Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | — | 2 | 0 |
| Staunton Health And Rehab Ctr | 13.1 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 August 2026) and official state health department websites.