Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Larchwood Health And Rehab Llc during CMS and state inspections, most recent first.
Hand hygiene was not followed during meal service and tray delivery. In the kitchen, a cook handled food, trash, and a thermometer with gloved hands without cleaning hands between task changes, and the DM touched her shirt collar and cheek with a gloved hand, removed gloves, and did not perform hand hygiene before handling hot food. During room tray delivery, a CNA repeatedly handled trays, water cups, and resident meals without hand hygiene between rooms and tasks, and the DM stated staff should clean hands after each task change and before new gloves are donned.
Fall Prevention and Unsafe Water Temperatures: The DON and surveyors found that one resident with moderate cognitive impairment lacked a complete fall care plan after a head-strike fall, and another resident with severe cognitive impairment had repeated falls with inconsistent documentation of toileting status, alarms, call light use, and root-cause analysis. Surveyors also measured several resident room sinks at 122 to 129 degrees F, above the safe range noted in facility policy and CPSC guidance, while residents reported the water was very hot.
The facility failed to provide and document written bed hold notices for two residents when they were transferred to the hospital. One resident had acute kidney failure and CHF and was cognitively intact, and another had acute and chronic respiratory failure, pulmonary hypertension, and a respiratory virus with intact cognition and wheelchair dependence. Records did not show completed bed hold forms, and staff stated the forms were not provided at transfer.
A resident with severe cognitive impairment, immobility, and an unstageable right heel pressure injury was not consistently protected with ordered heel offloading measures. The care plan included heel protectors, an air mattress, and frequent repositioning, but records showed the resident repeatedly removed the podus boots and the care plan did not reflect that behavior. Survey observations found the resident in bed with the boot on the floor on multiple occasions, including a prolonged period with no staff entering the room, despite staff stating they monitored the resident and kept the boots on.
Hand hygiene was not maintained during wound care for two residents. A wound doctor contaminated his gloves by touching non-sterile items, then continued wound cleansing, photography, debridement, and dressing application without changing gloves or cleaning his hands between dirty and clean tasks. He also entered a resident room, handled sterile supplies, and changed gloves without hand hygiene. Staff interviews confirmed that hand hygiene was expected between glove use and between dirty and clean wound care steps.
The facility failed to maintain an effective antibiotic stewardship program for a resident receiving doxycycline as suppressive therapy for infected orthopedic hardware and osteomyelitis. Record review showed the antibiotic had been ordered for an extended period, but there was no ongoing documentation justifying continued use or showing regular monitoring in the EMR or medication regimen reviews. The IP and DON both acknowledged the resident’s antibiotic regimen had not been followed up on regularly to determine whether it remained appropriate.
A resident with a history of stroke and cognitive intactness was subject to a behavior contract that was used in a manner perceived as a threat, causing anxiety about possible discharge. The contract remained in place beyond its intended goal date without updates, and staff reminded the resident that further incidents could lead to transfer, despite unclear communication about the contract's status. This resulted in a failure to uphold the resident's dignity and right to self-determination.
A resident with a history of verbal outbursts became agitated during a card game, verbally abusing another resident who then felt fearful due to past trauma. Staff were unable to immediately de-escalate the situation, and the victim did not receive timely counseling or care plan updates. The aggressor's care plan was also not updated to reflect new behavioral interventions or psychotropic medication orders.
A resident's POA contact information was not updated in the EMR after a change in designation, leaving staff unable to reach the correct representative in case of emergency. Staff interviews confirmed reliance on outdated information and highlighted gaps in the process for updating records following changes in resident representatives.
A resident with severe cognitive impairment did not receive timely personal care after her representative repeatedly requested regular haircuts, which were not provided for several months due to a vacancy in the beautician position. Despite multiple requests during care conferences and to staff, the facility did not initiate the formal grievance process or communicate effectively with the representative until a formal grievance was submitted.
Two residents did not receive timely dental services, including one who lost a tooth and another with a broken tooth, due to staff not identifying or documenting the issues and failing to offer routine dental care or assessments as required by facility policy.
A resident's transfer or discharge was not managed in a way that met their needs and preferences, and the facility did not ensure the resident was adequately prepared for a safe transition.
Failure to Document and Notify for Facility-Initiated Discharge: A resident with subdural hemorrhage, falls, cognitive impairment, and mobility deficits was sent to the ED after elopement and combative behavior, then the facility refused readmission. The EMR did not document the discharge process or reason, and the resident/rep was not given written discharge notice with the reason, effective date, discharge location, appeal rights, or LTC ombudsman contact info; timely ombudsman notification was also not documented.
A resident's legal representative did not receive requested medical records in a timely manner, with a delay of 12 weekdays after the request was made. The delay was due to the facility's process of seeking attorney approval and staff's lack of awareness regarding the required timeframe for releasing records. The facility's policy also did not specify the timeframe for providing records.
A resident with a history of sexually inappropriate behavior engaged in multiple incidents of abuse against two other residents, despite being on 15-minute checks and line-of-sight supervision. Another resident with aggressive behavior physically assaulted a fellow resident, highlighting the facility's failure to protect residents from harm. The facility's lack of consistent monitoring, documentation, and communication contributed to these incidents.
The facility failed to ensure appropriate hand washing and glove usage in the kitchen, did not enforce the use of beard nets, improperly reheated food without checking temperatures, and neglected to offer hand hygiene to residents during meal times. These actions were in direct violation of the facility's policies and professional standards.
