HavenCare at Litchfield Woods: Medication Lapse - CT
The resident, identified in inspection records only as Resident #1, was prescribed Apixaban, sold under the brand name Eliquis, twice daily. The drug prevents blood clots, a particular concern for someone with atrial fibrillation, a condition that causes irregular heart rhythms and raises the risk of stroke. His 9:00 P.M. dose on July 28, 2025 went undelivered for hours. When a nurse finally gave it to him, just before midnight, she didn't properly document that she had.
Federal inspectors from the Centers for Medicare and Medicaid Services cited HavenCare at Litchfield Woods following a complaint inspection completed September 4, 2025. The violation was rated at the level of minimal harm or potential for actual harm.
The charge nurse responsible for Resident #1 during the 3:00 P.M. to 11:00 P.M. shift, identified in the report as RN #4, told inspectors she knew the internet was down. She said she could not access the physician orders or the medication administration record. She did not give Resident #1 his Apixaban. She did not produce a paper record to work from. She did not administer any of his scheduled 9:00 P.M. medications during her shift.
When the next nurse, LPN #5, arrived for the 11:00 P.M. to 7:00 A.M. shift, RN #4 told her during handoff that she had skipped Resident #1's medications entirely. Resident #1 told LPN #5 directly that he had been waiting since 9:00 P.M. for his Eliquis.
LPN #5 did not call the facility's IT support or wait for the network to come back. She connected the electronic medical record system to the personal hotspot on her iPhone, pulled up his physician orders and medication record herself, and gave him the Apixaban just before midnight, roughly three hours after it was due.
She thought she had documented it. She hadn't. When inspectors reviewed the medication administration record weeks later, the July 28 dose of Apixaban appeared unsigned, with no notation from any nurse confirming it had ever been given.
The former Director of Nurses, RN #5, told inspectors that nurses are expected to sign the medication administration record immediately after giving a drug. She said she expected LPN #5 to have signed a paper record at the time of administration. She could not explain why no signature appeared.
What the inspection record shows is a gap that stretched from 9:00 P.M. on July 28 through the early hours of July 29, during which a fully alert resident, the inspection notes his mental status score was a perfect fifteen out of fifteen, knew he needed his medication, said so, and waited.
The facility's own undated medication administration policy directed nurses to document administration immediately following the dose. The policy did not appear to include any contingency for internet outages, and no nurse on either shift produced a paper backup until LPN #5 improvised one using her phone.
Resident #1's care plan, dated two weeks before the incident, noted he was receiving medication to increase blood clotting time related to his atrial fibrillation, with instructions to administer it as ordered. His physician orders had been in place since July 11.
The inspection covered three residents flagged for medication administration review. The documentation failure was found in one of the three.
Resident #1 told LPN #5 he had been waiting. That detail, a resident tracking his own medication schedule and reporting the delay himself, appears in the inspection record without further comment.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 26, 2026 · Our methodology
HAVENCARE AT LITCHFIELD WOODS in TORRINGTON, CT was cited for violations during a health inspection on September 4, 2025.
The resident, identified in inspection records only as Resident #1, was prescribed Apixaban, sold under the brand name Eliquis, twice daily.
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.