Litchford Falls Health and Rehabilitation Center

Inspectors wroteBased on record review, resident and Responsible Party interviews and staff interviews, the facility failed to provide written grievance summaries for a grievance filed by or on behalf for 4 of 4 residents reviewed for grievances (Resident #3, Resident #33, Resident #68 and Resident #48).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, a form used by skilled nursing facilities to inform residents about potential costs and coverage limitations for services that may not be covered by Medicare) to beneficiaries who intended to continue services and the SNF believed the services may not be covered under Medicare prior to discharge from Medicare Part A skilled services for 1 of 3 residents reviewed for beneficiary notification review (Residents #113).

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain accurate daily nurse staffing sheets for 10 of 30 days reviewed for daily posted nurse staffing information (6/17/26, 6/19/26, 6/24/26, 6/26/26, 6/28/26, 7/1/26, 7/2/26, 7/3/26, 7/5/26, and 7/6/26).

Inspectors wroteBased on record review, and interviews with staff, Nurse Practitioner, and Physician, for a resident with multiple pressure sores, the facility failed to 1) have effective systems and communication in place to ensure treatment orders were entered correctly after assessments by the Wound Nurse Practitioner and Facility Wound Nurse and based on the correct anatomical site so that the plan of care would be clear and able to be followed by all staff 2) ensure a nurse knew where to access a wound vac so it could be applied per orders and 3) evaluate how a resident's nutritional status and significant weight loss were potentially contributing to multiple pressure sores developing in order to determine if additional interventions were needed. This was for 1 of 3 sampled residents reviewed for pressure sores (Resident #1).

Inspectors wroteBased on record review and interviews with staff, Registered Dietician (RD), and Physician the facility failed to 1) initiate a supplement per the Registered Dietician's recommendation when the Registered Dietician noted the resident's intake was not consistently meeting nutritional needs and 2) obtain weights on a newly admitted resident per the facility's reported system to establish future individualized weight monitoring timeframes 3) evaluate a resident's significant weight loss and declining albumin levels for 1 of 3 residents whose weights were reviewed (Resident #1).

Inspectors wroteBased on record review and interviews with staff, the facility failed to ensure the resident's medical record was accurate and complete for 1 of 7 sampled residents (Resident # 1).

Inspectors wroteBased on observations and staff interviews, the facility failed to clean and maintain in good repair the floors, walls, and the individual heating and air conditioning units (PTAC units) in 5 of 7 resident rooms (room [ROOM NUMBER], #305, #306, #308, and #309) on 1 of 3 halls observed for a clean, comfortable and homelike environment (300 Hall).

Inspectors wrote2. Resident #20 admitted to the facility on [DATE]. A nursing progress note dated 11/17/24 noted Resident #20 discharged home with a family member. Review of the Minimum Data Set (MDS) assessments for Resident #20 did not include a Discharge MDS assessment. In an interview on 5/08/25 at 4:45 PM, MDS Coordinator #1 stated the Discharge MDS assessment should have been completed when Resident #20 discharged and it was an oversight and was missed. In an interview on 5/08/25 at 5:08 PM, the Administrator stated the MDS was missed and should have been done. Based on staff interviews and record reviews, the facility failed to accurately complete the Minimum Data Set (MDS) assessment to reflect the use of an antibiotic (Resident #4) and failed to complete an MDS at discharge (Resident #20). This occurred for 2 of 41 residents whose MDS assessments were reviewed.

Inspectors wroteBased on observations, resident and staff interviews, and record reviews, the facility failed to accurately care plan the interventions related to smoking for 1 of 2 residents reviewed and identified as an independent smoker (Resident #58).

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to provide routine fingernail care for a dependent resident, and shave a resident's facial hair in accordance with his preference to be clean shaven. This occurred for 1 of 7 dependent residents (Resident #4) reviewed for Activities of Daily Living (ADLs).

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a medication cart in clean and sanitary conditions for 1 of 2 medication carts reviewed for medication storage (100 [NAME] medication cart).

Inspectors wroteBased on record review and interviews with staff, the facility failed to ensure a system was in place in order that a resident's advance directive not to be resuscitated was honored upon her death. This was for one of three (Resident # 8) residents reviewed for emergency responses by facility staff prior to emergency medical systems being called.

