Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Larchwood Care during CMS and state inspections, most recent first.
A CNA provided care to a resident with severe cognitive and physical impairments while the resident showed abnormal breathing and then stopped visibly moving, but the CNA did not attempt to arouse or communicate with the resident during the care. Video showed the resident becoming unresponsive before staff returned much later; when an RN assessed the resident, she had no pulse or respirations and CPR was started, but EMS later pronounced the resident deceased. Interviews with family and staff confirmed the breathing pattern in the video was not normal.
A resident with severe cognitive impairment, total ADL dependence, and bladder and bowel incontinence had a coccyx pressure injury that was not accurately identified on the admission skin assessment. The care plan was incomplete, wound tx was not ordered until several days after admission, and weekly skin observations were not completed timely and consistently. The wound note later documented a stage 2 pressure injury with drainage, and the MDS RN and Wound LPN/ADON confirmed the assessment and care plan deficiencies.
Failure to Provide Two-Person Assistance During Incontinence Care: A resident who was dependent for bed mobility, transfers, and toileting fell while being changed by only one CNA. The resident had severe cognitive impairment, was always incontinent, and required a Hoyer lift with two staff assist per the care plan. The fall caused a head laceration, a dislodged J-tube, and a hemorrhagic contusion, and hospital records showed the resident required neurosurgical monitoring.
A resident with significant respiratory and mobility needs was left waiting for an extended period after activating her call light for assistance with dressing and hydration. Despite being alert and dependent on staff for ADLs, her requests were delayed as staff prioritized other tasks and did not follow facility policy requiring all staff to respond to call lights. The DON confirmed that care should have been better coordinated to prevent such delays.
A resident with severe cognitive and physical impairments was combative during trach care and suctioning, and an RT used her knee to hold down his arm and bent his finger back when he grabbed the suction catheter. The resident’s daughter was present and objected to the restraint, offering to help instead. Witness statements and the SRI documented the event as inappropriate restraint during care, contrary to the facility’s restraint-free policy.
Failure to provide mouth care for a dependent resident. A resident with anoxic brain damage, chronic respiratory failure with hypoxia, and cerebral infarction was dependent on staff for ADLs and had a guardian. He was observed with dry, cracked, and peeling lips on multiple occasions, and the guardian reported staff had to be repeatedly reminded to keep his lips moisturized. A CNA later stated she did not know when the resident last received mouth care and confirmed the condition of his lips.
A resident with anoxic brain damage, cerebral infarction, severe cognitive impairment, and bilateral hand contractures did not have splints in place despite the guardian’s preference and a room sign directing bilateral hand splint use for several hours daily. Staff confirmed the resident was in bed without splints, the LPN and CNA said therapy handled splinting, and the TD and DON stated there were no current splint orders and staff were not following the guardian’s request.
Medications were left unattended during administration for a resident with DM, mild cognitive impairment, and major depressive disorder who was not approved to self-administer. Surveyors observed several unknown pills mixed with applesauce in a medication cup on the resident’s bedside table with no staff present. The RN said she became distracted with another resident and left the remaining medications at the bedside, despite no order for self-administration and a policy requiring observation of medication consumption.
Failure to Recognize and Respond to a Resident’s Change in Breathing During Care
Penalty
Summary
The facility failed to monitor for changes in condition by not engaging with a resident during care to ensure timely treatment after a change in the resident's condition. Resident #70 had multiple serious diagnoses, including cerebral infarction, respiratory failure, type 2 diabetes with hyperglycemia, hemiplegia and hemiparesis, nontraumatic subarachnoid and intracerebral hemorrhage, cognitive communication deficit, tracheostomy, gastrostomy, and obstructive sleep apnea. The quarterly MDS showed severely impaired cognition, dependence on staff for all ADLs, and total incontinence of bladder and bowel. The care plan included an intervention for all staff to converse with the resident while providing care. Video recordings showed CNA #262 entering the resident's room and providing care while the resident opened her mouth to take a breath and moved her eyes and head. The CNA announced turning on the light but did not attempt to arouse the resident or communicate what care was being provided. Over the next several minutes, the resident was no longer visibly moving, yet the CNA continued care without attempting to arouse her or speak to her. The CNA adjusted the head of bed and pillows and then left the room at 11:11 P.M.; there was no video evidence of staff returning until 11:53 P.M. A progress note documented that RN #196 was alerted around 11:55 P.M. that the resident was unresponsive. At that time, the resident had no pulse, no respirations, and no response to verbal or tactile stimuli; CPR was started and 911 was called. EMS arrived, found no pulse, and pronounced the resident deceased on scene. Family members reported that the resident's breathing changed during the CNA care and that she appeared to stop breathing, and multiple staff interviews confirmed the resident's breathing in the video was abnormal and that she was not moving in later recordings.
