Deficiencies (last 4 years)
Deficiencies (over 4 years)
19.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
271% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 9, 2025
Visit Reason
The inspection was conducted due to complaints related to resident dignity and abuse concerns involving residents at Larchwood Inn nursing home.
Complaint Details
The complaint investigation substantiated that Resident #1 was threatened with discharge related to a behavior contract, which caused distress. Resident #2 was verbally abused by Resident #1 during a card game altercation on 8/22/25. The facility investigation confirmed the incidents and documented staff interventions and resident interviews.
Findings
The facility failed to ensure Resident #1's behavior contract was not used as a threat, impacting the resident's dignity. Additionally, the facility failed to protect Resident #2 from verbal abuse by Resident #1. Both incidents were substantiated by the facility investigation.
Deficiencies (2)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights, specifically misuse of Resident #1's behavior contract as a threat.
Failure to protect residents from all types of abuse, specifically failure to protect Resident #2 from verbal abuse by Resident #1.
Report Facts
Behavior contract goal dates: 31
Frequency of monitoring: 15
BIMS score: 15
Dates of verbal outbursts by Resident #2: 3
Dates of verbal outbursts by Resident #1: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | SSD | Involved in updating behavior contract, interviewing residents, and coordinating counseling referrals. |
| Social Services Assistant #1 | SSA #1 | Present during Resident #1 interview and involved in behavior contract discussions. |
| Assistant Nursing Home Administrator | Assistant NHA | Participated in meetings with Resident #1 regarding behavior contract. |
| Activities Director | AD | Participated in meetings with Resident #1 regarding behavior contract. |
| Certified Nurse Assistant #1 | CNA #1 | Observed Resident #1's behaviors and provided de-escalation support. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 9, 2025
Visit Reason
The inspection was conducted to investigate complaints related to resident dignity, behavior management, and abuse incidents at the nursing home.
Complaint Details
The complaint investigation substantiated that Resident #1 was verbally abusive towards Resident #2 on 8/22/25. The facility failed to protect Resident #2 from verbal abuse and did not adequately update care plans or provide counseling services as recommended.
Findings
The facility failed to ensure Resident #1's behavior contract was not used as a threat and failed to protect Resident #2 from verbal abuse by Resident #1. The investigation substantiated verbal abuse incidents and identified deficiencies in behavior management and counseling services.
Deficiencies (2)
F550: The facility failed to ensure Resident #1's behavior contract was not used as a threat, impacting the resident's right to dignity and self-determination.
F600: The facility failed to protect Resident #2 from verbal abuse by Resident #1, violating the resident's right to be free from abuse.
Report Facts
Residents reviewed for dignity: 4
Residents reviewed for abuse: 4
Behavior contract goal dates: 1
Behavior contract review meeting date: 1
Behavior monitoring frequency: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Involved in behavior contract updates, resident interviews, and investigation of abuse incidents. |
| SSA #1 | Social Services Assistant | Present during Resident #1 interview and involved in behavior contract discussions. |
| Assistant NHA | Assistant Nursing Home Administrator | Participated in behavior contract review meeting with Resident #1. |
| Activities Director | Activities Director (AD) | Participated in behavior contract review meeting with Resident #1. |
| Certified Nurse Assistant #1 | Certified Nurse Assistant (CNA) | Observed Resident #1's behaviors and provided de-escalation support. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 5, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to update resident contact information, failure to address resident grievances promptly, and failure to provide timely dental services to residents.
Complaint Details
The complaint investigation substantiated failures in updating resident contact information, addressing grievances timely, and providing dental care. Resident #2's POA phone number was missing from records, Resident #1's haircuts were delayed for months despite repeated requests, and Residents #1 and #2 did not receive timely dental care, including failure to identify a lost tooth and failure to offer routine dental services.
Findings
The facility failed to update resident contact information for one resident, failed to promptly address grievances related to haircuts for another resident, and failed to ensure timely dental services for two residents, including failure to identify and refer a resident for dental care after tooth loss and failure to offer routine dental care to another resident.
Deficiencies (3)
Failed to periodically update resident contact information, specifically missing power of attorney phone number for Resident #2.
Failed to honor the resident's right to voice grievances without discrimination or reprisal and failed to make prompt efforts to resolve grievances, specifically regarding delayed haircuts for Resident #1.
