible party later confirmed there was no call from the facility until 2/3/25, when he was notified about the resident’s subsequent fracture. The DNS, LPN, and nursing supervisor each stated that notifying the responsible party of the fall would have been their responsibility, and the facility policy required verbal notification of the resident’s conservator/responsible party and documentation in the clinical record.
Portable Oxygen Tanks Not Safely Stored in Resident Rooms
Penalty
Summary
The facility failed to ensure portable oxygen E-tanks were safely stored in resident rooms for three sampled residents who required oxygen therapy. Resident #56 had diagnoses including diabetes, heart failure, and anemia, was cognitively intact, and required oxygen therapy. The resident care plan dated 6/18/25 identified anemia but did not identify oxygen therapy, although an interdisciplinary care plan meeting form dated the same day documented oxygen at 2 liters per minute via nasal cannula. On 7/18/25 at 6:26 AM, a freestanding oxygen E-tank was observed by the room entry doorway without a holder or stand. Resident #86 had diagnoses including COPD, bipolar disorder, and transient cerebral ischemic attack, was cognitively intact, and required oxygen therapy. The resident care plan dated 4/21/25 identified oxygen therapy related to COPD and included extension tubing or portable oxygen apparatus, and a physician order directed oxygen at 2 lpm for oxygen saturation less than 92%. The resident care card failed to identify that the resident was on oxygen and did not include directions for nursing staff related to care and storage of the portable oxygen tank. On 7/16/25 and again on 7/18/25, a full portable oxygen E-tank was observed inside a transport bag standing upright on the floor, leaning against a chair and the wall, and not secured in a stand. A nurse aide stated the tank was stored in that position when not in use so the resident could easily reach it. Resident #109 had diagnoses including heart failure, COPD, and anemia, was severely cognitively impaired, and used a manual wheelchair. The annual MDS identified oxygen therapy, assistance with eating, partial/moderate assistance with transfers, and substantial/maximal assistance with wheelchair mobility. The resident care plan dated 6/9/25 identified COPD and oxygen therapy via nasal cannula at 2 to 4 lpm, and a physician order directed oxygen at 2 lpm and checking and filling portable oxygen every shift. On 7/18/25 at 6:26 AM, a freestanding oxygen E-tank was observed next to a wheelchair without a holder or stand; later that morning, the tank was observed secured in a holder on the back of the wheelchair. Facility documentation also showed in-service education on portable oxygen tanks, but the attendance form did not identify one LPN as having attended, and the oxygen administration policy stated oxygen tanks should be stored in a cart or stand designed for oxygen tanks.
Medication Administration Errors Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent; the observed error rate was 6.9 percent during medication administration observation for one of three residents reviewed. Resident #66 had diagnoses including chronic kidney disease, acute and chronic respiratory failure with hypoxia, diabetes, and COPD, and was cognitively intact but required assistance with several activities of daily living. The resident’s care plan included interventions for COPD and incontinence, including elevating the head of bed and offering toilet assistance every 2 hours and as needed. During medication administration observation, RN #3 prepared Bethanechol Chloride 25 mg for the resident at a time when the resident had already eaten breakfast, despite the pharmacy label directing that it be taken on an empty stomach. RN #3 stated he had not seen the empty-stomach instruction and could not identify how long the resident had been receiving the medication at that time. The same nurse also administered Guaifenesin extended release 12 hour 600 mg tablets, but the medication in the cart was actually Guaifenesin 600 mg/dextromethorphan 30 mg extended release, which was not the same medication ordered. The DNS stated the medications were not interchangeable and that nurses should verify OTC medications against the physician order before administration.
Failure to Assist Resident With Dental Follow-Up
Penalty
Summary
The facility failed to assist a resident with arranging a consultation with the dentist to discuss treatment options for broken and missing teeth. The resident had diagnoses including COPD, depression, anxiety, and dysphagia, and the clinical record showed Medicaid as the payor source. An APRN ordered a dental consult for teeth removal, and later ordered a dental appointment and then a dental consultation regarding broken teeth, the need for extractions, and dentures. The resident was taken to a dental appointment, and the consultation report identified recommendations for extraction of the remaining teeth and root tips, with dentures as the next step. After the dental consultation, nursing documented that the dentist called and agreed the resident’s teeth needed to be extracted but felt the resident was not a good candidate for dentures because the mouth was too dry. The resident still wanted to explore dentures, and nursing gave the resident the dentist’s contact information and told the resident to call to discuss options, but did not assist with contacting the dentist. An APRN later ordered staff to assist the resident with obtaining an insurance quote for dentures and a follow-up appointment because the resident did not have the executive function to do the task independently. Survey findings showed the resident still had no follow-up appointment for dentures or extractions, and the resident stated that a staff member had helped place a call to the dentist but no follow-up appointment was made when the resident requested another opinion about dentures.
