Litchford Falls Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Litchford Falls Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Dec 17, 2024

  Based 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). […]

• Immediate jeopardy, isolatedF756Dec 17, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF760Dec 17, 2024

  Based 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 12/3/24. […]

• No harm, potential for more than minimal, patternF585Jul 10, 2026

  Based 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). The findings included: 1. Resident #3 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was moderately cognitively impaired. A review of Medical Records revealed a responsible party (RP) listed for Resident #3. A review of the facility's grievance log for May 2026 through June 2026 revealed a grievance filed on behalf of Resident #3 by the RP on 5/18/26, 5/19/26 and 6/10/26. a. […]

• No harm, potential for more than minimal, patternF584May 8, 2025

  Based 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). The findings included: Accompanied by the facility's Maintenance Director, a tour of seven (7) residents' rooms on the 300 Hall was conducted on 5/7/25 from 3:00 PM to 3:20 PM. Concerns related to the cleanliness and condition of five of these rooms included the following: --room [ROOM NUMBER]: An observation of room [ROOM NUMBER] was conducted. Two of the vent louvers on the PTAC unit were observed to be broken. […]