Failed to provide or obtain dental services timely for Residents #1 and #2, including failure to identify and refer Resident #2 after tooth loss and failure to offer routine dental care to Resident #1.
Report Facts
Residents reviewed: 5
Residents affected: 3
Grievance investigation report timeframe: 5
Haircut schedule interval: 6
Pain scale rating: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Registered Nurse | Interviewed regarding missing POA contact information and oral care for Resident #2 |
| Social Service Director | Social Service Director | Interviewed regarding updating POA information and grievance process |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding POA contact information, grievance process, and dental care deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding POA contact information and dental care deficiencies |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided facility policies on grievances and dental care |
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Regular CNA for Resident #1, interviewed about oral care and missing tooth |
| Registered Nurse #1 | Registered Nurse | Regular nurse for Resident #1, interviewed about oral care and missing tooth |
| Medical Records Director | Scheduling Coordinator | Interviewed regarding coordination of dental services and appointment scheduling |
| MDS Coordinator | MDS Coordinator | Interviewed regarding importance of POA contact info and dental care scheduling |
| Nurse Manager | Nurse Manager/Assistant Director of Nursing | Provided grievance card and interviewed regarding dental care investigation |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 5, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to update resident contact information, failure to address resident grievances promptly, and failure to provide timely dental services to residents.
Complaint Details
The complaint investigation substantiated issues with failure to update resident contact information, failure to promptly resolve grievances related to haircuts, and failure to provide timely dental care services to residents.
Findings
The facility failed to update resident contact information for one resident, failed to promptly address grievances related to haircuts for another resident, and failed to ensure timely dental care for two residents, including failure to identify and refer for dental issues and failure to offer routine dental care.
Deficiencies (3)
F 0580: The facility failed to update Resident #2's power of attorney phone number in the electronic medical record, preventing timely contact in emergencies.
F 0585: The facility failed to honor Resident #1's right to voice grievances by not promptly addressing concerns about delayed haircuts due to lack of a beautician.
F 0791: The facility failed to provide timely dental services by not identifying and referring Resident #2 after tooth loss and not offering routine dental care to Resident #1.
Report Facts
Residents reviewed: 5
Residents affected: 3
Grievance investigation timeframe: 5
Haircut delay duration: 4
Pain scale: 5
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 21, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure a safe transfer/discharge process and proper discharge planning for Resident #2.
Complaint Details
The complaint investigation focused on Resident #2's discharge process, including failure to allow return after hospital discharge, lack of proper notification to resident and representative, failure to notify the ombudsman, and inadequate discharge planning. The complaint was substantiated with findings of minimal harm.
Findings
The facility failed to allow Resident #2 to return after an unplanned hospital discharge, did not provide required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies, and did not notify the resident or representative properly about the discharge or appeal process. The facility also failed to reassess Resident #2 for readmission after stabilization and did not notify the ombudsman timely.
Deficiencies (2)
Failed to ensure Resident #2 was allowed to return to the facility after an unplanned hospital discharge and failed to provide required documentation and reassessment for readmission.
Failed to provide required documentation or notification related to Resident #2's needs, appeal rights, or bed-hold policies, including timely notification to the resident, representative, and ombudsman.
Report Facts
Residents reviewed: 7
Residents affected: 1
Date of hospital discharge: Jul 31, 2025
Date of survey completion: Aug 21, 2025
Date of report: Mar 17, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #2's combative behavior and hospital transfer |
| NHA | Nursing Home Administrator | Interviewed regarding decision not to allow Resident #2 to return and discharge process |
| ADON | Assistant Director of Nursing | Provided facility policy and interviewed about Resident #2's behavior and discharge |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 21, 2025
Visit Reason
The investigation was conducted due to a complaint regarding the facility's failure to ensure a safe transfer/discharge process and appropriate discharge planning for Resident #2.
Complaint Details
The complaint investigation focused on Resident #2, who was discharged to the hospital after an incident involving aggressive behavior. The facility refused to allow the resident to return despite medical clearance. The resident's representative and hospital case manager reported lack of proper notification and discharge process. The facility also failed to notify the ombudsman and provide appeal rights in writing in a timely manner.
Findings
The facility failed to allow Resident #2 to return after an unplanned hospital discharge, did not provide required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies, and failed to notify the resident, representative, and ombudsman in writing about the discharge and appeal rights in a timely manner.
