Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avenues At Litchfield during CMS and state inspections, most recent first.
A resident-to-resident abuse incident occurred when one resident became angry about another resident’s music, yelled at him, and slapped him across the face. The Activity Director heard the altercation, entered the room, and saw the aggressive resident standing over the other resident while continuing to yell. Both residents had psychiatric diagnoses and were documented as cognitively intact, and the facility substantiated the physical abuse after interviews confirmed the event.
Failure to prevent resident-to-resident physical abuse occurred when two cognitively intact residents with psychiatric diagnoses were involved in a room altercation over music. Staff heard yelling and a loud slap, then found one resident standing over the other while yelling at him to turn down his music. The abused resident said he was slapped across the face while resting, and the other resident admitted he slapped his roommate because the music was driving him crazy.
The facility did not ensure an RN was on duty for 8 consecutive hours daily, affecting all 62 residents. The Director of Nurses believed the night RN's shift from 10 PM to 6 AM met the requirement, but only 6 hours fell within the new day. The facility lacks a specific RN coverage policy, relying on CMS guidelines.
The facility failed to maintain proper food temperatures during a lunch service, affecting four residents on a mechanical diet. Observations showed that the food served was below the required temperature, with tater tots at 130.0 F and mechanical hot dog meat at 112.0 F. Dietary staff did not record food temperatures as required, and the Dietary Manager, still in training, acknowledged the issue. The facility's policy on food temperature monitoring was not followed.
The facility failed to implement pharmacist recommendations for medication adjustments for two residents. One resident continued to receive a higher insulin dose despite low blood sugar levels, while another experienced delays in diuretic dosage adjustments despite increased creatinine levels. The facility did not follow its policy for timely notification and follow-up on pharmacist recommendations.
The facility did not meet the required 80 square feet of floor space per resident bed for 58 residents, with rooms providing only 76 square feet per bed. The administrator acknowledged the deficiency and mentioned having a waiver for the room sizes. No resident complaints were noted, and the facility lacked a policy on room measurements.
Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two residents, both of whom had psychiatric diagnoses and were documented as cognitively intact on their MDS assessments. R3’s record included schizophrenia and anxiety, and R4’s record included paranoid schizophrenia, anxiety, and depression. The abuse investigation and staff interviews documented that R4 became angry over R3 listening to music and yelled at him in their shared room. V6, the Activity Director, heard yelling, then heard a loud slap and heard R3 yell, “stop hitting me,” before entering the room and seeing R4 standing over R3 while continuing to yell at him. The investigation further documented that R3 reported R4 slapped him across the face, and R4 admitted he slapped R3 because the music was bothering him. Nursing documentation noted the residents were separated and assessed after the altercation, and the facility substantiated the allegation of physical abuse between the two residents. R3 later stated R4 slapped him “out of the blue,” and R4 later stated he slapped R3 because he would not turn down his music. The report shows the incident occurred between roommates and involved physical aggression by one resident toward the other.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy and prevent resident-to-resident physical abuse involving two residents, both of whom had psychiatric diagnoses and were documented as cognitively intact on their quarterly MDS assessments. One resident had diagnoses including schizophrenia and anxiety, and the other had diagnoses including paranoid schizophrenia, anxiety, and depression. The abuse investigation and staff interviews documented that the two residents were in the same room when one resident became angry about the other resident listening to music and yelled at him. The investigation found that the angry resident made open-hand contact to the other resident’s face, and staff separated the residents after the altercation. The record review and interviews showed that the incident was reported after staff heard yelling and a loud slap, and a staff member entered the room to find one resident standing over the other while yelling at him to turn down his music. The abused resident stated he was resting and listening to music when his roommate slapped him across the face, and the other resident admitted he slapped his roommate because the music was driving him crazy. The facility’s abuse investigation concluded that the resident was in his room resting when his roommate became angry, yelled, and made open-hand contact to his face, which met the policy definition of physical abuse as hitting and slapping.
Failure to Ensure RN Coverage for 8 Consecutive Hours Daily
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, which has the potential to affect all 62 residents living in the facility. The facility's daily assignment sheets for August 30 and 31, 2024, and the RN staffing records for multiple dates in September 2024, documented that there was not 8 consecutive hours of RN coverage. The Director of Nurses (V2) stated that she was informed by her corporate nurse that the night RN, who works from 10 PM to 6 AM, would count as the RN for the new day starting at 12 AM, but acknowledged that only 6 of the 8 hours would be on the new day. The Administrator (V1) confirmed that the facility does not have a specific RN coverage policy and follows CMS guidelines. The facility's Long Term Care application for Medicare and Medicaid, CMS 671, dated September 30, 2024, documented a census of 62 residents.
Failure to Maintain Proper Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure that food was served at the proper holding temperature during a lunch service, affecting four residents who were on a mechanical diet. Observations revealed that the mechanical hot dog meat and tater tots served to these residents were below the required temperature of 135 degrees Fahrenheit. Specifically, the tater tots were at 130.0 F, and the mechanical hot dog meat was at 112.0 F. This deficiency was identified after the last lunch plate had been served, indicating that the food was not maintained at a safe temperature throughout the meal service. Interviews with the dietary staff revealed lapses in the monitoring and recording of food temperatures. The Dietary Manager, who was in the process of certification training, acknowledged the temperature discrepancies and the expectation for food to be held at 165 degrees or higher. The cook admitted to taking temperatures but failing to record them in the designated log. The facility's policy on monitoring food temperatures, which requires corrective actions if temperatures fall below 135 F, was not adhered to, as evidenced by the lack of recorded temperatures and corrective measures during the first lunch service.
Failure to Implement Pharmacist Recommendations for Medication Adjustments
Penalty
Summary
The facility failed to ensure that residents were receiving the lowest effective doses of medications as recommended by licensed pharmacists. For one resident, the pharmacist recommended a reduction in insulin dosage due to low blood glucose levels, but this recommendation was not addressed by the attending physician. The resident continued to receive the higher insulin dose, despite documented low blood sugar readings and a recommendation for dosage reduction. Another resident experienced an increase in creatinine levels, indicating potential kidney issues, which prompted the pharmacist to recommend a reduction in diuretic dosage. However, there was a delay in implementing this recommendation, as the necessary orders were not processed in a timely manner. The resident's blood pressure readings remained low, suggesting that the medication adjustments were not made promptly. The facility's policy requires that the Director of Nursing or designee notify the attending physician of pharmacist recommendations within three business days. However, there was a failure to follow up on these recommendations in a timely manner, leading to delays in addressing the medication irregularities. This lack of timely action contributed to the deficiencies identified during the survey.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet of floor space per resident bed for 58 out of 62 residents reviewed for room size requirements. The deficiency was identified during a survey conducted from September 30, 2024, to October 1, 2024. The facility has 33 two-bed resident rooms, each providing only 76 square feet per bed, which is below the regulatory requirement. All rooms are certified for Medicaid. The administrator, V1, confirmed that there have been no changes to the room sizes since the last survey and mentioned having a waiver for these rooms due to their size. Despite the deficiency, no concerns or complaints were vocalized by residents regarding the waivered room size during the survey period. Additionally, the facility did not have a policy on room measurements.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Litchfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Litchfield Health & Rehab Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Hillsboro Rehab & Hcc | 8.9 mi | ★★★★★ | 7 | 0 |
| Montgomery Nursing & Rehab Ctr | 10.1 mi | ★★★★★ | 1 | 0 |
| Gillespie Health & Rehab Ctr | 10.1 mi | ★★★★★ | 3 | 0 |
| Staunton Health And Rehab Ctr | 13.1 mi | ★★★★★ | 3 | 0 |
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