Larchwood Care

In the surveyor’s words

From the most serious findings on record at Larchwood Care, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 8, 2025

  Based on observation, record review, interview, and facility policy review, the facility failed to provide adequate staff assistance to prevent a fall with injury. Actual Harm occurred on 07/26/25 at 10:20 A.M. when Resident #7, who was dependent on staff for bed mobility, transfers, and toileting, fell during incontinence care when assisted by only one Certified Nursing Assistant (CNA), resulting in an intracerebral contusion (closed head injury) and a dislodged jejunostomy tube (feeding tube). Resident #7 was transferred to the hospital and admitted for additional care and monitoring before returning to the facility on [DATE]. This affected one resident (#7) of three residents reviewed for accidents. The facility census was 67. […]

• No harm, potential for more than minimal, isolatedF684May 12, 2026

  Based on interviews, record reviews, and review of video recordings, the facility failed to monitor for changes in condition by not engaging with Resident #70 during care provided to ensure timely treatment related to a change in the resident's condition. This affected one resident (Resident #70) out of three residents reviewed for change in condition. The facility census was 59.Findings include: Review of the closed medical record for Resident #70 revealed an admission date of [DATE] and a discharge date of [DATE]. […]

• No harm, potential for more than minimal, isolatedF686May 12, 2026

  Based on interviews. record review, and facility policy, the facility failed to ensure proper wound care assessments, treatment and skin monitoring was in place for Resident #70. This affected one resident (#70) of three reviewed for skin impairments. The facility census was 59.Findings include:Review of the closed medical record for Resident #70 revealed an admission date of 12/19/25 and a discharge date of 04/25/26. Resident #70's diagnoses included but were not limited to cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, respiratory failure, type 2 diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis, nontraumatic subarachnoid and intracerebral hemorrhage, cognitive communication deficit, tracheostomy, gastrostomy, and obstructive… […]

• No harm, potential for more than minimal, isolatedF558Sep 8, 2025

  Based on observations, medical record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure a resident's request for assistance was responded to in a timely manner. This affected one resident (#5) of one reviewed for timely care and assistance. The facility census was 67.Findings include: Review of the medical record for Resident #5 revealed she was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and attention to tracheostomy (a surgically-created artificial airway).Review of the care plan dated 06/27/25 revealed Resident #5 had an ADL self-care performance deficit related disease process and generalized weakness with interventions… […]

• No harm, potential for more than minimal, isolatedF604Sep 8, 2025

  Based on resident record review, staff interview, facility Self-Reported Incident (SRI) review, and facility policy review, the facility failed to ensure Resident #67 was not inappropriately restrained during resident care tasks. This affected one resident (#67) of one reviewed for physical restraints. The facility census was 67.Findings include: Review of the medical record for Resident #67 revealed he was admitted to the facility on [DATE] with diagnoses that included diffuse traumatic brain injury with loss of consciousness, carrier of carbapenem-resistant Acinetobacter baumannii (a multi-drug resistant organism), and chronic respiratory failure with hypoxia. Review of the care plan initiated 09/17/24 revealed Resident #67's daughter was his guardian. […]