Deficiencies (2)
F 0627: The facility failed to allow Resident #2 to return after an unplanned discharge to the hospital and did not document the resident's needs or reassess for readmission after stabilization.
F 0628: The facility failed to provide required documentation or notification related to Resident #2's needs, appeal rights, or bed-hold policies, including timely written notice to the resident, representative, and ombudsman.
Report Facts
Residents reviewed for discharge planning: 3
Residents in sample: 7
Resident #2 age: 65
Date of hospital discharge: 2025
Date of incident report: 2025
Date of minimum data set assessment: 2025
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Provided facility policy and participated in interviews regarding Resident #2's discharge. | |
| Licensed Practical Nurse (LPN) #1 | Reported on Resident #2's aggressive behavior and hospital transfer. | |
| Nursing Home Administrator (NHA) | Interviewed regarding decision not to allow Resident #2 to return and discharge process. | |
| Hospital Case Manager | Interviewed about hospital clearance and communication with the facility. |
Inspection Report
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding timely provision of medical records to residents or their representatives.
Findings
The facility failed to provide medical records in a timely manner for one of three sampled residents, specifically Resident #1, whose representative did not receive requested records for over two weeks after the request.
Deficiencies (1)
Failure to ensure medical records were provided in a timely manner upon request for Resident #1 from his resident representative.
Report Facts
Days delay in providing medical records: 12
Date of medical record request: Feb 24, 2025
Date medical records received: Mar 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Records Director | Interviewed regarding medical records request process and delays. | |
| Nursing Home Administrator | Interviewed regarding facility policy and timelines for providing medical records. |
Inspection Report
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding timely provision of resident medical records upon request.
Findings
The facility failed to provide requested medical records in a timely manner for one of three sampled residents. The delay was due to procedural issues including difficulty contacting the facility's attorney and unclear policy timeframes.
Deficiencies (1)
F 0573: The facility failed to ensure medical records were provided in a timely manner upon request for Resident #1 from his resident representative. The representative did not receive the records for 12 weekdays after the request.
Report Facts
Days delay in providing medical records: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding facility policy and timeline for providing medical records. |
| Medical Records Director | Medical Records Director | Interviewed about the process and timeline for releasing medical records. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 11, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse, including sexual and physical abuse incidents involving multiple residents.
Complaint Details
The complaint investigation substantiated allegations of sexual abuse by Resident #2 against Residents #1 and #8, and physical abuse by Resident #5 against Resident #6. The facility's investigations revealed multiple incidents, inadequate supervision, and failure to implement effective interventions. Resident #2 was placed on 15-minute checks but still committed abuse. Resident #5 was discharged after a physical assault incident.
Findings
The facility failed to protect three residents from abuse by other residents, including sexual abuse by Resident #2 towards Residents #1 and #8, and physical abuse by Resident #5 towards Resident #6. The facility's monitoring and intervention efforts were inadequate, and care plans and behavior monitoring were inconsistently implemented.
Deficiencies (2)
Failed to protect Resident #1 and Resident #8 from sexual abuse by Resident #2.
Failed to protect Resident #6 from physical abuse by Resident #5.
Report Facts
Residents affected: 3
15-minute checks: 15
30-day discharge notice: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #5's aggressive behavior and physical assault incident. |
| CNA #1 | Certified Nurse Aide | Interviewed about monitoring residents with wandering behaviors and interactions between Resident #2 and victims. |
| ANHA | Assistant Nursing Home Administrator | Interviewed about monitoring Resident #2 and discharge procedures. |
| ISSD | Interim Social Services Director | Interviewed Resident #2 and provided education on unacceptable behavior. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 11, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse, including sexual and physical abuse incidents involving multiple residents.
Complaint Details
The complaint investigation substantiated allegations of sexual abuse by Resident #2 against Residents #1 and #8, and physical abuse by Resident #5 against Resident #6. The facility failed to adequately monitor and intervene to prevent these incidents despite prior knowledge and care plans.
Findings
The facility failed to protect three residents from abuse by other residents, including sexual abuse by Resident #2 towards Residents #1 and #8, and physical abuse by Resident #5 towards Resident #6. The facility's monitoring and intervention efforts were insufficient to prevent repeated incidents despite known risks and care plans.