Failure to Provide Quarterly Patient Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly patient trust fund statements to Resident #70 and multiple other residents for the 1/1/25 to 3/31/25 period. Resident #70 had diagnoses including heart failure, diabetes mellitus, and anxiety disorder, and the quarterly MDS assessment identified the resident as cognitively intact. During interview, Resident #70 stated that a quarterly statement had not been received even though funds were kept in a trust account with the facility. The Accounts Receivable Assistant stated that Resident #70 had a $30.21 balance in the Resident Trust Account and that facility policy required quarterly statements to be provided to residents and/or their responsible parties, with statements generated and sent by her. She also stated she tracked statements by obtaining signed receipts, but she could not produce a log or tracking sheet showing statements sent or received. Record review and interview with the Accounts Receivable Assistant identified that only 23 personal trust accounts received quarterly statements for that quarter, while 99 accounts were eligible to receive statements and 130 total active patient trust fund accounts existed; 33 were not eligible due to representative payee status, money owed to the facility, or family/conservator request not to receive statements. The Accounts Receivable Assistant could not identify where the other receipts were or why they were unavailable.
Resident lounge storage and laundry handling failures
Penalty
Summary
The facility failed to maintain resident lounge areas as safe, clean, comfortable, and homelike environments by storing wheelchairs and a geri-recliner in two resident lounges. Observations showed three wheelchairs and one geri-recliner in the 1st floor resident lounge, and three wheelchairs in the 2nd floor resident lounge. In both areas, two of the wheelchairs were electric but were not charging or plugged in, and one was a custom standard wheelchair. The geri-recliner in the 1st floor lounge blocked access to other chairs and furniture. A resident who regularly used the 1st floor lounge for puzzles stated the room was being used as a storage room and that access to the table was often difficult. Another resident in the 2nd floor lounge stated the wheelchairs were always stored there and the room often felt cluttered. The Administrator acknowledged the equipment was being stored in resident areas and that the lounges were frequently used by residents and visitors. The facility also failed to ensure residents’ personal laundry was returned and laundered appropriately. Resident Council minutes documented repeated complaints about laundry delays, a broken dryer, missing clothing, and clothing returned in poor condition. Residents reported missing items, bleached clothing, and offensive-smelling or stained linens. One resident stated clothing had been lost multiple times and a sweatshirt was returned months later after being found in the laundry department. Another resident reported expensive jeans and sweaters were returned bleached and that bed sheets smelled offensive and were stained. Additional residents reported missing clothing, clothing returned bleached, and having to do their own laundry or go off-site because of the condition of the facility laundry service. Staff interviews and observations supported the laundry concerns. A nurse aide stated she frequently did not have personal clothes available for residents on her assignment and had to search the laundry room for clean clothing, which was often not laundered or missing. Observation of the soiled laundry room showed overflowing bins of soiled and sorted laundry. A laundry aide stated only one of five dryers and two of four washers were working, that he dried laundry left in washers from the previous day, and that linens were prioritized over residents’ personal clothing. The facility’s personal clothing policy stated belongings would be safeguarded and clean clothing returned to the correct unit, room, and closet, but it did not identify a timeline for return. A resident with dementia and significant ADL dependence had multiple missing personal items, including clothing, shoes, a comforter set, and a blanket, and the social worker could not provide documentation of follow-up or resolution. The environmental director stated permanent-marker labels were not permanent and that the facility had iron-on labels, while also noting multiple bags of unidentified laundry.
Failure to Resolve Grievances for Missing Personal Items
Penalty
Summary
The facility failed to resolve grievances related to missing personal items for a resident who was admitted with dementia, congestive heart failure, and anxiety and whose annual MDS identified severe cognitive impairment and dependence for bathing, toileting, personal hygiene, eating, oral hygiene, dressing, and transfers. The resident’s care plan identified an ADL deficit related to cognitive loss and dementia, with interventions to assist with clothing, toiletries, equipment, and keeping needed items within reach. The resident’s representative reported that numerous items had gone missing since admission, including a comforter set, clothing, shoes, and a blanket, despite the items being labeled with the resident’s name in permanent black marker. The resident’s representative stated the missing items were reported to the SW when they disappeared, but the SW could not provide documentation of the missing items or what was done to resolve the issue. The SW stated the representative had reported the missing shoes, clothing, comforter set, and blanket, but there was no documentation and no follow-up with the representative. The Environmental Director stated he was aware of missing clothing items but not the comforter, blanket, or shoes, and reported that permanent marker labeling was not permanent because it usually washed out. He also stated the facility had an iron-on label maker and that laundry had 8 large black bags filled with unidentified laundry.
Medication Administration Error Due to Improper Resident Identification
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders, resulting in a medication error for a resident. The error occurred when an LPN, who was feeling overwhelmed and behind in her medication pass, administered medications intended for another resident to Resident #1. The LPN did not properly verify the resident's identity before administering the medications, leading to the administration of multiple incorrect medications, including beta blockers, diuretics, anti-seizure, and antidiabetic medications. Resident #1, who was admitted with diagnoses including chronic obstructive pulmonary disease, chronic kidney disease stage 2, and anxiety, was at risk for dehydration and had episodes of anxiety. The resident was alert and oriented with a BIMS score of 15. After receiving the wrong medications, the resident was evaluated by an APRN and transferred to the hospital for further assessment. Despite the error, the resident did not exhibit any significant adverse effects and was discharged home as scheduled. The LPN involved was a newly graduated nurse who had not previously worked the day shift and was working an extra shift on the day of the incident. The LPN failed to verify the resident's identity by not checking the photo in the electronic medical record or the resident's ID band, and mistakenly called the resident by their first name, which was the same as another resident's. The error was realized when the LPN returned to her medication cart and immediately reported it to her supervisor.