Inaccurate wound assessment and delayed treatment for coccyx pressure injury
Penalty
Summary
Proper wound care assessments, treatment, and skin monitoring were not in place for Resident #70, who had diagnoses including cerebral infarction, respiratory failure, type 2 diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis, nontraumatic subarachnoid and intracerebral hemorrhage, cognitive communication deficit, tracheostomy, gastrostomy, and obstructive sleep apnea. The hospital after-visit summary identified a pressure injury to the coccyx with treatment ordered on admission, but the facility admission nursing assessment documented the coccyx area as a skin tear measuring 3 cm by 2 cm and did not accurately identify the pressure ulcer. The care plan was incomplete and did not properly identify the resident’s pressure ulcer or location, and the physician orders did not include wound treatment until seven days after admission. The wound physician note later documented a stage 2 pressure injury to the coccyx measuring 1.0 cm by 0.5 cm by 0.1 cm with moderate serous drainage and no signs of infection. Facility weekly skin observations were not completed timely and weekly, with the first observation completed after admission and additional observations documented only on a few later dates. The MDS assessment showed the resident had severely impaired cognition, was dependent for all ADLs, and was always incontinent of bladder and bowel. The MDS RN confirmed the care plan was not comprehensive and individualized, and the Wound LPN/ADON confirmed the admission skin assessment was inaccurate, the resident was admitted with a coccyx pressure injury, and wound treatment was started seven days after admission.
Failure to Provide Two-Person Assistance During Incontinence Care
Penalty
Summary
The facility failed to provide adequate staff assistance to prevent a fall with injury when a resident who was dependent on staff for bed mobility, transfers, and toileting fell during incontinence care while being assisted by only one CNA. The resident had diagnoses including chronic respiratory failure, protein-calorie malnutrition, intracranial hemorrhage, Alzheimer's disease, and gastrostomy, and the care plan identified the resident as at risk for falls and requiring a mechanical Hoyer lift with two staff assist for transfers. The resident's MDS also showed severely impaired cognition, dependence for bed mobility, transfers, toileting hygiene, and ambulation, and that the resident was always incontinent of bowel and bladder and had a feeding tube and tracheostomy. On 07/26/25 at 10:20 A.M., CNA #963 was changing the resident without a second staff member at bedside when the resident's leg slid and the resident fell to the floor. The fall resulted in a 1 cm laceration behind the right ear, blood on the floor near the resident's head, and the resident's J-tube becoming dislodged. The resident was transported to the hospital for evaluation after staff called 911. Hospital records documented a right parietal hemorrhagic contusion, a hematoma of the left thigh, and a dislodged jejunostomy tube, with neurosurgery consulted for monitoring and non-operative management. Interview with the LPN and DON confirmed that the resident on an air mattress required two-person assistance for turning and changing, and that the CNA had transferred the resident by herself. The facility's fall investigation also stated the resident was being changed without a second staff member present when the fall occurred.
Failure to Provide Timely Response to Resident's Request for Assistance
Penalty
Summary
A deficiency occurred when a resident with acute and chronic respiratory failure, chronic obstructive pulmonary disease, and a tracheostomy was not provided timely assistance after requesting help. The resident, who was alert and oriented but dependent on staff for activities of daily living due to lower extremity impairments, was observed waiting for two hours for assistance with dressing after a bed bath. The resident's call light was activated, and she expressed distress over the long wait. Staff interviews revealed that the LPN was aware of the resident's needs but prioritized medication administration for other residents, stating the resident would have to wait until the medication pass was complete. The CNA communicated the delay to the resident but was unable to provide the required assistance herself. Further observations showed that another nurse did not respond to the resident's call light, even when in proximity, and only acknowledged the request after being prompted by a state surveyor. The facility's policy required all staff to respond to call lights, but this was not followed. The Director of Nursing confirmed that multiple staff members were available and that the resident's care should have been coordinated to prevent extended waiting times. The failure to respond promptly to the resident's request for assistance with dressing and hydration, despite clear facility policy and available staff, led to the deficiency.