Deficiencies (1)
F 0600: The facility failed to protect Resident #1 and Resident #8 from sexual abuse by Resident #2 and failed to protect Resident #6 from physical abuse by Resident #5.
Report Facts
Residents affected: 3
BIMS scores: 10
BIMS scores: 12
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #5's aggressive behavior and physical intervention during abuse incident. |
| CNA #1 | Certified Nurse Aide | Interviewed about monitoring residents with wandering behaviors and interactions involving Resident #2. |
| ANHA | Assistant Nursing Home Administrator | Interviewed about monitoring Resident #2 and facility's response to abuse incidents. |
Inspection Report
Routine
Deficiencies: 12
Date: Apr 11, 2024
Visit Reason
Routine state inspection survey to assess compliance with healthcare facility regulations including resident care, medication administration, dietary services, and facility safety.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, medication administration errors, failure to provide timely dental services, improper food texture preparation, inadequate infection control practices in the kitchen, and oxygen therapy management. Several residents experienced issues with care plans, medication errors, and dietary needs not being met according to physician orders.
Deficiencies (12)
F 0550: Facility failed to ensure resident privacy and dignity for two residents who were partially exposed while sleeping and had delayed call light response causing an incontinent episode.
F 0553: Facility failed to involve resident or medical durable power of attorney in care conferences for one resident.
F 0554: Facility failed to ensure safe and appropriate self-administration of medications for two residents, including lack of assessment and physician orders.
F 0582: Facility failed to provide timely notice of Medicare Part A service termination and advance beneficiary notice to one resident.
F 0677: Facility failed to provide consistent bathing per care plans for two residents dependent on staff assistance.
F 0695: Facility failed to ensure proper respiratory care for three residents including oxygen administration not in accordance with physician orders and lack of physician orders for oxygen use.
F 0759: Facility had a medication error rate of 16%, including insulin given after meals and missed medications.
F 0760: Facility failed to ensure residents were free from significant medication errors including improper administration of midodrine and insulin.
F 0761: Facility failed to ensure all medications and biologicals were properly labeled, stored securely, and not expired in medication storage rooms and carts.
F 0791: Facility failed to provide timely replacement of missing dentures and proper oral care for one resident, and failed to communicate denture issues among staff and vendors.
F 0805: Facility failed to provide food and fluids prepared in a form designed to meet individual needs for nine residents on mechanical soft diets.
F 0812: Facility failed to store, prepare, distribute and serve food in a sanitary manner including improper hand hygiene, lack of beard net use, failure to reheat food to proper temperature, and failure to offer hand hygiene to residents before meals.
Report Facts
Medication error rate: 16
Residents affected by bathing deficiency: 2
Residents affected by respiratory care deficiency: 3
Residents affected by medication self-administration deficiency: 2
Residents affected by food texture deficiency: 9
Residents affected by hand hygiene deficiency: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Failed to administer insulin per physician's order for Resident #193. |
| RN #1 | Registered Nurse | Failed to administer medications within prescribed time for Resident #38. |
| LPN #1 | Licensed Practical Nurse | Documented midodrine administration without confirming resident took medication. |
| DA #2 | Dietary Aide | Observed wiping nose on gloves and not changing gloves or washing hands. |
| DA #3 | Dietary Aide | Used same gloves to handle clean dishes and food, did not change gloves appropriately. |
| NHA | Nursing Home Administrator | Provided education on privacy, dignity, medication administration, and dietary training. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication errors and resident care. |
| SSD | Social Service Director | Involved in follow-up for missing dentures and resident care coordination. |
| ADON | Assistant Director of Nursing | Interviewed about oxygen therapy and resident denture issues. |
| RD | Registered Dietitian | Interviewed about dietary deficiencies and training. |
| ST | Speech Therapist | Interviewed about diet texture evaluations and resident safety. |
Inspection Report
Routine
Deficiencies: 12
Date: Apr 11, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, medication administration, dietary services, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, medication administration errors, failure to provide appropriate dental and dietary care, improper oxygen administration, medication storage issues, and inadequate food handling and hygiene practices.
Deficiencies (12)
Failed to ensure resident privacy and dignity for residents sleeping partially exposed and delayed call light response.
Failed to involve resident or medical durable power of attorney in care conferences.
Failed to ensure self-administration of medications was clinically appropriate and properly assessed.