The facility failed to ensure the self-administration of medications was clinically appropriate for two residents, leading to medication errors. One resident with dementia and blindness was found self-administering eye drops and nasal spray without proper assessment, while another resident with end-stage renal disease and congestive heart failure was observed self-administering medications without staff supervision. Both residents' care plans lacked documentation for safe self-administration.
The facility failed to ensure proper respiratory care for three residents who required supplemental oxygen. One resident adjusted her own oxygen settings without proper documentation or physician notification. Another resident used oxygen without a physician's order, and the third resident's oxygen flow rate was not specified in the physician's order. The facility did not consistently monitor or adjust the oxygen settings according to the physician's orders.
The facility failed to ensure proper storage and labeling of medications and biologicals. Observations included expired medications, incorrectly labeled inhalers, and a bag of pills found on the conference room floor. Staff interviews revealed that the facility's policies were not being followed, and the responsibility for checking medication carts was inadequately performed.
The facility failed to ensure that nine residents with orders for a mechanical soft diet received food prepared according to their needs. Observations revealed that residents were served inappropriate food items, and staff lacked proper training on diet textures, leading to inconsistencies in meal preparation and serving.
The facility failed to maintain residents' dignity and respect by not ensuring privacy for a resident sleeping in limited clothing and not responding timely to another resident's call light, leading to an incontinent episode. Staff interviews revealed issues with time management and consistent implementation of privacy measures.
The facility failed to notify or involve a resident and their MDPOA in care conference discussions. The resident, with moderate cognitive impairment and multiple diagnoses, was not invited to care conferences, and the MDPOA was also not informed or involved. Interviews confirmed the oversight, and facility staff acknowledged the deficiency.
The facility failed to ensure that two residents, who were dependent on staff for bathing assistance, received showers consistently with their plan of care. One resident with multiple sclerosis received only 12 baths over eight weeks, missing several opportunities for bathing. Another resident with diabetes, dementia, and stroke received only 12 baths out of 16 opportunities over nine weeks, with no documentation of re-offering baths after refusals. Staff interviews confirmed the lack of consistent bathing assistance.
The facility had a medication error rate of 16.00%, with errors including an LPN administering insulin after a meal and an RN failing to administer scheduled medications within the prescribed time frame. Both staff members acknowledged the importance of following physician's orders and administering medications on time.
The facility failed to ensure proper medication administration for two residents. One resident self-administered midodrine without a physician's order, and the exact timing of doses was not confirmed. Another resident received insulin after eating, contrary to the physician's order to administer it before meals. These errors were identified through observations, record reviews, and staff interviews, highlighting gaps in the facility's medication administration process.
A resident experienced prolonged discomfort and potential health risks due to the facility's failure to provide timely dental services and adequate oral care. The resident's missing dentures were not promptly replaced, leading to mouth sores and difficulties with chewing and swallowing. The facility's records and staff interviews revealed a lack of proper communication and follow-up regarding the resident's dental needs.
The facility failed to provide a resident with a Notice of Medicare Provider Non-Coverage (NOMNC) two days prior to the discharge of Medicare Part A funded services, issuing it on the same day the benefits ended. Additionally, the Skilled Nursing Facility-Advance Beneficiary Notice (SNF ABN) was not provided when the resident continued to reside in the facility after the discharge.
Hand Hygiene Not Followed During Meal Service and Tray Delivery
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served under sanitary conditions in the main kitchen because staff did not follow appropriate hand hygiene practices during meal service. During a continuous observation of lunch meal service in the kitchen, cook #1 began plating residents' meals, then left the steam table and handled soup from a box with gloved hands while touching the bottom shelf and the outside of the box before returning to continue plating food. Later, the dietary manager touched her shirt collar and wiped her cheek with a gloved hand, removed her gloves, pulled a pan of manicotti from the oven with pot holders, and did not perform hand hygiene after removing the gloves. Cook #1 also pushed trash down in the bin with gloved hands, removed the gloves, put on new gloves without hand hygiene, and then used the same gloved hands to take the temperature of the pan of manicotti. During observation of room tray delivery, CNA #5 repeatedly handled resident trays and meal items without hand hygiene between tasks. She picked up a cart delivered to the first room tray room without hand hygiene, helped set up a resident's meal, filled another resident's water cup without hand hygiene, and collected another resident tray without hand hygiene before later performing hand hygiene. She then pulled out another room tray without hand hygiene, shut the cart door with her foot, served a meal to a resident, picked up an item off the floor, knelt with her hands on the floor near the cart, and pulled another tray without hand hygiene. She later entered another resident's room without hand hygiene before finally performing hand hygiene and delivering the last room tray. The dietary manager stated hand hygiene should be completed thoroughly for 30 seconds after every task change and before putting on new gloves, and said she had not conducted recent staff training on hand hygiene during meal service and delivery.
