Littlefork Care Center

Inspectors wroteBased on interview and document review, the facility failed to follow through on a grievance regarding staffing levels to complete baths for 4 of 4 (R14, R15, R21, R32) residents who voiced concerns during resident council.

Inspectors wroteBased on interview and document review, the facility failed to develop and implement a comprehensive antibiotic stewardship program with established protocols and monitoring to help reduce unnecessary antibiotic use and reduce potential drug resistance for 1 of 1 resident (R6) reviewed for antibiotic use. The lack of a program had potential to affect all 37 residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess potentially abusive behaviors and identify interventions to prevent abuse for 1 of 1 resident (R30) reviewed for abuse and involved R3. R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had a severe cognitive impairment and diagnoses that included Alzheimer's disease. R3's nursing progress note dated 12/5/25 at 6:46 p.m., identified a physical altercation with another patient at 6:20 p.m. R3 had his clothing protector pulled on repeatedly by another patient. R3 did appear to be alarmed while incident was happening as staff witnessed facial expression and fast paced breathing. R3 did not appear to have any marks left from clothing protector being pulled. R3 did not retaliate. R3 appeared to be calm at this time. Clothing protector removed. Other patient removed from vicinity. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to immediately report allegations of abuse to the state agency for 1 of 1 resident (R30) reviewed for abuse, who had an altercation with R3

Inspectors wroteBased on interview and document review, the facility failed to conduct a thorough investigation of possible abuse for 1 of 2 resident (R30) reviewed for abuse who had an altercation with another resident (R3).

Inspectors wroteBased on observation, interview and document review, the facility failed to provide timely assistance with toileting for 2 of 3 residents (R3, R30) reviewed for toileting.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide timely assistance with repositioning for 2 of 3 residents (R3, R30) reviewed for pressure ulcers. R3R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had a severe cognitive impairment and required maximal assistance with transfers and bed mobility. R3 was at risk for pressure injury/ulcer but did not have a current pressure injury/ulcer. R3's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 7/30/25, identified R3 had a Braden score of 16, indicating he was at mild risk for pressure ulcer/injury. R30 was always incontinent of bowel/bladder, usually resistive to allowing staff to perform peri cares and other hygiene tasks. R30 was able make changes in his position frequently and independently as he chose. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess and implement interventions to prevent weight loss for 1 of 1 resident (R30) reviewed for nutrition.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure as needed (PRN) medications were administered as prescribed for 1 of 1 resident (R12) observed to have lower extremity edema and weight gain. In addition, the facility failed to ensure medications were given per manufacturer instructions for 1 of 1 resident (R20) observed to receive insulin administration from a insulin flex pen during observations of medication pass in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure staff consistently implemented enhanced barrier precautions (EBP) in accordance with the Centers for Disease Control (CDC) guidelines to reduce the risk of infection spread for 2 of 2 residents (R6, R5) in the sample that were on EBP. In addition, the facility failed to establish a system to identify, investigate and control infections to prevent the spread of infection.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure pneumococcal immunizations were offered, addressed and/or provided in accordance with Centers for Disease Control (CDC) guidelines for 3 of 5 residents (R11, R23, R37) reviewed for immunizations.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Coronavirus Disease (COVID-19) vaccination was offered and/or provided to reduce the risk of severe illness to 3 of 5 residents (R11, R23. R37) reviewed for immunizations.

Inspectors wroteBased on interview and document review the facility failed to ensure timely reporting of an allegation of resident to resident abuse to the state agency (SA) for 2 of 2 residents (R1, R2) reviewed for abuse.

