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 Litchfield Health & Rehab Center during CMS and state inspections, most recent first.
The facility did not ensure an RN was present for at least 8 consecutive hours each day, as required, with multiple days lacking adequate RN coverage according to staffing schedules. Staff and leadership were unaware of these lapses, and no specific RN policy was in place.
Several residents requiring assistance with transfers did not receive proper supervision or adherence to safety protocols. Staff failed to use gait belts when required, did not check mechanical lift straps for stability, and did not provide necessary support during transfers, contrary to facility policy. These actions resulted in unsafe transfer practices for residents with cognitive and physical impairments.
Surveyors observed that several residents dependent on staff for toileting and hygiene did not receive complete incontinence or catheter care, including improper use of cleansing agents, incomplete cleaning of affected areas, and failure to dry the skin as required by facility policy. Staff interviews revealed inconsistent practices and understanding of proper procedures.
Staff failed to consistently perform hand hygiene and change gloves during incontinence care and meal service, and did not properly don PPE when caring for residents on enhanced barrier precautions. In several cases, CNAs used soiled gloves to handle clean items and did not secure gowns appropriately, despite facility policies requiring these infection control practices.
A resident with cognitive impairment and multiple medical diagnoses received wound care for a pressure ulcer while their pants and brief were pulled down and the room curtain and window shade were left open, exposing the resident. Multiple staff were present during the incident, and the Assistant DON acknowledged forgetting to close the curtain. Staff interviews confirmed that privacy measures, such as closing curtains and window shades, are expected during resident care.
A resident with a gastrostomy tube, dependent on enteral feeding due to hemiplegia and dysphagia, received water flushes from an LPN who did not verify tube placement or check residuals as required by physician orders and facility policy. Staff interviews confirmed the omission, and facility protocols were not followed.
A resident with moderate cognitive impairment experienced a significant delay in obtaining a stat-ordered x-ray for right knee pain and deformity. Despite the order being placed in the morning, the x-ray was not performed until nearly 11 hours later, leading to the resident's transfer to the hospital with a confirmed right femur fracture.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled in the facility for at least 8 consecutive hours a day, 7 days a week, as required. Review of nursing staff schedules from January 1 to March 19, 2025, revealed multiple dates where there was no RN coverage for 8 consecutive hours within a 24-hour period. Interviews with the Assistant Director/Infection Preventionist, a CNA, and the Director of Nursing indicated a lack of awareness regarding any RN staffing issues, and the Director of Nursing stated she would come in if notified of a gap in RN coverage. The facility administrator confirmed there was no specific RN policy in place, only a general staffing policy. At the time of the survey, there were 61 residents residing in the facility.
Failure to Ensure Safe Transfer Practices and Accident Prevention
Penalty
Summary
The facility failed to ensure proper and safe transfer techniques for four residents who required assistance, resulting in deficiencies related to accident prevention and supervision. For one resident with moderate cognitive impairment and a self-care deficit, a CNA assisted with transfers without using a gait belt, despite the resident's care plan requiring one-person physical assistance with a wheeled walker. The CNA admitted to not having a gait belt available and did not follow the protocol of obtaining one before assisting the resident. Another resident with severe cognitive impairment and multiple diagnoses, including dementia and chronic kidney disease, required a full mechanical lift for all transfers according to her care plan. During a transfer from a wheelchair to bed, two CNAs failed to check the straps of the mechanical lift sling for stability and did not provide gentle support during the transfer, as required by facility policy. Similarly, a resident with severe cognitive impairment and dependency for transfers was moved using a mechanical lift by two CNAs, but the lift pad straps were not checked prior to the transfer. A fourth resident, also dependent on a full mechanical lift for transfers, was transferred by a CNA and an LPN without verifying that the lift pad straps were secured. No staff member supported or guided the resident during the transfer, resulting in the resident swaying back and forth. Interviews with multiple staff members confirmed that the expected procedure is to check the straps and have one person operate the lift while the other supports the resident. Facility policies require at least two staff for mechanical lift transfers, checking strap stability, and providing gentle support, but these procedures were not followed in the observed incidents.
Incomplete Incontinence and Catheter Care Practices
Penalty
Summary
The facility failed to provide complete and appropriate incontinence and catheter care for four residents, as observed and documented by surveyors. In one instance, a resident with severe cognitive impairment and dependence on staff for toileting was not cleaned using proper technique; the same section of a washcloth was used to wipe multiple areas, and the area was not dried after rinsing. Another resident, who was at high risk for urinary tract infection due to an indwelling catheter, received peri and catheter care with antibacterial hand soap intended only for handwashing, contrary to the product's instructions and the facility's own policy. Staff interviews revealed inconsistent practices regarding the cleansing agents used for incontinence care. Additional deficiencies were observed in the care of two other residents. One resident, dependent on staff for toileting, was not fully cleansed after being incontinent of stool; only partial areas were cleaned, and the peri area, groin, labia, and part of the buttocks were not addressed before a new brief was applied. Another resident, also dependent on staff for toileting, was not fully cleansed after being incontinent of urine; only the groin was cleaned, while the inner thighs and buttocks were not. These actions were inconsistent with the facility's peri care policy, which requires thorough cleaning of all affected areas. Staff interviews indicated a lack of consistent understanding and adherence to proper incontinence care procedures. While some CNAs described appropriate cleaning of both front and back areas, others demonstrated incomplete care during direct observation. The facility's peri care policy outlines the need for an authorized cleansing agent and thorough cleaning and drying of all relevant areas, but these standards were not consistently met during the survey period.