Fall Prevention and Unsafe Water Temperatures
Penalty
Summary
The facility failed to keep the resident environment as free from accident hazards as possible by not consistently identifying, documenting, and implementing fall interventions for residents with repeated falls, and by allowing tap water temperatures in resident rooms to exceed a safe range. The report identified deficiencies involving two residents with significant fall histories and multiple room water temperatures above 120 degrees Fahrenheit. Resident #60 had diagnoses including asthma, heart failure, and CVA, and his MDS showed moderate cognitive impairment with a BIMS score of 11. His care plan addressed decreased physical mobility and included reminders to use a walker, but the comprehensive care plan did not include a fall care plan with person-centered fall interventions. After a fall in which he reported dizziness while returning from the bathroom and struck his head on a bedside table, the fall risk evaluation still documented no falls in the past three months and did not include the recent fall event. Resident #84 had severe cognitive impairment, repeated falls, osteoporosis, dementia, and required extensive assistance with transfers and toileting-related care. He experienced multiple falls in April, including unwitnessed and witnessed events in his room, bathroom area, dining room, and commons area. The documentation for several falls did not consistently identify key circumstances such as when he was last toileted, whether he was incontinent, whether call light or alarm devices were in place and functioning, or what staff were doing at the time. The report also noted that several interventions identified after falls were not included on the care plan, and that the investigation of the repeated falls was not thorough enough to identify patterns or fully document the events. The facility also failed to maintain safe tap water temperatures in resident rooms. Although monthly logs showed temperatures in one room per hall within range, surveyors measured multiple resident room sinks at 122 to 129 degrees Fahrenheit after running the water for about one minute. Residents in those rooms stated the water got pretty hot or took a while to warm up. Maintenance later identified a leaking hot water heater and adjusted the temperature valve after the survey observation.
Failure to Provide Bed Hold Notices at Hospital Transfer
Penalty
Summary
The facility failed to provide and document sufficient discharge preparation for two residents transferred to the hospital by not ensuring a written bed hold notice was completed at the time of transfer. Facility policy stated residents or their representatives were to receive written information about bed-hold policies well in advance of transfer and again at the time of transfer, or within 24 hours if the transfer was an emergency, including the duration of the bed-hold policy, payment requirements, and return policy. Resident #111, who had diagnoses including acute kidney failure and congestive heart failure and was cognitively intact with a BIMS score of 13, was transported to the hospital emergency room and later noted by nursing staff as admitted to the hospital, but the EMR did not show a completed bed hold form and the SSD said none was provided. Resident #12, who had diagnoses including acute and chronic respiratory failure, pulmonary hypertension, and respiratory virus and was cognitively intact with a BIMS score of 14 and dependent on a wheelchair for mobility, was discharged to the hospital for shortness of breath, but the EMR also did not show that a bed hold notice was provided when he was transferred.
Failure to Consistently Offload and Protect a Heel Pressure Injury
Penalty
Summary
The facility failed to provide the necessary treatment and services to prevent and treat a pressure injury for one resident with an unstageable pressure injury to the right heel. The resident had diagnoses including osteoporosis, COPD, peripheral vascular disease, and anxiety, and the MDS indicated severe cognitive impairment with a BIMS score of 4 out of 15, partial to moderate assistance with ADLs, a pressure injury, and use of a pressure-reducing mattress. The resident’s care plan identified the right heel pressure ulcer as related to immobility and included interventions such as an alternating air mattress, heel protectors on both feet, frequent repositioning, and ongoing wound monitoring. Record review showed the resident’s right heel wound had been documented as dark red and purple discoloration, later as an unstageable wound, and later as improved with minimal slough and epithelial tissue. However, the record also showed the resident repeatedly removed her protective podus boots and dressing, and the care plan did not reflect these refusals or removal behaviors. Observations showed the resident lying in bed on her back with the protective podus boot on the floor next to the bed on multiple occasions. During one continuous observation period lasting over two hours, no staff entered the room and the boot remained off the resident. Staff interviews stated the resident often removed her boots and that staff kept a close eye on her, but the observations showed staff were not consistently ensuring the podus boot was on. The DON stated the resident continued to remove her protective boots and that the wound could decline from poor or inconsistent interventions.
Hand Hygiene Not Maintained During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when hand hygiene was not performed appropriately during wound care for two residents. During wound care for one resident, the wound doctor donned a mask, gloves, and a gown, removed the soiled dressing, then touched his glasses, mask, and the resident's headboard with contaminated gloves. Without changing gloves or performing hand hygiene, he cleaned the wound, applied lidocaine gel, picked up a camera to take wound photographs, and continued the procedure using the same gloves to debride the wound and apply sterile packing and a bordered bandage. He then opened the room door with the same gloves before removing PPE and washing his hands at the resident's sink. During wound care for another resident, the wound doctor donned a mask and gown, reached into his pocket for gloves, entered the room, opened a sterile utensil package, removed the gloves he had in his pocket, and put on a new pair of gloves found in the resident's room without performing hand hygiene. He removed soiled dressings from three areas of the resident's foot, cleaned the wounds, applied lidocaine gel, took wound photographs, and used sterile utensils to debride the wound and apply sterile packing and a bordered bandage. Staff interviews confirmed that hand hygiene was expected between dirty and clean procedures during wound care, and the infection preventionist stated she had not provided education to outside agencies on hand hygiene or PPE use.
