HavenCare at Valerie Manor: Oxygen Tank Failure - CT
That call came during an outside appointment for a resident at HavenCare at Valerie Manor, a severely cognitively impaired patient who had been sent out of the facility without a staff member, without the orthopedic office being told the patient was on oxygen, and, inspectors found, possibly with the wrong tank entirely. The resident was transferred to the hospital. By the time inspectors arrived on May 26, 2026, that resident had been discharged from the hospital to another facility.
The charge nurse on duty that morning, identified in the inspection report as LPN #1, told inspectors she had switched Resident #1 from an in-room oxygen concentrator to a portable cylinder tank right before the resident left at approximately 9:30 AM for the orthopedic appointment. She said she checked the gauge, it read just past full, and she could feel air coming out. She said she sent the larger of the two tank sizes the facility kept on hand, the E-cylinder, which the facility's oxygen vendor confirmed would last roughly three hours if set at three liters.
She did not tell the orthopedic office the patient was on oxygen.
The Director of Nursing told inspectors she believed Resident #1 had left with a large tank that would last about four hours if full. But she also said she did not know whether the tank level had been checked before the resident left. And the inspection report notes a detail that cuts against the charge nurse's account: the oxygen vendor's Director of Operations was not asked, or did not provide, information about how long the smaller D-cylinder tank would last. The report does not resolve which tank actually went with the resident.
What is clear is that the tank ran out before the appointment ended.
Nobody accompanied Resident #1 in the transport vehicle. The facility's standard practice, the Director of Nursing confirmed, was not to send a nurse along to outside appointments. A representative from the resident's prior living situation, identified as Person #1, met the resident at the orthopedic office. Person #1 told inspectors she did not adjust the oxygen tank's liter flow at any point during the visit.
The Director of Rehabilitation told inspectors she did not think Resident #1 would have been capable of adjusting the liter flow either. The resident had severe cognitive impairment.
Inspectors noted the gap plainly: nobody explained why a severely cognitively impaired resident who could not manage their own oxygen equipment was sent to an outside appointment without any facility staff in the transport vehicle to monitor whether the oxygen was actually flowing at the ordered rate.
The facility's own oxygen administration policy, which carried no date, directed staff to verify oxygen was flowing when placing a resident on it. Inspectors found no facility policy at all governing how to ensure a sufficient oxygen supply for residents leaving on outside appointments.
The APRN who reviewed the case told inspectors the resident's medical findings, atelectasis and a large pleural effusion documented on imaging, would not have been caused by the oxygen tank running out. The inspection report records that statement without further elaboration on the resident's condition or what did cause those findings.
The Director of Nursing was direct about where responsibility sat. It was the nurse's job, she said, to make sure the resident had enough oxygen before going out.
That did not happen. The tank ran out at the orthopedic office. The office called the nursing home. The resident went to the hospital.
Inspectors cited the violation at a level of minimal harm or potential for actual harm, affecting few residents. The resident was at another facility by the time the inspection was complete.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Havencare At Valerie Manor from 2026-05-26 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: August 12, 2026 · Our methodology
HAVENCARE AT VALERIE MANOR in TORRINGTON, CT was cited for violations during a health inspection on May 26, 2026.
The resident was transferred to the hospital.
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.