Inspectors wroteBased on interview and document review the facility failed to provide notice of intent to discharge for 1 of 1 residents (R1) who was sent to the hospital and discharged from the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement transmission-based precautions (TBP) for respiratory symptoms until confirmatory respiratory test results were obtained for 6 of 38 residents (R34, R31, R11,R22, R36, R32), failed to initiate droplet precautions for 1 of 6 residents (R31) known to test positive for influenza A, failed to implement strategies to mitigate the risk of an influenza outbreak, including initiating active surveillance of residents for signs and symptoms of influenza A, isolation of residents presenting with symptoms of influenza A, and post signage at the facility entrances to notify visitors of active illness in the facility. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure use of an as-needed psychotropic medication was limited to a 14-day period and/or re-evaluated by the provider to ensure ongoing need and efficacy of the medications for 2 of 5 residents (R18,R22) reviewed for unnecessary medication use. In addition, the facility failed to complete comprehensive assessment and ongoing monitoring of behaviors for an administered antipsychotic medication to ensure efficacy of the medication for 1 of 5 residents (R11) reviewed for unnecessary medication use.

Inspectors wroteBased on interview and document review the facility failed to timely notify the physician when a hematoma (localized collection of blood outside of blood vessels) was identified and subsequently opened requiring a new intervention for 1 of 2 (R18) residents reviewed for wound care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the care plan was updated timely to to prevent falls for 1 of 1 residents (R19) reviewed for falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assistance was offered with meal setup to promote safety and independence with eating for 1 of 1 resident (R38) reviewed for activities of daily living (ADL) and needed set up and supervision to eat.

Inspectors wroteBased on observation, interview and document review, the facility failed to perform ongoing monitoring and wound care for an injury for 1 of 2 residents (R18) reviewed for wound care; and the facility failed to implement interventions for edema for 1 of 1 resident (R38) reviewed for edema.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide timely assistance with repositioning for 1 of 2 residents (R4); and failed to follow pressure ulcer treatments as ordered to promote healing for 1 of 2 residents (R31) reviewed for pressure ulcers

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess each fall to ensure interventions were followed; and failed to ensure fall interventions were care planned timely and implemented to prevent falls for 1 of 1 residents (R19) reviewed for falls.

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess for trauma informed care and identify potential triggers, to avoid potential re-traumatization for 1 of 1 residents (R7) reviewed for trauma informed care.

Inspectors wroteBased on observation, interview and document review, the facility failed to assess dementia related behaviors and implement appropriate interventions to minimize verbal and physical resident to resident altercations for 1 of 2 residents (R22) reviewed for dementia care.

Inspectors wroteBased on interview and document review, the facility failed to ensure the consulting pharmacist recommendations were addressed and acted upon and documented in the medical record for 3 of 5 residents (R11, R22, R36) reviewed for unnecessary medication use.

Inspectors wroteBased on interview and document review the facility failed to offer pneumococcal vaccination according to Centers for Disease Control (CDC) guidelines for 1 of 5 residents (R36) reviewed for vaccinations.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the state agency (SA) survey results were available for residents voiced by 2 of 3 residents (R4, R25) who attended resident council meetings. In addition, the facility failed to ensure the most recent SA survey results were readily accessible at all times. This had the potential to affect all 38 residents and families that may wish to review the results.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a posting was updated daily and ensure the census was on the nurse staff posting. This had the potential to effect all 38 residents residing in the facility and/or visitors who may wish to view the information.

Inspectors wroteBased on observation, interview and document review the facility failed to perform a comprehensive assessment of falls to include root cause and failed to implement appropriate interventions to reduce the risk for falls from bed for 1 of 3 residents (R2) reviewed who had multiple falls from bed.

Inspectors wroteBased on interview and document review the facility failed to act on grievance filed for 1 of 3 residents (R1) reviewed who filed a grievance alleging verbal abuse by staff.

Inspectors wroteBased on interview and document review the facility failed to immediately report an allegation of abuse to the state agency, but no later than two hours, for 1 of 3 residents (R1) reviewed who alleged abuse from staff in the facility.

Inspectors wroteBased on interview and document review the facility failed to investigate an allegation of abuse for 1 of 3 residents (R1) reviewed when R1 reported an allegation of abuse.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess for removing and placing a Wander Guard (WG- alarming device) and ensure the fenced in area for residents was secure for 1 of 3 residents (R1) reviewed for resident safety.