Failure to Monitor Ongoing Antibiotic Use
Penalty
Summary
The facility failed to establish an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one resident reviewed for antibiotic stewardship. Resident #92, who had Alzheimer disease, severe cognitive impairment, dependence in ADLs, and diagnoses including osteomyelitis and infection involving internal orthopedic hardware, was receiving doxycycline 100 mg daily as suppressive therapy for infected hardware in the left ankle. The physician order for doxycycline had been in place since 6/15/23, and a nurse practitioner note and medical director note from January 2025 documented that the resident remained on suppressive antibiotics and was tolerating the medication well. Record review did not show any further documentation supporting the continued use of doxycycline or ongoing monitoring of the antibiotic regimen. The EMR did not reveal additional justification or monitoring, and medication regimen reviews dated 7/30/25 and 2/26/26 did not show that doxycycline was reviewed. The infection preventionist stated she had not followed up on the resident’s antibiotic use since the original order was placed in 2023, and the DON stated the facility had not looked at the resident’s antibiotic regimen regularly to determine whether the medication remained appropriate.
Failure to Maintain Resident Dignity in Use of Behavior Contract
Penalty
Summary
The facility failed to ensure that care was provided in a manner that maintained or enhanced the dignity of a resident, specifically by using a behavior contract in a way that was perceived as a threat. The resident in question, who was cognitively intact but dependent on staff for several activities of daily living due to a history of stroke with left-sided paralysis and aphasia, expressed concern about being removed from the facility. During interviews, the resident repeatedly asked if he was in trouble and referenced a fear of being discharged, indicating anxiety related to the behavior contract and its implications. Review of the resident's care plan and behavior contract revealed that the contract, initially set with a specific goal date, remained in place beyond that date without updates. Documentation showed that after an incident where the resident expressed frustration over waiting for assistance, staff reminded him of the behavior contract and stated that another aggressive episode could result in consideration of transfer to another facility. This interaction contributed to the resident's ongoing concern about his status and potential discharge. Staff interviews confirmed that the resident was the only one in the facility with a behavior contract and that there was a lack of clarity regarding the contract's current status and purpose. The social services director and MDS coordinator were unaware of the resident's uncertainty about the contract and the previous communication that linked contract violations to possible discharge. The behavior contract was not updated as intended, and the resident was not adequately informed about his standing, leading to a failure to support his right to a dignified existence and self-determination.
Failure to Protect Resident from Verbal Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident during a card game. One resident became agitated, hit the table, made a fist toward another resident, and yelled profanities and accusatory statements. Staff were unable to immediately redirect the agitated resident, resulting in the other resident feeling fearful and tearful, especially due to a personal history of abuse. The incident was witnessed by staff and substantiated by the facility's investigation. The resident who was the victim of the verbal abuse was cognitively intact and had no prior behavioral issues. She reported feeling afraid of the other resident's outbursts and requested counseling services, but there was no documentation that counseling was provided or that she was notified of any appointments. Her care plan did not include any focus on behavior, mood, or trauma, despite her expressed fears and the incident that occurred. The resident who exhibited the aggressive behavior had a documented history of verbal outbursts toward staff and other residents, including previous incidents of yelling and using profanity. Although there was a behavior contract in place and interventions such as counseling were offered, the care plan was not updated to reflect new orders for psychotropic medication or to include ongoing assessment and monitoring of behaviors. Staff interviews revealed gaps in care planning and documentation, as well as inconsistencies in communication regarding behavioral interventions and counseling services.
Failure to Update POA Contact Information in Resident Record
Penalty
Summary
The facility failed to periodically update and maintain accurate contact information for a resident's power of attorney (POA). Specifically, after a change in POA from the resident's daughter to her son, the facility did not obtain or enter the new POA's phone number into the electronic medical record (EMR). Staff interviews confirmed that neither the social service director (SSD) nor the registered nurse (RN) could locate the POA's contact information in the EMR. The SSD, who had recently started working at the facility, stated she would have to use outdated contact information for the former POA in the event of an emergency. The RN also indicated she would have attempted to contact other family members due to the missing information. The deficiency was further substantiated by the nursing home administrator (NHA) and the director of nursing (DON), who both confirmed the absence of the POA's phone number in the EMR. The NHA recalled that the omission likely occurred when the new POA paperwork was processed, and the staff member responsible for medical records was unable to locate the updated contact information. The MDS coordinator emphasized the importance of having current POA contact details for emergency situations and noted that the oversight may have been due to the SSD's recent hire and unfamiliarity with her responsibilities regarding updating resident records.
Failure to Promptly Address and Resolve Resident Grievance Regarding Personal Care
Penalty
Summary
The facility failed to ensure that a resident's grievance regarding personal care was addressed in a timely and effective manner, as required by its own grievance policy. The resident, who had severe cognitive impairment, was dependent on staff for all activities of daily living and required specialized equipment for mobility and transfers. Her representative repeatedly requested that the resident receive regular haircuts, as had been her routine, but these requests were not acted upon for several months after the facility's beautician position became vacant. Documentation shows that the resident's representative brought up the need for a haircut during care conferences and in conversations with various staff members. Despite these repeated requests, there was no documentation that the resident was placed on a consistent haircut schedule until several months later. The representative eventually submitted a formal grievance after four months of unsuccessful attempts to resolve the issue informally. Staff interviews confirmed that concerns raised during care conferences were not escalated through the formal grievance process unless specifically requested by the resident or representative, and that the staff member responsible for social services was still learning the grievance process at the time. The facility's own policies required prompt investigation and resolution of grievances, with findings to be communicated both verbally and in writing to the complainant. However, the grievance process was not initiated until a formal grievance card was submitted, despite earlier verbal and written requests. The administrator and staff acknowledged that concerns raised in care conferences should have been addressed through the grievance process, and that communication with the resident's representative regarding the status of the request was lacking.