Failed to provide timely notice of Medicare Part A service termination and required beneficiary notices.
Failed to provide consistent bathing per care plans for residents dependent on staff assistance.
Failed to ensure proper respiratory care including oxygen administration per physician orders and documentation.
Medication error rate exceeded 5%, including insulin administration after meals and missed medications.
Failed to ensure residents were free from significant medication errors related to midodrine and insulin administration.
Failed to ensure all drugs and biologicals were properly labeled, stored securely, and not expired.
Failed to provide timely and appropriate dental services including replacement of missing dentures and oral care.
Failed to provide food and fluids prepared in a form designed to meet individual resident needs for mechanical soft diets.
Failed to store, prepare, distribute and serve food in a sanitary manner including hand hygiene, glove use, hair restraints, reheating food, and resident hand hygiene before meals.
Report Facts
Medication error rate: 16
Bathing opportunities: 15
Bathing opportunities: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication error findings related to midodrine administration and self-administration observation. |
| LPN #3 | Licensed Practical Nurse | Named in medication error finding related to insulin administration after meals. |
| RN #1 | Registered Nurse | Named in medication error findings and interview about medication administration timing. |
| DON | Director of Nursing | Named in multiple interviews related to findings on resident care, medication errors, oxygen administration, and facility operations. |
| NHA | Nursing Home Administrator | Named in multiple interviews related to findings on resident care, medication errors, oxygen administration, and facility operations. |
| DA #3 | Dietary Aide | Named in food handling and hygiene observations and interviews. |
| DA #2 | Dietary Aide | Named in food handling and hygiene observations and interviews. |
| SSD | Social Service Director | Named in interviews related to dental care and resident denture issues. |
| ADON | Assistant Director of Nursing | Named in interviews related to oxygen administration and dental care. |
| RD | Registered Dietitian | Named in interviews related to dietary care and food texture compliance. |
| ST | Speech Therapist | Named in interviews related to dietary care and food texture compliance. |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 3, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity and safety, including meal service timeliness and wander guard system functionality following an incident of resident elopement and injury.
Findings
The facility failed to ensure residents received meals in a timely manner, with documented delays up to two hours, and failed to maintain a functional wander guard system, resulting in a resident eloping, falling, and sustaining a femur fracture. Multiple staff interviews and record reviews confirmed systemic issues with meal service and wander guard monitoring.
Deficiencies (2)
Failure to ensure residents did not wait extended periods after posted meal times to receive meals.
Failure to ensure a safe environment and prevent major injury for a resident at risk for elopement and falls due to nonfunctional wander guard system.
Report Facts
Residents waiting for lunch: 24
Meal service completion time: 85
Resident fall date: Nov 17, 2023
Wander guard battery check dates: 3
Number of residents with wander guards: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided facility policies, interviewed regarding meal service delays and wander guard system issues. |
| Dietary Manager | Dietary Manager (DM) | Interviewed about meal service delays and kitchen staffing issues. |
| DA #1 | Dietary Aide | Interviewed about meal service delays and meal cart logistics. |
| DA #2 | Dietary Aide | Interviewed about meal service delays and kitchen frustrations. |
| Quality Assurance Manager | Quality Assurance Manager (QAM) | Interviewed regarding resident fall incident and wander guard system investigation. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed about facility response to resident fall and wander guard system improvements. |
| Restorative Nurse Aide #1 | Restorative Nurse Aide (RNA) | Responsible for checking wander guard batteries and system functionality. |
| Physical Therapy Assistant | Physical Therapy Assistant (PTA) | Oversees restorative department and wander guard checks. |
| Maintenance Service Director | Maintenance Service Director (MSD) | Responsible for monthly checks of wander guard door panels and system. |
| Registered Nurse #2 | Registered Nurse (RN) | Witnessed resident fall and assisted with emergency response. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 3, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding late meal service and a resident safety incident involving elopement and injury.
Complaint Details
The complaint investigation was substantiated. The facility was found to have deficiencies related to late meal service and failure to prevent a resident elopement resulting in injury.
Findings
The facility failed to provide timely meal service, resulting in residents waiting extended periods after posted meal times. Additionally, the facility failed to ensure the safety of a resident at risk for elopement, resulting in the resident leaving the facility unsupervised, falling, and sustaining a femur fracture due to a non-functioning wander guard system.
