Inspection Report — Dec 9, 2025
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 — Dec 5, 2025
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 — Aug 21, 2025
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 — Apr 24, 2025
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 — Mar 11, 2025
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 — Apr 11, 2024
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 — Jan 3, 2024
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 — Jan 3, 2024
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 — Dec 22, 2022
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 — Aug 26, 2021
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 |
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