Failure to Provide Timely Dental Services and Assess Oral Health
Penalty
Summary
The facility failed to ensure timely dental services for two out of three sampled residents, resulting in deficiencies related to both the identification and referral for dental care. In the first case, a resident with moderate cognitive impairment and multiple physical diagnoses lost her left upper canine tooth while eating. Although she reported the incident to staff and her daughter, there was no documentation in her electronic medical record regarding the missing tooth, despite staff assisting her with oral care. Staff interviews revealed that none of the CNAs or nurses were aware of the missing tooth until the time of the survey, and no assessment or referral for dental services was made at the time of the incident. In the second case, another resident with severe cognitive impairment and total dependence on staff for activities of daily living, including oral care, was found by her representative to have a broken tooth. The representative reported the issue to the facility, which led to the resident being placed on antibiotics and eventually having the tooth extracted. However, prior to this, the resident had not been offered routine dental care or seen by the dental hygienist during scheduled visits. Documentation inconsistencies were noted, with the care plan indicating poor dental condition but no evidence of routine dental assessments or offers for dental services. Staff interviews and record reviews indicated a lack of consistent processes for tracking and offering dental services, with reliance on resident or representative requests rather than proactive scheduling. The facility's own policy required emergency dental care to be available and for staff to notify the dental consultant in cases of acute dental issues, but this was not followed in either case. The deficiencies were further compounded by staff turnover and inadequate communication regarding changes in residents' oral health conditions.
Failure to Ensure Safe and Appropriate Resident Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident care planning and transition.
Failure to Document and Notify for Facility-Initiated Discharge
Penalty
Summary
The facility failed to revise and implement an effective discharge plan for a resident who was discharged to the hospital and then not allowed to return to the facility. The resident had diagnoses including non-traumatic acute subdural hemorrhage, reduced mobility, mild cognitive impairment, repeated falls, need for assistance with personal care, lack of coordination, and generalized muscle weakness. The resident’s MDS assessment identified him as cognitively intact with a BIMS score of 15 out of 15, and he required partial to moderate physical assistance for transfers, bed mobility, and walking, and used a motorized wheelchair. Record review showed the discharge care plan identified the resident as a long-term care resident with no intent to discharge, and the progress notes did not document why he went to the hospital or that he had been formally discharged from the facility. An incident report documented that he eloped through a door, fell, and became violent when staff attempted to stop him. Staff contacted his physician and requested an order to send him to the hospital. The hospital record documented that EMS brought him to the ED for a possible fall and that he was somewhat combative, but the ED note stated there did not appear to be evidence of an acute emergency condition requiring hospitalization. The hospital also documented that it attempted to transfer him back to the facility, but the facility declined to accept him because of his combativeness. The facility’s involuntary discharge notice stated that the resident would be discharged to the hospital and that the facility was pursuing immediate discharge because of safety and wellness concerns and because it could no longer provide the level of care required due to unsafe physical and verbal aggression. However, the resident’s EMR did not show documentation that the resident or his representative was notified in writing of the discharge with the reason for the move, the effective date, the discharge location, appeal rights, and the ombudsman’s contact information. The EMR also did not show that the ombudsman was notified in writing in a timely manner. Interviews with the resident’s representative and a frequent facility visitor indicated the representative was not told why the resident was sent out, was not told he would not be allowed to return, and did not receive discharge notice or appeal information from the facility at the time of the discharge.
Delay in Providing Medical Records to Resident Representative
Penalty
Summary
The facility failed to provide a resident's medical records to the resident's legal representative in a timely manner after a written request was made. According to the facility's policy, residents or their representatives may request access to records, but the policy did not specify the required timeframe for fulfilling such requests. In this case, the representative requested the records after the resident's death, and the records were not provided until 12 weekdays later. The delay was attributed to the facility's process of sending records to their attorney for approval, which was further prolonged due to difficulty contacting the attorney. Interviews with facility staff revealed a lack of awareness regarding the regulatory timeframe for providing medical records. The Medical Records Director was unaware that records needed to be provided within 24 hours, and the Nursing Home Administrator believed the timeframe was 72 hours. The facility's policy was also found to be incomplete, as it did not specify the number of hours within which records must be provided. This lack of clarity and knowledge among staff contributed to the delay in fulfilling the representative's request.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving inappropriate sexual behavior and physical aggression. Resident #2, who had a history of sexually inappropriate behavior, was involved in several incidents of sexual abuse against Residents #1 and #8. Despite being placed on 15-minute checks and line-of-sight supervision, Resident #2 was able to engage in inappropriate touching of these residents. The facility's investigation revealed that staff did not consistently monitor Resident #2's behavior, and there was a lack of documentation regarding the incidents and the residents' emotional responses. Resident #1, who had severe cognitive impairments, was a victim of sexual abuse by Resident #2 on multiple occasions. The facility's records indicated that Resident #1 had a history of wandering, yet staff failed to follow care plan interventions to monitor her wandering and provide meaningful activities. Observations during the survey showed that Resident #1 wandered without direct staff supervision, placing her in vulnerable situations. Additionally, there was no documentation of efforts to assess her emotional state following the incidents of abuse. Resident #5, who had a history of aggressive behavior, physically assaulted Resident #6. The facility's investigation revealed that Resident #5 had been aggressive towards staff and other residents since admission, yet there was no effective intervention to manage his behavior. The facility did not receive a pre-admission referral for Resident #5 until after his acceptance, and staff were not adequately informed of his behavioral issues. This lack of communication and preparation contributed to the incident of physical abuse, highlighting the facility's failure to protect residents from harm.