Deficiencies (2)
F 0550: The facility failed to ensure residents did not wait extended periods after posted meal times, causing delays and cold meals. Meal service was disorganized and inefficient, with staff shortages and inadequate kitchen resources contributing.
F 0689: The facility failed to maintain a safe environment for a resident at risk for elopement. A resident exited the facility unsupervised due to a non-functioning wander guard device, resulting in a fall and femur fracture requiring hospitalization.
Report Facts
Residents waiting for lunch: 13
Residents served late: 2
Wander guard battery checks: 2
Time to find missing resident in drill: 6
Time to find missing resident in drill: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNA #1 | Restorative Nurse Aide | Responsible for checking wander guard batteries and system functionality; last checked Resident #1's wander guard on 10/17/23. |
| QAM | Quality Assurance Manager | Led investigation of Resident #1's fall and wander guard failure; interviewed regarding incident and follow-up. |
| DON | Director of Nursing | Provided facility policies, interviewed about meal service and wander guard system issues, and training plans. |
| NHA | Nursing Home Administrator | Interviewed regarding incident, facility response, and system improvements. |
| PTA | Physical Therapy Assistant | Oversaw restorative department; described wander guard system checks and training. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Dec 22, 2022
Visit Reason
The inspection was conducted due to complaints regarding failure to protect residents from abuse and neglect, failure to provide appropriate wound care, failure to provide safe respiratory care, and failure to maintain infection prevention and control.
Complaint Details
The complaint investigation was substantiated with findings of verbal abuse between residents, inadequate wound care, respiratory care deficiencies, and infection control failures.
Findings
The facility failed to prevent repeated verbal abuse between residents, failed to provide adequate wound care and weekly wound assessments for pressure ulcers, failed to ensure proper respiratory care including CPAP orders, and failed to implement effective infection prevention and control measures including timely isolation and proper hand hygiene.
Deficiencies (5)
F0600: The facility failed to protect residents from verbal abuse and neglect, specifically between Residents #14 and #420, resulting in actual harm including a fractured hip for Resident #420.
F0686: The facility failed to provide appropriate pressure ulcer care and weekly wound assessments for Residents #47 and #60, resulting in deterioration of wounds and failure to implement timely preventative measures.
F0695: The facility failed to ensure complete physician orders for Resident #64's CPAP use, including settings and cleaning instructions, compromising respiratory care.
F0695: The facility failed to ensure appropriate oxygen titration orders and monitoring for Resident #5, risking inadequate respiratory care.
F0880: The facility failed to maintain an effective infection prevention and control program, including unsanitary room cleaning, improper hand hygiene by dietary staff, delayed isolation of residents with influenza A, and failure to protect residents and staff from influenza transmission.
Report Facts
Residents reviewed: 26
Residents affected by abuse: 2
Residents affected by wound care deficiencies: 2
Residents affected by respiratory care deficiencies: 2
Residents affected by infection control deficiencies: 3
Date of verbal abuse incidents: 2022
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 22, 2022
Visit Reason
The inspection was conducted due to allegations of abuse and neglect involving resident-to-resident verbal altercations and failure to protect residents from abuse.
Complaint Details
The complaint investigation was triggered by allegations of abuse and neglect involving resident-to-resident verbal altercations, specifically between Residents #14 and #420, with findings of actual harm and failure to protect residents from abuse.
Findings
The facility failed to ensure residents were free from abuse, neglect, and exploitation, specifically failing to prevent repeated verbal altercations between Residents #14 and #420, resulting in actual harm including a fractured hip. Additionally, the facility failed to provide appropriate pressure ulcer care for residents #47 and #60, failed to ensure proper respiratory care for residents #5 and #64, and failed to maintain infection prevention and control measures including timely isolation for residents with influenza and proper hand hygiene.
Deficiencies (4)
Failure to protect residents from verbal abuse and neglect, resulting in actual harm including a fractured hip.
Failure to ensure weekly wound assessments and appropriate pressure ulcer care for Resident #47 and Resident #60.
Failure to ensure physician orders for Resident #64's CPAP and appropriate respiratory care for Resident #5.
Failure to provide and implement an infection prevention and control program, including unsanitary room cleaning, improper hand hygiene, and failure to implement droplet precautions timely for residents with influenza.