Failure to Protect Residents from Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of their medications, specifically controlled substances such as Oxycodone and Percocet, as evidenced by multiple incidents involving six residents. In several cases, narcotic audits revealed missing doses, incomplete or missing documentation, and discrepancies between medication administration records (MARs) and narcotic proof of use sheets. For example, one resident with osteomyelitis and diabetes did not receive a scheduled dose of Oxycodone, despite documentation indicating it had been administered, and the resident confirmed not receiving the medication. Another resident with dementia and osteoarthritis was documented as having received Oxycodone by an LPN, but both the resident and the MAR did not support this, and the resident reported only receiving non-narcotic pain relievers. Additional incidents included missing blister packs and documentation sheets for controlled medications, with audits showing unrecovered quantities of Oxycodone for several residents. In one case, a resident's medication was discontinued, but the remaining tablets were not returned or accounted for, and no notification was made to nursing management. Interviews with residents, some of whom were cognitively intact, consistently indicated that they had not received the narcotic medications as documented, or had not required such medications for pain management. In several instances, the only nurse involved in the administration and documentation of these medications was the same LPN. The facility's internal investigation and interviews with staff revealed that the process for receiving and documenting controlled medications was not consistently followed, leading to the loss and misappropriation of resident medications. The facility's policy defined misappropriation as the wrongful use of resident property, and the events described in the report demonstrate a failure to safeguard residents' medications from deliberate misplacement or unauthorized use. The incidents were reported to appropriate authorities, but the deficiencies stemmed from failures in medication handling, documentation, and oversight.
Failure to Timely Report Alleged Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to report allegations of misappropriation of controlled substances to the State Agency in a timely manner for four residents. Multiple incidents were identified through clinical record review, facility documentation, and interviews, where narcotic medications, specifically Oxycodone, were missing or unaccounted for. In each case, the required narcotic proof of use documentation sheets were also missing, and the medications were not recovered. These events were discovered during routine narcotic audits and internal investigations. For one resident with severe cognitive impairment and chronic pain, a full blister pack of Oxycodone (30 tablets) and its documentation went missing after pharmacy delivery, with the loss only identified during a subsequent audit. Another resident, cognitively intact and with chronic back pain, had a discontinued Oxycodone order, but the remaining medication and documentation were not returned or reported to nursing management, resulting in 19 missing tablets. A third resident, also cognitively intact, was found to have a missing Oxycodone blister pack and documentation during a routine audit, despite all medications being accounted for a week prior. The fourth resident, with chronic pain syndrome and diabetic neuropathy, reported not receiving pain medication as documented, and discrepancies were noted between staff accounts and the resident's report during an audit. Despite these findings, the facility did not notify the State Agency of the allegations of misappropriation from late August through late October. Interviews with facility leadership revealed a misunderstanding of reporting requirements, with the Assistant Director of Nursing indicating that only the DEA was notified and expressing unawareness of the need to report to the State Agency. Facility policy, however, required immediate reporting of all alleged violations, including misappropriation, to the State Agency and other authorities.
Failure to Accurately Document Narcotic Administration in Medical Records
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medication administration for two residents with cognitive impairments and pain management needs. For one resident with dementia and osteoarthritis, physician orders directed the administration of Oxycodone as needed for pain. However, review of the narcotic proof of use documentation showed multiple instances where the medication was administered by an LPN, but these administrations were not recorded in the Medication Administration Record (MAR) for several dates across three months. The resident's care plan required pain medications to be given as ordered, but the MAR did not reflect all doses given, as evidenced by discrepancies between the narcotic proof of use sheets and the MAR. Similarly, another resident with chronic congestive heart failure and vascular dementia had physician orders for Percocet as needed for pain. The narcotic proof of use documentation indicated the medication was administered on several occasions, but these administrations were not documented in the MAR for multiple dates. Facility policy required licensed nursing personnel to document all medication administration in the resident's medical record. An interview with the ADON confirmed that the LPN failed to document narcotic administration in the electronic MAR on multiple occasions, as discovered during a facility narcotic diversion investigation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 494 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Torrington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wolcott Hall Nursing Center Inc | 0.7 mi | ★★★★★ | 1 | 0 |
| Torrington Center For Nursing & Rehabilitation Llc | 1.7 mi | ★★★★★ | 1 | 0 |
| Havencare At Valerie Manor | 3.5 mi | ★★★★★ | 20 | 0 |
| Cook Willow Health & Rehabilitation Center, Inc. | 10.6 mi | ★★★★★ | 14 | 0 |
| Cherry Brook Health Care Center | 11.5 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Havencare At Litchfield Woods.
100% money-back within 48 hours.
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.