Multiple Deficiencies in Kitchen Sanitation and Resident Hand Hygiene
Penalty
Summary
The facility failed to ensure appropriate hand washing and glove usage in the main kitchen. During observations, dietary aides were seen wiping their noses, scratching their bodies, and handling meal tickets without changing gloves or washing their hands. This was in direct violation of both the facility's policy and professional standards, which require hand hygiene and glove changes after any activity that contaminates the hands. The executive director and registered dietitian acknowledged these lapses and noted that the dietary staff were new and still learning their duties. The facility also failed to ensure that the cook wore a beard net while serving food. During observations, a dietary aide was seen preparing meals without a beard net, which was only corrected after the executive director intervened. The dietary aide admitted to not being accustomed to wearing a beard net as he usually served meals in the dining room and did not work as the cook. This was a clear violation of the facility's policy and professional standards, which mandate the use of hair restraints to prevent potential contamination. Additionally, the facility did not reheat food appropriately. Observations showed that dietary aides microwaved and served food without taking its temperature to ensure it reached the required 135 degrees Fahrenheit. This was acknowledged by the executive director, who stated that all food items' temperatures needed to be checked before serving. Furthermore, the facility failed to offer hand hygiene to residents during meal times. Multiple residents were observed eating without being offered hand hygiene, despite the presence of hand sanitizers and wipes on the tables. Interviews with residents and staff confirmed that hand hygiene was not consistently offered before meals, which was against the facility's policy.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the self-administration of medications was clinically appropriate for two residents, leading to medication errors. Specifically, the facility did not implement an interdisciplinary team (IDT) approach to assess if the residents were clinically safe and appropriate for self-administration of medications. This deficiency was observed in two residents, one with dementia and blindness and another with end-stage renal disease and congestive heart failure, who were found self-administering medications without proper assessment or documentation in their care plans. Resident #7, who had diagnoses including unspecified dementia, blindness, and anxiety disorder, was observed self-administering eye drops and nasal spray without staff supervision. The resident's care plan did not document that she was deemed appropriate or safe to self-administer her medications. Interviews with the resident and her family revealed that she had difficulty finding her medications due to her visual impairment, and staff were aware but did not take appropriate actions to secure the medications. Resident #46, with diagnoses including end-stage renal disease and congestive heart failure, was observed self-administering medications without staff present. The resident's care plan did not include an order for self-administration, and the medication administration record (MAR) inaccurately documented that a nurse had administered the medications. Interviews with staff confirmed that the resident was not assessed for self-administration, and medications were left at the bedside without proper supervision.
Failure to Ensure Proper Respiratory Care for Residents
Penalty
Summary
The facility failed to ensure proper respiratory care for three residents who required supplemental oxygen. Resident #55 was observed using an oxygen concentrator set at 5 liters per minute (lpm), despite having a physician's order for 2 lpm. The resident had been adjusting her own oxygen settings, which was not documented in her care plan. The staff did not notify the physician of the increased oxygen need, and the resident's oxygen settings were not properly monitored or adjusted according to the physician's orders. Resident #37 was observed using a nasal cannula attached to a portable oxygen canister with a flow rate of 3 lpm, but there was no physician's order for oxygen use in her medical record. The resident's care plan indicated she was on oxygen PRN (as needed), but the facility failed to document and monitor her oxygen use appropriately. The resident's oxygen saturation levels were not consistently recorded, and there was no documentation to support the need for continuous oxygen therapy. Resident #77 was observed using an oxygen concentrator set at 3 lpm, although the physician's order did not specify the flow rate. The resident's care plan directed staff to titrate oxygen to maintain saturation levels above 90%, but the facility did not ensure the physician was notified to adjust the oxygen order. The resident's oxygen settings were not consistently monitored, and the staff failed to verify the correct oxygen flow rate as per the physician's order.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure all drugs and biologicals were properly labeled and stored in accordance with professional standards. Specifically, medications and biologicals were not stored in secure locations, were not appropriately labeled with resident names and dates they were opened, and some medications were found to be expired. Observations included a clear plastic bag containing four different pills found on the floor of the conference room, an opened bottle of guaifenesin that expired in March 2024 in medication storage cart F, and several expired over-the-counter medications in medication storage room [ROOM NUMBER]. Additionally, medication storage cart B contained incorrectly labeled medications, including a Fluticasone inhaler, an albuterol inhaler, a Trelegy Ellipta inhaler, and a Flovent diskus with a handwritten date indicating it was opened 11 months ago. Interviews with staff revealed that the facility's policies were not being followed. The NHA and DON acknowledged that medications should be locked and secured at all times, except during administration. The DON mentioned that the facility used to employ a pharmacist to check medication carts, but the position was not replaced, leaving the responsibility to the nurses. The nurses were supposed to check medication carts for expired medications twice weekly, but this task was not being adequately performed. The NHA and DON were unable to identify the owner of the bag of medications found in the conference room, and the NHA admitted that medications should not be stored in a plastic bag on the floor of the conference room.