Failure to Follow Hand Hygiene, Glove Change, and PPE Protocols During Resident Care and Meal Service
Penalty
Summary
Staff failed to perform proper hand hygiene and glove changes during incontinence care and meal service, as well as failed to don personal protective equipment (PPE) appropriately when providing care for residents on enhanced barrier precautions. In multiple observed instances, certified nursing aides (CNAs) were seen performing incontinence care for residents with significant self-care deficits and cognitive impairments, including those with diagnoses such as dementia, heart failure, and overactive bladder. During these care activities, CNAs used soiled gloves to touch clean items, such as incontinent briefs, linens, and resident clothing, and to open closet doors, without changing gloves or performing hand hygiene between tasks, thereby breaching infection control protocols. Additionally, during meal service, a CNA was observed donning gloves without performing hand hygiene before assisting residents with their meals, handling food items, and adjusting residents' positions. Hand hygiene was only performed after glove removal, contrary to facility policy, which requires hand hygiene both before donning and after removing gloves. Interviews with other CNAs confirmed knowledge of the correct procedures, but the observed practices did not align with these standards. Further, when providing care to a resident on enhanced barrier precautions due to an indwelling catheter, a CNA did not secure her gown properly, resulting in the gown sliding off during care. This failure to properly don PPE was observed despite staff interviews indicating awareness of the correct procedures for gown application and securing. Facility policies reviewed emphasized the importance of hand hygiene and proper glove use as primary means to prevent infection, but these were not consistently followed during the observed care activities.
Failure to Provide Privacy During Wound Care
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including hemiplegia, polyneuropathy, and chronic kidney and heart disease, was provided wound care without adequate privacy measures. During the procedure, the resident's pants and brief were pulled down to expose a pressure ulcer on the right flank, while the room curtain and window shade remained open. This was observed by multiple staff members, including the Assistant Director of Nursing/Infection Preventionist, two RNs, and the MDS Coordinator. The Assistant Director of Nursing acknowledged forgetting to close the curtain during the procedure. Interviews with other staff members, including CNAs and an LPN, confirmed that the standard practice is to close curtains and window shades to ensure resident privacy during care. The facility's own documentation of resident rights also specifies the right to bodily privacy and dignity, especially during care and treatment. The administrator stated that staff are expected to close curtains and window shades when a resident's body is exposed during care.
Failure to Verify Gastrostomy Tube Placement Prior to Water Flush
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to check the placement of a gastrostomy tube prior to administering water flushes for a resident with a history of hemiplegia, hemiparesis, and dysphagia. The resident was dependent on tube feeding and water flushes, with physician orders specifying that tube placement and residuals should be checked before feedings and medication administration. During observation, the LPN performed water flushes without verifying tube placement or checking residuals, contrary to both the physician's orders and the facility's enteral tube flushing policy. Interviews with nursing staff confirmed that tube placement should have been checked prior to flushing, and the facility's policy explicitly required verification of tube placement before administering water or feedings. The resident's care plan also documented the need to check for tube placement and gastric contents per protocol. The failure to follow these procedures was directly observed and acknowledged by the staff involved.
Failure to Obtain Timely X-ray for Resident
Penalty
Summary
The facility failed to obtain a timely x-ray for a resident (R3) who was experiencing right knee pain and deformity. The resident, who has moderate cognitive impairment, was first noted to have a knee deformity and pain at 7:30 AM. The medical doctor was notified, and an x-ray was ordered at 8:30 AM. Despite the order being marked as 'stat,' the x-ray was not performed until approximately 7:30 PM, nearly 11 hours later. During this time, the resident's condition included discoloration and increased pain, and the resident was eventually sent to the emergency room after the x-ray confirmed a fracture. The resident was admitted to the hospital with a right femur fracture early the next morning. Interviews with staff and the resident's son revealed that there was a significant delay in obtaining the x-ray. The son was informed early in the day about the x-ray order and visited the facility in the evening, only to find that the x-ray had not yet been performed. The facility's agreement with the mobile imaging service provider stated that services would be provided within a reasonable time frame, usually within a few hours, but this was not adhered to in this case. The delay in obtaining the x-ray and subsequent diagnosis of the fracture led to the resident's transfer to the hospital for further evaluation and treatment.
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Illustrative
What surveyors actually found near you
We read the 39 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Litchfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avenues At Litchfield | 0.7 mi | ★★★★★ | 2 | 0 |
| Hillsboro Rehab & Hcc | 9 mi | ★★★★★ | 7 | 0 |
| Gillespie Health & Rehab Ctr | 10.4 mi | ★★★★★ | 3 | 0 |
| Montgomery Nursing & Rehab Ctr | 10.4 mi | ★★★★★ | 1 | 0 |
| Staunton Health And Rehab Ctr | 13.7 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.