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 26
Dates of altercations: 5
Wound assessments missing: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding oxygen titration orders and notification of influenza lab results |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding lack of CPAP orders for Resident #64 and follow-up with physician |
| RNWN | Registered Nurse/Wound Nurse | Provided wound care and acknowledged being behind on weekly wound documentation |
| HSK #1 | Housekeeper | Observed performing incomplete room cleaning and interviewed about cleaning practices |
| DA #1 | Dietary Aide | Observed not performing hand hygiene before and after delivering meals |
| DA #2 | Dietary Aide | Observed wearing gloves but not performing hand hygiene between residents |
| DON | Director of Nursing | Interviewed regarding wound care, respiratory care, and infection control policies and practices |
| LPN #2 | Licensed Practical Nurse | Notified physician of influenza positive result but failed to notify on-call RN |
Inspection Report
Routine
Deficiencies: 11
Date: Aug 26, 2021
Visit Reason
The inspection was conducted to assess compliance with resident rights, dignity, abuse prevention, medication management, food service, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were treated with dignity and respect, failure to prevent and investigate abuse and neglect, failure to maintain proper medication storage and administration, failure to provide adequate dementia care, failure to ensure food safety and palatability, and failure to properly manage physical restraints.
Deficiencies (11)
Failure to treat residents with dignity and respect during activities of daily living, call light response, dining, and family visits.
Failure to provide personal privacy during care for residents #78 and #84.
Failure to ensure freedom from abuse and neglect for residents #31, #47, #49, #50, and #87.
Failure to ensure residents were free from physical restraints unless medically necessary, including failure to release seat belt during supervised activities and lack of care plan and consent for seat belt use for Resident #62.
Failure to timely report allegations of abuse for Residents #6 and #87 to the State Agency.
Failure to timely and thoroughly investigate an allegation of physical abuse for Resident #87.
Failure to provide adequate dementia care for Residents #84 and #49, including lack of dementia care plan, lack of non-pharmacological interventions, and failure to prevent resident-to-resident altercations.
Failure to prevent a significant medication error for Resident #84 who was administered 10 times the ordered dose of antianxiety medication.
Failure to ensure proper storage and labeling of drugs and biologicals, including unsecured controlled medications, improper refrigerator temperatures, expired and undated medications, and undated insulin pens.
Failure to ensure food was palatable, attractive, and served at safe temperatures, with multiple resident complaints about food quality, temperature, and variety.
Failure to ensure food was prepared, distributed, and served under sanitary conditions, including improper hand hygiene, glove use, and cross-contamination risks in two kitchens.
Report Facts
Residents in sample: 44
Residents reviewed for abuse: 7
Residents affected by abuse: 5
Residents reviewed for restraints: 3
Residents affected by restraint deficiency: 1
Medication error overdose: 4.5
Medication refrigerator temperature out of range days: 24
Expired medications found: 15
Food temperature out of range: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #8 | Certified Nurse Aide | Named in abuse and neglect findings related to Resident #31 |
| CNA #11 | Certified Nurse Aide | Named in dignity and privacy deficiencies related to Residents #27, #78, and #84 |
| LPN #3 | Licensed Practical Nurse | Named in dignity and privacy deficiencies related to Residents #27 and #78 |
| CNA #12 | Certified Nurse Aide | Named in dignity and abuse allegation by Resident #6 |
| RN #2 | Registered Nurse | Named in abuse allegation by Resident #87 |
| RN #5 | Registered Nurse | Named in reporting abuse allegation by Resident #87 |
| LPN #1 | Licensed Practical Nurse | Named in medication cart inspection and expired medication findings |
| LPN #2 | Licensed Practical Nurse | Named in medication cart inspection and expired medication findings |
| RN #4 | Registered Nurse | Named in medication refrigerator inspection and controlled medication storage findings |
| DA #1 | Dietary Aide | Named in food temperature and food handling deficiencies |
| Cook #1 | Cook | Named in food handling and hygiene deficiencies |
| Cook #2 | Cook | Named in food handling and hygiene deficiencies |
| Cook #3 | Cook | Named in food handling and hygiene deficiencies |
| Cook #4 | Cook | Named in food handling and hygiene deficiencies |
| DA #2 | Dietary Aide | Named in food temperature and food handling deficiencies |
| Social Service Director | Social Service Director | Named in multiple interviews related to abuse investigations and dignity concerns |
| Quality Assurance Nurse Manager | Quality Assurance Nurse Manager | Named in multiple interviews related to abuse investigations and dignity concerns |
| Director of Nursing | Director of Nursing | Named in multiple interviews related to abuse investigations, medication management, and dignity concerns |
| Nursing Home Administrator | Nursing Home Administrator | Named in multiple interviews related to abuse investigations, medication management, and dignity concerns |
| Staff Development Coordinator | Staff Development Coordinator | Named in interview related to dementia care training |
| Registered Dietitian | Registered Dietitian | Named in interviews related to food service and dietary staff training |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in medication error follow-up |
Inspection Report
Routine
Deficiencies: 10
Date: Aug 26, 2021
Visit Reason
Routine state inspection survey of Larchwood Inn nursing home to assess compliance with regulatory requirements including resident care, dignity, abuse prevention, medication management, food service, and safety.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were treated with dignity and respect, failure to prevent and investigate abuse and neglect, failure to provide adequate dementia care, medication errors, improper medication storage, unsafe food handling and preparation, and failure to maintain food at proper temperatures.