Failure to Provide Mechanically Altered Diets as Ordered
Penalty
Summary
The facility failed to ensure that nine out of 13 residents with an order for an altered mechanical soft texture received food and fluids prepared in a form designed to meet their needs per physician orders. Observations revealed that residents were served food items that did not comply with the mechanical soft diet requirements. For instance, Resident #3 was served a dry and crumbly slice of frosted cake, and Resident #1 was served shrimp, spaghetti noodles, tater tots, and a piece of frosted spice cake, none of which were altered to mechanical soft texture. Additionally, Resident #22 was served an egg salad sandwich on a croissant with raw lettuce and tomato, which did not meet the mechanical soft diet criteria. The report also highlighted that the dietary staff lacked proper training and understanding of the mechanical soft diet requirements. Dietary aides and certified nurse aides were unsure about the correct texture modifications needed for the residents' meals. For example, DA #3 was unsure if spaghetti noodles needed to be cut up or could go out whole, and CNA #2 was unsure if residents on a mechanical soft diet could have bread. This lack of knowledge and training led to the incorrect preparation and serving of meals, putting residents at risk. Interviews with staff, including the speech therapist, registered dietitian, and executive director, revealed that the facility was following the National Dysphagia Diet but planned to switch to the International Dysphagia Diet Standardization Initiative. The speech therapist mentioned that the facility had residents on pureed, level three dysphagia advanced (mechanical soft), and regular diet textures. However, the dietary staff had not received adequate training on these diet textures, leading to inconsistencies in meal preparation and serving. The facility's policy on therapeutic diets emphasized the importance of following physician orders and ensuring that diet orders matched the terminology used by the food and nutrition services department, but this was not consistently implemented.
Deficiencies in Resident Privacy and Call Light Response
Penalty
Summary
The facility failed to ensure care for residents in a manner that maintains or enhances each resident's dignity and respect. Specifically, Resident #186 was observed sleeping in a shirt and briefs with her door wide open and her shirt raised, exposing her stomach. This occurred on multiple occasions, and staff and residents could see her sleeping partially exposed. The resident's baseline care plan did not document her preference for sleeping attire or interventions to ensure her privacy was respected. Interviews with staff, including the DON and NHA, confirmed that privacy measures such as closing the door or pulling the privacy curtain should have been implemented to protect the resident's dignity. Resident #193 experienced delays in call light responses, leading to an incontinent episode. The resident reported that call lights took longer to answer during the night shift, with some instances taking up to 45 minutes. Call light logs confirmed multiple instances of delayed responses, with one instance taking over three hours. Interviews with the staffing coordinator and other staff members revealed issues with time management, staff familiarity with residents' needs, and staff not staying for their entire shifts. The SC acknowledged that time management was a significant issue and that no recent training had been conducted to address it. The facility's policies on confidentiality, personal privacy, and dignity were not adequately followed, resulting in residents' rights being compromised. Staff interviews indicated a lack of consistent implementation of privacy measures and timely response to call lights. The facility's failure to provide adequate privacy for Resident #186 and timely assistance for Resident #193 highlights deficiencies in maintaining residents' dignity and respect.
Failure to Involve Resident and MDPOA in Care Conferences
Penalty
Summary
The facility failed to ensure the right of a resident to participate in the development and implementation of their person-centered plan of care. Specifically, the facility did not notify or involve Resident #44 and/or the appointed Medical Durable Power of Attorney (MDPOA) in care conference discussions. Resident #44, who had moderate cognitive impairment and multiple diagnoses including diabetes, dementia, and cerebral infarction, was not invited to care conferences held on 11/3/23 and 2/2/24. Additionally, there was no documentation indicating that the MDPOA or the resident's alternate MDPOA were invited or attended these meetings. Interviews revealed that the alternate MDPOA was unaware of the care conferences and expressed a desire to be notified to participate. The Social Services Director (SSD) and the Nursing Home Administrator (NHA) both acknowledged that the MDPOA should have been involved in the care conferences. The SSD confirmed that while future care conference involvement was discussed with the MDPOA, this did not apply to the past conferences. The NHA agreed that the MDPOA should have been involved in the care conferences on the specified dates.
