Larchwood Health and Rehab LLC

In the surveyor’s words

From the most serious findings on record at Larchwood Health and Rehab LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Aug 24, 2026

  Based on record review and interviews, the facility failed to prevent a significant medication error for one (#1) of three residents out of seven sample residents.Resident #1 was admitted to the facility on [DATE] with a history of cerebral infarctions due to an embolism (stroke) and a prosthetic mechanical heart valve.On 7/8/26 the facility entered the following physician's orders from Resident #1's admission orders:Coumadin (a blood thinning medication) 3 milligram (mg) tablets, give 9 mg every day for five days. Recheck the international normalized ratio (INR - a test to measure if the blood thinner is within the therapeutic level to prevent blood clotting) on day five and obtain new physician's orders for Coumadin, scheduled to start on 7/9/26 and end on 7/13/26. […]

• Actual harm, isolatedF689Jan 3, 2024

  Based on observations, record review and interviews, the facility failed to ensure one (#1) of three residents remained free from accident hazards out of 16 sample residents. The facility failed to ensure a safe environment and prevent major injury for a resident at risk for elopement and falls. Resident #1 was let out of the facility doors by a facility visitor on 11/17/23. The resident was wearing a wander guard device but the device was not functioning properly and the wander guard system door panel did not sound an alarm to alert staff the resident was exiting the facility. The resident rolled out in the parking lot with her wheelchair and hit a parking lot bumper. Resident #1's wheelchair tipped over and the resident landed on the parking lot asphalt. […]

• Actual harm, isolatedF600Dec 22, 2022

  Based on observation, record review and interviews, the facility failed to ensure that all residents were free from abuse, neglect, and exploitation, for two residents (#14 and #420) in two allegations of abuse of five allegations reviewed out of 26 sample residents. Specifically, the facility failed to provide adequate supervision and effective interventions to prevent repeated incidents of resident-to-resident verbal altercations between Residents #14 and #420. Resident #420 and Resident #14 were roommates at one point in time while living in the same facility. As time went by the two stopped getting along, and Resident #14 moved to a new room on the opposite side of the facility. Still Resident #420 continued to target Resident #14 when he saw him in common areas. […]

• Actual harm, isolatedF686Dec 22, 2022

  Based on record review, observations, and interviews, the facility failed to ensure two (#60 and #47) of four residents reviewed for pressure injuries received care and services, consistent with professional standards of practice, to prevent development and promote healing of pressure injuries, out of 26 sample residents. Resident #60, who was at risk for wound development due to immobility, admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke), hemiplegia/hemiparesis (paralysis), enteral feeding, dysphagia and excoriation to her coccyx/sacrum. Resident #60 developed and redeveloped wounds to her sacral area (see record review below). On 11/16/22 Resident #60 developed a stage 3 wound to her coccyx/sacrum. […]

• Actual harm, isolatedF684Sep 13, 2022

  Based on record review and interviews, the facility failed to ensure residents received treatment and care which met professional standards of practice, was consistent with comprehensive assessments, and comprehensive care plans for one (#1) out of three sample residents. Specifically, the facility failed to prevent a fall off of the toilet in the bathroom with injury for Resident #1 on 7/10/22 at 11:10 p.m. The resident was left on the toilet by herself where she fell forward and struck her head on the ground resulting in a contusion on the left side of her forehead. Upon assessment, the resident's injuries consisted of a contusion on her left forehead, a skin tear to her left wrist and a skin tear to her right elbow. […]