Inappropriate physical restraint during respiratory care
Penalty
Summary
The facility failed to ensure Resident #67 was free from inappropriate physical restraint during tracheostomy care and suctioning. Resident #67 was admitted with diagnoses including diffuse traumatic brain injury with loss of consciousness, chronic respiratory failure with hypoxia, and severe cognitive impairment, and he was dependent on staff for ADLs. His care plan noted his daughter was his guardian and that staff should approach him calmly and ensure a safe environment. The medical record also documented repeated episodes of combativeness during respiratory care, including tracheostomy care and suctioning. On 02/27/25, during respiratory care, Resident #67 was combative and his daughter was present at the bedside. Witness statements and the facility’s SRI documented that RT #500 placed her knee on Resident #67’s arm to hold him down while providing care and bent his finger back when he grabbed the suction catheter. The daughter told RT #500 not to hold the resident down or bend his finger back and offered to assist with holding him, but RT #500 stated she had to do what she had to do and that she was not going to get hit. The SRI also recorded that RT #500 entered the room without knocking or identifying herself before providing care. The incident was reviewed by facility leadership after the daughter reported inappropriate care. The record shows the resident was assessed afterward and a bruise was noted to the back of his left hand, which was ruled out as being caused by a recent blood draw. The facility policy titled Restraint Free Environment stated that physical restraints are prohibited for discipline or convenience, including holding down a resident during care if the resident is resistive or refusing care. The report identified this event as abuse involving the use of a physical restraint during resident care tasks.
Failure to Provide Mouth Care for a Dependent Resident
Penalty
Summary
The facility failed to ensure mouth care was provided for a dependent resident. Resident #21 was admitted with diagnoses including anoxic brain damage, chronic respiratory failure with hypoxia, and cerebral infarction, and the medical record showed he had a guardian, short- and long-term memory problems, severe impairment in tasks of daily life, impaired upper and lower extremities, and dependence on staff for ADLs. His care plan noted an electronic monitoring device in his room and the need for staff assistance with ADLs, including ongoing family support and assistance with care. On observation, Resident #21 was found in bed with dry, cracked, and peeling lips, and later the same day was observed in a chair with the same condition. The guardian stated his lips were always dry and that she had to constantly tell facility staff to keep them moisturized, adding that dry, cracked, and peeling lips would hurt if it built up. A CNA later confirmed Resident #21 was assigned to another staff member and was not aware of the last time he received mouth care, and also verified the resident's dry, cracked, and peeling lips.
Failure to Follow Guardian’s Splint Preference for Resident With Hand Contractures
Penalty
Summary
The facility failed to ensure splint orders were obtained and followed per the guardian’s preference for a resident with bilateral upper extremity contractures. The resident was admitted with diagnoses including anoxic brain damage, chronic respiratory failure with hypoxia, and cerebral infarction, and the record showed he had a guardian, severe cognitive impairment, dependence on staff for ADLs, and impairment of both upper and lower extremities. The care plan noted pain potential related to contractures, and prior physician orders had included bilateral dorsiflexion assist splints and restorative services for splinting, PRAFO boots, and ROM, but those orders were later discontinued and there were no active splint orders at the time of the survey. Surveyors observed the resident lying in bed with both hands contracted and a white cloth rolled up in the palm of his left hand. A sign posted in the room stated that resting hand roll splints were to be used on both hands for 6 hours per day, with skin checks and hand hygiene before and after use, but staff confirmed the resident was in bed without splints in place. The LPN stated therapy was responsible for maintaining ROM and splinting, and the CNA stated she had never seen the splints in place despite being aware of the guardian’s request shown on the wall sign. The therapy director confirmed the wall signs were provided by the guardian, not the facility, and stated they were not followed by staff. The therapy director and DON confirmed the resident did not have a current order for splints and that staff were not putting splints on per the guardian’s request. The guardian stated the resident had contractures in both hands and that splints were supposed to be in place, and she reported that when she checked the room camera or visited, the bilateral hand splints were not in place as she preferred.
Unattended Medications During Administration
Penalty
Summary
Medications were left unattended during medication administration for one resident who was reviewed for safe storage of medications. The resident had diagnoses including diabetes, mild cognitive impairment, and major depressive disorder, and her self-medication assessment showed she did not wish to self-administer medications and was not a candidate for self-administration; there was also no physician order allowing self-administration. During observation, several unknown pills mixed with applesauce were found in a medication cup on the resident’s bedside table with no staff in the room or observing from the doorway. The resident had a tracheostomy and ventilator and could not be understood, but appeared to shake her head no when asked if she had concerns. The RN stated the resident took a long time to swallow medications and that she became distracted with another resident and left the remainder of the medications at the bedside, confirming the resident had no order to self-administer. The facility policy stated that medication administration includes observing resident consumption of medications.
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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.
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Nursing homes near Cleveland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rocky River Gardens Rehab And Nursing Ctr | 0 mi | ★★★★★ | 7 | 0 |
| Aristos Nursing And Rehabilitation | 1 mi | ★★★★★ | 33 | 0 |
| Westpark Healthcare Campus | 1.1 mi | ★★★★★ | 15 | 0 |
| O'neill Healthcare Fairview Park | 1.6 mi | ★★★★★ | 0 | 0 |
| Welsh Home The | 2.6 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.