Havencare at Litchfield Woods

In the surveyor’s words

From the most serious findings on record at Havencare at Litchfield Woods, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 21, 2025

  Based on review of the clinical record, facility documentation, facility policy and staff interviews for 1 of 5 residents reviewed for accidents (Resident #72), the facility failed to provide transfer assistance per the physician's order which resulted in a fall with a fracture. The findings include:Resident #72's diagnosis included dementia, hemiplegia (paralysis) and hemiparesis (weakness) affecting the left dominant side, and right proximal humerus fracture.Review of the resident care card dated 10/18/24 indicated that Resident #72 was an assist of 1 for transfers with a rolling walker (RW)/four wheeled walker (FWW). […]

• Actual harm, isolatedF580Jan 2, 2024

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for falls, the facility failed to ensure the physician was notified timely of changes in condition timely. The findings include: Resident #1 was admitted to the facility on [DATE] after a fall at home with diagnoses that included fracture of the hip after a fall, fractured left pubic rami, severe protein-calorie malnutrition, chronic myeloid leukemia (CML), and a history of deep vein thrombosis lower extremity (blood clot in the vein). The Resident Care Plan (RCP) dated [DATE] identified Resident #1 was at risk for falls secondary to generalized weakness, a history of falls, and was able to make needs known. […]

• Actual harm, isolatedF684Jan 2, 2024

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for falls, the facility failed to identify a change in neurological status timely and failed to transfer the resident to the emergency room in a timely manner following a change in condition. The findings include: Resident #1 was admitted to the facility on [DATE] after a fall at home with diagnoses that included fracture of the hip after a fall, fractured left pubic rami, severe protein-calorie malnutrition, chronic myeloid leukemia (CML), and a history of deep vein thrombosis lower extremity (blood clot in the vein). […]

• No harm, potential for more than minimal, widespreadF804Jul 21, 2025

  Based on observations, interviews, facility documentation, and facility policy, the facility failed to ensure food served appeared appetizing, at appropriate temperatures and was palatable. The findings include: 1. Interview with Resident #135 on 7/15/25 at 10:00 AM identified the food was either undercooked or overcooked.Interview with the Director of Dining Services (DDS) on 7/15/25 at 10:17 AM identified that the facility used a point of service, steam table, system for meal service with breakfast items placed in the steam tray at 7:00 AM for service beginning at 7:30 AM, lunch items placed in the steam table at 11:00 AM for service beginning at 11:30 AM, and dinner items placed in the steam table at 4:30 PM for service beginning at 5:00 PM.Interview with Resident #136 on 7/15/25 at… […]

• No harm, potential for more than minimal, widespreadF812Jul 21, 2025

  Based on observations, interviews, facility documentation, and facility policy, the facility failed to ensure that refrigerator/freezers out of range temperatures in 3 of 3 kitchenettes were identified and reported to the Director of Dining Services and failed to identify/recognize when low temperatures were displayed on the dial during the dishwasher cycle. The findings include: During a kitchen tour and interview with the Director of Dietary Services (DDS) on 7/15/25 at 10:17 AM it was identified that the dietary service department cooks completed the Daily Temperature Log for all refrigerators in the kitchen and the refrigerator logs that were on the resident units in the kitchenettes. […]