Inspectors wroteBased on record review and interviews with staff and the physician, the facility failed to notify the physician when a resident experienced nausea, vomiting, and decreased urine output following an increase in her diuretic medication. (A diuretic medication increases excretion of fluid). This was for one of four sampled residents (Resident # 1) reviewed for physician notification.

Inspectors wroteBased on record review and interviews with staff and physician, the facility failed to 1) ensure labs were drawn as ordered on a resident whose diuretic medication was increased (A diuretic medication increases excretion of fluid) and 2) ensure effective communication between Nurse Aides and Nurses so that a resident with vomiting and decreased urine output could receive nausea medication as prescribed and the physician would be made aware of the resident's lower urine output after he had increased the resident's diuretic medication. This was for one of four sampled residents (Resident # 1) reviewed for professional standards of practice.

Inspectors wroteBased on record review and interviews with staff, Wound Nurse Practitioner (NP), and Physician, the facility staff failed to communicate effectively with the Wound NP, who was assessing and overseeing the care of Resident # 1's pressure sore, to ensure timing of dressing changes and the use of a cleansing agent was done per the Wound NP's plan of care for Resident # 1's pressure sore. This was for one of one sampled resident (Resident # 1) with a pressure sore.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the medical record was complete regarding circumstances of a fall and assessments following a fall when a resident was injured. This was for one of four (Resident # 5) residents reviewed for falls.

Inspectors wroteBased on facility staff interviews, physicians' interviews, and facility and hospital record reviews, the facility failed to immediately consult with the resident's Medical Doctor (MD) for order clarification when there was a lapse in the resident's coverage of an oral anticoagulant medication (Eliquis). Eliquis is a prescription medication used to reduce the risk of stroke and blood clots in people who have atrial fibrillation (a type of irregular heartbeat). Eliquis was discontinued 11 days before Resident #6 returned for a one-month Vascular follow-up appointment by an outside provider due to a recent diagnosis of bilateral lower extremity deep vein thrombosis (or DVTs, a condition where a blood clot forms in a deep vein, typically in the legs). [...]

Inspectors wroteBased on staff interviews, consultant pharmacist and physician interviews, and facility and hospital record reviews, the consultant pharmacist failed to urgently report an irregularity related to the omission of Eliquis (an oral anticoagulant medication) for 1 of 1 resident reviewed for a significant medication error (Resident #6) with a history of strokes, deep vein thrombosis (or DVTs, a condition where a blood clot forms in a deep vein, typically in the legs), pulmonary embolism (or PE, a condition where a blood clot travels to the lungs), and atrial fibrillation (a type of irregular heartbeat). Eliquis is a prescription medication used to reduce the risk of stroke and blood clots in people who have atrial fibrillation. Resident #6 was initially seen for a Vascular consultation on 9/27/24 with a follow-up consultation conducted on 11/8/24. [...]

Inspectors wroteBased on facility staff interviews, physicians' interviews, and facility and hospital record reviews, the facility failed to provide an uninterrupted course of Eliquis (an oral anticoagulant or blood thinner used to reduce the risk of stroke and blood clots in people who have atrial fibrillation) when the medication was discontinued 11 days before Resident #6 returned for a one-month follow-up from an outside Vascular consultation. The resident was seen for the follow-up Vascular consultation on 11/8/24. At that time, the facility failed to transcribe an order for the Eliquis into her electronic medical record (EMR), which resulted in the resident missing this medication for a total of 36 days until she was discharged to the hospital on [DATE]. [...]

Inspectors wroteBased on facility staff interviews, physicians' interviews, and facility and hospital record reviews, the facility failed to initiate the use of compression stockings for 1 of 1 resident reviewed (Resident #6) with a history of deep vein thrombosis or DVTs (a condition where a blood clot forms in a deep vein such as the legs), pulmonary embolism or PE (a condition where a blood clot travels to the lungs) and atrial fibrillation (a type of irregular heartbeat).

Inspectors wroteBased on observations, residents and staff interviews, the facility failed to maintain an electrical outlet for room [ROOM NUMBER] and seal the gap around a wall heating and cooling unit for 2 of 2 rooms (rooms [ROOM NUMBERS]) reviewed for environment.

Inspectors wroteBased on record review and resident, staff and Physician interviews, the facility failed to provide care in a safe manner which resulted in a fall from the bed and a hospitalization for 1 of 3 residents reviewed for accidents (Resident #1).