Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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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) |
|---|---|---|---|---|
| Wolcott Hall Nursing Center Inc | 0.7 mi | — | 1 | 0 |
| Torrington Center For Nursing & Rehabilitation Llc | 1.7 mi | — | 0 | 0 |
| Havencare At Valerie Manor | 3.5 mi | — | 4 | 0 |
| Cook Willow Health & Rehabilitation Center, Inc. | 10.6 mi | — | 14 | 0 |
| Cherry Brook Health Care Center | 11.5 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 August 2026) and official state health department websites.