Littlefork Care Center

In the surveyor’s words

From the most serious findings on record at Littlefork Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Feb 27, 2025

  Based 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. […]

• Actual harm, isolatedF689Feb 16, 2023

  Based on interview and document review, the facility failed to ensure one of one resident (R1) remained free of an avoidable accident and injury when R1 was transferred by one staff with an improper sling on a mechanical lift operated by one staff member. R1 was dropped from a mechanical lift resulting in a laceration to her left posterior scalp, requiring three staples at the emergency room . Findings include: Minimum Data Set (MDS) assessment, dated 1/18/2023, indicated R1's diagnoses included Alzheimer's disease, dementia, psychotic disorder, and non-traumatic brain dysfunction. R1's functional mobility indicated she was dependent on staff for transfer and repositioning. R1's Brief Interview for Mental Status (BIMS) score was 2 out of 15 indicating sever cognitive impairment. […]

• Actual harm, isolatedF686Mar 22, 2021

  Based on observation, interview, and document review, the facility failed to comprehensively assess facility acquired pressure ulcers, consistently implement identified interventions, reassess nursing interventions to promote healing when the pressure ulcer deteriorated and communicate with the medical provider regarding current treatment and pressure ulcer status for 1 of 4 residents (R10) reviewed for pressure ulcers. This caused actual harm to R10 who's pressure ulcer worsened to an unstageable pressure ulcer and warranted physician and surgeon recommendation for [MEDICAL CONDITION]. In addition, the facility failed to ensure the medical provider's orders for a pressure reducing cushion was processed and implemented for 1 or 4 residents (R39) reviewed for pressure ulcers. […]

• Actual harm, isolatedF689Mar 22, 2021

  Based on observation, interview and document review, the facility failed to comprehensively assess, per manufacturer's recommendation, the level of assistance required for use of the bath chair prior to use and failed to assess cause of injury and implement interventions to prevent subsequent injury while bathing for 1 of 1 resident (R39) reviewed for facility acquired lacerations while in the tub chair. This resulted in actual harm to R39 who sustained a second injury in the tub room resulting in a second laceration which required 16 sutures. Findings include: R39's significant change Minimum Data Set ((MDS) dated [DATE], indicated she had intact cognition and required extensive assistance for transfers. […]

• No harm, potential for more than minimal, widespreadF880Mar 22, 2021

  Based on interview and document review the facility failed to analyze monthly surveillance data for trends and patterns to reduce the spread of illness and infections. This had the potential to affect all 48 residents residing in the facility. In addition, the facility failed to ensure a standing lift was disinfected prior to use for 1 of 1 residents (R10) after 1 of 1 residents (R253) was observed to utilize the standing lift while on quarantine precautions for COVID-19 Findings include: A line list for infection surveillance was requested from December 2020, through March 2021. A line list was provided from 12/1/20, through 3/22/21, listing resident name, room number, infection date, diagnosis, medication, provider, outcome and dated of infection signs and symptoms were resolved. […]