Havencare at Litchfield Woods: Medication Failures - CT
That went on for five weeks.
By the time a federal inspector sat down with the facility's attending physician on September 4, the doctor had no idea any of this had happened. He did not know the internet had been out. He did not know nurses had been working from printed backup records. He did not know that medications had been omitted for 20 residents.
The physician, identified in the inspection report only as MD #1, said he would have expected to be told. He said he would have issued additional orders and adjusted medication regimens if he had known drugs were being missed. He had not been given the chance to do either.
The outage was reported to him, he told the inspector, on September 4, 2025 — the day of the survey. He became aware of it at the same moment investigators did.
When MD #1 reviewed the list of omitted medications after the inspection, he found no hospitalizations, no adverse events, no documented negative outcomes from the late or missed doses. That finding softened the severity of what inspectors recorded, and the violation was tagged at the lowest level of harm. But the physician's review came only after five weeks of silence from the facility. Whatever monitoring or intervention he might have provided during that window never happened, because no one told him he was needed.
The facility's own medication administration policy required staff to notify the physician "in a timely manner" when medications were held or unavailable. Its medication error policy required immediate physician notification when an administration error occurred. Medications omitted for 20 residents across an extended internet outage fit both descriptions. Neither policy was followed.
When inspectors asked to see a policy governing what staff should do during an internet outage, the facility could not produce one.
That absence is its own finding. The outage was not a freak event that overwhelmed an otherwise prepared staff. It exposed a gap in how the facility had thought through, or failed to think through, what happens when the system that holds resident medication records goes dark. Nurses improvised with printed backups. No one in a supervisory or administrative role appears to have escalated the situation to the physician whose patients were affected.
The inspection report does not name any of the 20 residents whose medications were omitted, nor does it specify which drugs were missed or for how long during the five-week period. It does not describe what conditions those residents were being treated for, or how many doses each person went without. The record establishes the number and the silence, but not the full shape of either.
MD #1's review after the fact found no harm. That conclusion is the most important fact in the report, and also the most contingent one. It reflects what he could determine in a single review session on September 4, looking backward at a period during which he had received no information in real time. Whether that review captured everything that mattered is a question the inspection report does not answer.
What the report does establish is that for more than a month, a physician responsible for 20 residents' care was making decisions without knowing that their medications were not being administered as he had ordered. He was kept out of the loop not by any single dramatic failure, but by the ordinary workings of a facility that had no plan for what to do when its systems broke down, and no one who made the call.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Havencare At Litchfield Woods from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 29, 2026 · Our methodology
HAVENCARE AT LITCHFIELD WOODS in TORRINGTON, CT was cited for violations during a health inspection on September 4, 2025.
By the time a federal inspector sat down with the facility's attending physician on September 4, the doctor had no idea any of this had happened.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.