Havencare at Litchfield Woods: 20 Residents Miss Meds - CT
That finding sits at the center of a September complaint inspection at the facility on Roberts Street, completed by federal surveyors on September 4, 2025.
One resident, identified in inspection records as Resident #2, was prescribed Melatonin, Senna-S, and Memantine — a drug used to treat Alzheimer's disease — all ordered for 9:00 P.M. that night. The charge nurse, RN #4, told inspectors she couldn't access the physician orders or the medication administration record when the facility's internet went down during her 3:00 to 11:00 P.M. shift. She did not give the medications. She did not call the physician or the advanced practice registered nurse. She said she assumed the Director of Nursing Services would handle it.
The Director of Nursing Services did not handle it.
A second resident, Resident #3, was prescribed Clonazepam for panic disorder, Dexilant for heartburn, Docusate Sodium as a stool softener, and Senna for constipation, all also ordered for 9:00 P.M. LPN #1, who was the charge nurse for that resident during the same shift, told inspectors the same thing: the internet was down, she couldn't get into the records, she didn't give the medications, and she didn't call anyone because she thought the Director of Nursing or the Assistant Director of Nursing would make that call.
Neither did.
RN #5, who was the Director of Nursing Services that night, told inspectors on September 4 that she was focused on printing paper medication administration records after the internet went down and was not aware that Residents #1, #2, and #3 had medications omitted. She said she could not explain why nobody told her.
The medical director, identified as MD #1, learned about the missed medications for the first time when inspectors interviewed him on September 4 — more than five weeks after the event. He said he had no idea that any medications had been omitted on July 28, and no idea that twenty residents had gone without their scheduled doses. "He would have expected to be notified," the inspection report states, "and if he was notified, he would have given additional orders."
APRN #1, the on-call advanced practice registered nurse, told inspectors she wasn't notified on the night of July 28 that the records were inaccessible. She said she heard about the internet outage a day or two later, and was told at that point that paper records had been printed and all residents had received their medications.
That was not accurate. Twenty residents had not received their medications.
The facility's own medication administration policy, reviewed by inspectors, directed staff to inform the physician in a timely manner when medications are held or unavailable. Its medication error policy required immediate physician notification when a medication error occurs. Neither policy was followed on July 28, and the inspection record contains no documentation that any physician or APRN was contacted that night about any of the twenty missed residents.
RN #1, identified in the report as a regional nurse, acknowledged to inspectors that the on-call physician, the APRN, and the Medical Director should all have been notified about the late administrations and the omissions. That notification never happened.
What the night of July 28 produced, instead, was a facility-wide medication failure absorbed quietly into the shift change, with each nurse assuming the person above her in the chain of command had made the call, and no one at the top of that chain knowing anything had gone wrong. Five weeks later, the medical director found out from a federal inspector.
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 24, 2026 · Our methodology
HAVENCARE AT LITCHFIELD WOODS in TORRINGTON, CT was cited for violations during a health inspection on September 4, 2025.
That finding sits at the center of a September complaint inspection at the facility on Roberts Street, completed by federal surveyors on September 4, 2025.
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.