Litchford Falls Health and Rehabilitation Center
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 72 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (1/5 stars)
- Low staffing rating (1/5 stars)
- Above-median deficiencies (8 vs median 4.0)
- High RN turnover (69%)
Bottom 25% in NC · Below recommended RN staffing · Worst in LIFEWORKS REHAB chain · $181,873 in fines
What this means for your family
While the facility has seen recent improvements in leadership and therapy services, the recurring reports of severe neglect and slow response times are concerning. If you choose this facility, ensure you have a plan for frequent family visits to advocate for your loved one's basic needs, as staffing consistency remains a significant issue.
Google Reviews
Google Reviews
72 reviews on Google“Litchford Falls Health and Rehabilitation Center receives highly polarized feedback, with recent reviews showing a sharp divide between praise for the therapy team and severe reports of neglect. While some families highlight improvements under new management and commend the therapy staff, others report critical issues including unresponsiveness to call lights, poor hygiene, and inadequate staffing levels. Prospective families should be aware of these significant inconsistencies in care quality.”
Quality Themes
Tap a score for detailsStrengths
- Highly skilled and dedicated physical/occupational therapy team
- Friendly and compassionate nursing staff (noted by some)
- Visible improvements under new administrative leadership
- Welcoming and clean environment (noted by some)
Concerns
- Chronic understaffing and slow response to call lights (mentioned by 9 reviewers)
- Poor hygiene, including soiled linens and facility cleanliness (mentioned by 6 reviewers)
- Inedible or cold food quality (mentioned by 4 reviewers)
- Lack of communication and unprofessional staff behavior (mentioned by 4 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 75 analyzed
How They Respond to Reviews
This facility actively engages with reviewer feedback.
Questions for Your Tour
- 1I noticed the administration has been very active in responding to feedback lately; what specific steps are being taken right now to improve the daily cleanliness and linen services in the resident rooms?
- 2With the therapy team being such a highlight for families, could you tell us more about how the physical and occupational therapists work with residents to meet their specific mobility goals?
- 3How does the nursing team manage call light response times to ensure that residents aren't waiting long periods for assistance with their needs?
- 4Could you describe the current meal service, specifically how the facility ensures food is served at the right temperature and meets different dietary preferences?
- 5What is the protocol for managing medications and ensuring there are no errors in the administration process?
- 6What kind of daily activities or social engagement programs are available to help residents stay connected with one another?
Personalized based on this facility's data
Key Review Excerpts
“The therapy team at Litchford is 2nd to none! The sessions are tailored to match each individual's needs and include music and good conversation to help reduce the stress of rehabilitation all while focusing on maximizing safety and independence.”
“It took NAs over 5 hours to give her a bedpan that she continued to request. Even with family there advocating for her, it took over an hour for them to bring her a bedpan to use the bathroom.”
“Karen, the new Admin has really transformed this whole place since she took over, the facility has newer equipment, response to issues is handled faster, more competent staff has been hired and the best retained.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
8
measures
7
measures
2
measures
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents whose walking got worse
Residents on anti-anxiety or sleep medication
Residents vaccinated for pneumonia
Residents who lost too much weight
Residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Litchfield Falls has significant concerns with 16 complaint-triggered deficiencies, indicating families have filed reports about care problems. The facility shows recurring issues with medication management, resident rights (particularly family notification), and basic care quality including wound care and nutrition. While the facility corrects deficiencies when cited, problems persist across multiple surveys, suggesting ongoing care challenges that warrant careful family evaluation before placement.
Jan 8, 2026Complaint3
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
May 8, 2025Routine15
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Install an approved automatic sprinkler system.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Construction Deficiencies
Use approved construction type or materials.
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Egress Deficiencies
Have exits that are accessible at all times.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
May 8, 2025Complaint2
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Feb 17, 2025Complaint5
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Dec 17, 2024Complaint4
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Mar 21, 2024Complaint1
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Federal Penalties
Fine
Dec 17, 2024
$177,911
Fine
Sep 28, 2023
$3,962
Ownership & Operations
Who Operates This Facility
Litchford Falls Health and Rehabilitation Center
for profit
Chain Affiliation
Lifeworks Rehab
66 facilities nationwide
Chain avg rating: 2.1/5 · Rank 52 of 57 (Worst)
Ownership & Management
Owners
Beaver, Donald
Owner
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
72 reviews from families & visitors
Official Website
Visit litchfordfallshealthrehab.com
Medicare data downloads
Original nursing home datasets
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