Deficiencies (10)
F0550: The facility failed to ensure residents received care and services with dignity and respect, including timely call light response, considerate staff interactions, and protection of residents' privacy and personal belongings.
F0583: The facility failed to provide personal privacy during care for two residents, including improper covering during transport and care with open doors and curtains.
F0600: The facility failed to ensure freedom from abuse and neglect for five residents, including physical and verbal abuse by staff and resident-to-resident abuse resulting in injuries.
F0609: The facility failed to timely report allegations of abuse to the State Survey and Certification Agency for two residents.
F0610: The facility failed to thoroughly and timely investigate an allegation of physical abuse for a resident.
F0744: The facility failed to provide adequate dementia care to ensure residents reached their highest practicable psychosocial potential, including failure to provide socialization, non-pharmacological interventions, and appropriate family visits.
F0760: Resident #84 was administered an incorrect dose of antianxiety medication, 10 times the ordered dose, resulting in a significant medication error.
F0761: The facility failed to ensure all drugs and biologicals were properly stored, including double locking controlled substances, maintaining medication refrigerator temperatures, labeling multi-dose medications with opening dates, removing expired medications, and dating insulin pens.
F0804: The facility failed to ensure food was palatable, attractive, and served at safe temperatures, with multiple resident complaints about food quality, temperature, and variety, and observations of food served at unsafe temperatures.
F0812: The facility failed to ensure food was prepared, distributed, and served under sanitary conditions, including failure to perform proper hand hygiene, glove use, and wearing of personal protective equipment in the kitchen.
Report Facts
Residents affected: 6
Residents affected: 2
Residents affected: 5
Residents affected: 2
Residents affected: 1
Residents affected: 1
Food temperatures out of range: 24
Medication error dose: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #8 | Certified Nurse Aide | Named in abuse and neglect findings for Resident #31 |
| CNA #11 | Certified Nurse Aide | Named in dignity, privacy, and abuse investigations |
| LPN #3 | Licensed Practical Nurse | Named in dignity and abuse investigations |
| CNA #12 | Certified Nurse Aide | Named in dignity and abuse investigations for Resident #6 |
| RN #2 | Registered Nurse | Named in abuse allegation by Resident #87 |
| RN #5 | Registered Nurse | Named in abuse allegation reporting for Resident #87 |
| DA #1 | Dietary Aide | Named in food service and sanitation deficiencies |
| Cook #1 | Cook | Named in food service and sanitation deficiencies |
| Cook #2 | Cook | Named in food service and sanitation deficiencies |
| Cook #3 | Cook | Named in food service and sanitation deficiencies |
| LPN #1 | Licensed Practical Nurse | Named in medication storage deficiencies |
| LPN #2 | Licensed Practical Nurse | Named in medication storage deficiencies |
| RN #4 | Registered Nurse | Named in medication storage deficiencies |
| LPN #4 | Licensed Practical Nurse | Named in medication error follow-up |
| SSD | Social Services Director | Named in multiple abuse and dignity investigations |
| QANM | Quality Assurance Nurse Manager | Named in multiple abuse and dignity investigations |
| NHA | Nursing Home Administrator | Named in multiple abuse and dignity investigations |
| SDC | Staff Development Coordinator | Named in dementia care training |
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