Failure to Provide Consistent Bathing Assistance
Penalty
Summary
The facility failed to ensure that two residents, who were dependent on staff for bathing assistance, received showers consistently with their plan of care. Resident #6, who had multiple sclerosis and required total assistance for bathing, reported that she often did not receive her preferred two baths per week due to staff unavailability. The comprehensive care plan for Resident #6 documented a preference for two baths per week, but records showed that she received only 12 baths over an eight-week period, missing several opportunities for bathing. Staff interviews confirmed that Resident #6 required total assistance from up to two staff members for bathing, and the Director of Nursing (DON) acknowledged that not enough baths were offered to Resident #6. Similarly, Resident #52, who had diagnoses including diabetes, dementia, and stroke, required substantial assistance with bathing. The care plan for Resident #52 failed to document her bathing assistance needs or preferences. Records indicated that Resident #52 received only 12 baths out of 16 opportunities over a nine-week period, with no documentation of re-offering baths after refusals. Staff interviews revealed that Resident #52 required extensive one-person assistance for bathing, and the DON admitted that not enough baths were offered to Resident #52. The DON also noted that the facility had sufficient staff to complete all baths and emphasized the need for better communication and teamwork among nursing staff to ensure all baths were completed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than five percent, resulting in a medication error rate of 16.00%. Specifically, there were four errors out of 25 opportunities for error. One incident involved an LPN administering insulin to a resident after the resident had already eaten, contrary to the physician's order that specified the insulin should be given before meals. The LPN acknowledged the mistake, stating that medications ordered before meals should not be given after meals and that physician's orders should always be followed. Another incident involved an RN who failed to administer a resident's scheduled 8:00 a.m. medications within the prescribed one-hour window. The medications included a lidocaine patch, Miralax powder, and eye drops, all of which were documented as not given on time according to the medication administration record. The RN admitted that medications should be administered within one hour of their prescribed time and that medication orders should always be followed. The DON confirmed that physician's orders should always be followed and that medications should be given within one hour of their prescribed time unless otherwise specified.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for two residents. Resident #46, who had diagnoses including end-stage renal disease and congestive heart failure, was observed self-administering medications without a physician's order or documentation in the care plan. The resident was supposed to receive midodrine three times a day, but the medication administration record did not confirm the exact time the medication was taken, and the LPN responsible did not witness the administration. This led to uncertainty about whether the doses were spaced appropriately, as required by the manufacturer's guidelines to prevent supine hypertension. Resident #193, diagnosed with type two diabetes mellitus and other conditions, did not receive her insulin according to the physician's order. The resident was supposed to receive 10 units of basal insulin before meals, but it was administered after she had already eaten. The LPN responsible acknowledged the error and confirmed that medications ordered before meals should not be given after meals. This failure to follow the physician's order was confirmed through interviews with the LPN and the DON, who reiterated the importance of adhering to medication administration times. Both incidents highlight a failure in the facility's medication administration process, where staff did not follow physician orders and facility policies. The deficiencies were identified through observations, record reviews, and staff interviews, revealing gaps in ensuring residents received their medications correctly and safely. The facility's policies on administering medications and self-administration were not adhered to, leading to significant medication errors for the residents involved.
Failure to Provide Timely Dental Services and Adequate Oral Care
Penalty
Summary
The facility failed to provide timely and adequate dental services for a resident, leading to significant discomfort and potential health risks. The resident, who had a history of swallowing difficulties, lost her bottom dentures in December 2023. Despite informing staff, the dentures were not replaced promptly, resulting in the resident developing mouth sores and experiencing pain while eating. The resident's dietary needs were not adequately addressed, and she struggled to chew and swallow food properly without her dentures. The facility's records and staff interviews revealed a lack of proper communication and follow-up regarding the resident's dental needs. The resident's care plans and medical records did not reflect the loss of the dentures, and there was no documentation indicating that the facility had reviewed the oral hygienist's note from January 2024, which mentioned the missing dentures. The resident's dietary profile and nutritional assessments inaccurately stated that she had her lower dentures, leading to inadequate dietary adjustments. Interviews with staff members, including CNAs, the SSD, and the RD, highlighted a breakdown in communication and responsibility. The SSD was unaware of the missing dentures and the denial of Medicaid coverage for replacements until the survey. CNAs did not report the missing dentures or the resident's mouth pain, and the RD was not informed of the resident's difficulties with chewing and swallowing. The facility's failure to ensure proper communication and timely response to the resident's dental needs resulted in prolonged discomfort and potential health risks for the resident.
Failure to Provide Timely Medicare Coverage Termination Notice
Penalty
Summary
The facility failed to inform a resident of changes in their services covered by Medicare Part A in a timely manner. Specifically, the facility did not provide a Notice of Medicare Provider Non-Coverage (NOMNC) to the resident two days prior to the discharge of Medicare Part A funded services. Instead, the NOMNC was given on the same day the benefits ended, which did not allow the resident the required 48-hour notification timeframe to appeal the decision. Additionally, the facility did not provide the Skilled Nursing Facility-Advance Beneficiary Notice (SNF ABN) when the resident continued to reside in the facility after the discharge from Medicare Part A services. The facility's policy required that the NOMNC be delivered at least two calendar days before the end of Medicare coverage services. However, the resident's medical record showed that the NOMNC was provided on the same day the Medicare Part A benefits ended. Interviews with the nursing home administrator and admissions coordinator revealed that the admissions coordinator was new to her position and was still training her assistant on the beneficiary notice process. The delay in providing the NOMNC was due to the assistant waiting for information regarding the resident's continued need for skilled nursing services. The admissions coordinator acknowledged the oversight and indicated that further training and oversight would be provided to ensure compliance with the notification requirements.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 17 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grand Junction
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Red Cliffs Post Acute | 0.1 mi | ★★★★★ | 1 | 0 |
| La Villa Grande Care Center | 0.6 mi | ★★★★★ | 1 | 1 |
| Mantey Heights Rehabilitation & Care Center | 1.1 mi | ★★★★★ | 2 | 0 |
| Eagle Ridge Post Acute | 1.3 mi | ★★★★★ | 4 | 1 |
| Center At Foresight Llc, The | 2.1 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.