Larsen Health Center

In the surveyor’s words

From the most serious findings on record at Larsen Health Center, in the surveyor’s own words.

• Actual harm, patternF689Dec 11, 2024

  Based on record review, and interview, the facility failed to ensure staff followed the individualized care plan to ensure the safe transfer of 3 (Residents #1, #2 and #3) of 3 residents reviewed, resulting in residents injury and transfer to a higher level of care. The findings included: The Facility Policy titled Transfer of Resident using support devices, revision date 11/17 indicated Under Procedure: The Therapy Department will screen residents and determine a level of assistance needed for transfers and movement. This determination will be incorporated into the plan of care for the resident and communicated to the staff by means of the care plan. Under bullet 2 (d) Total Assistance - resident is non-weight bearing and requires mechanical devices for lifting. […]

• Actual harm, patternF867Dec 11, 2024

  Based on record review, and interview, the facility, after identifying an adverse incident, failed to initiate actions aimed at performance improvement, implement action, measure success and track performance to ensure that improvements are realized and sustained for 1 (Resident #4) of 1 resident identified with a medication error and 3 (Residents #1,# 2 and #3) of 3 residents reviewed for improper transfer. The findings included: 1. On 8/9/24, the facility reported to the Agency for Healthcare Administration (Agency) an incident in which a Staff D Registered Nurse (RN) had falsified Resident #4's medical administration record (MAR) signing off that a controlled substance was given on 8/8/24 at 9 a.m. and 12 p.m. and controlled drug sign out sheet, when it had not been given. […]

• Actual harm, isolatedF600Jan 16, 2025

  Based on record review, review of facility's policies and procedures, and staff interviews, the facility failed to protect residents' rights to be free from abuse by failing to honor the residents' right to refuse care for 1 (Resident #999) of 3 sampled residents when the resident displayed agitated and aggressive behaviors during care. The findings included: The facility policy Abuse Policy and Procedure Manual with a review date of 3/24/23 noted, Each person served has the right to be free from abuse and mistreatment . Some examples, rough handling a resident. Prevention. […]

• Actual harm, isolatedF689Mar 16, 2023

  Based on observation, review of facility policy and procedures, record review and staff interviews, the facility failed to provide adequate supervision and implement necessary interventions to prevent avoidable accidents for 1 (Resident #143) of 4 residents reviewed who were identified as being at risk for falls and sustained multiple falls at the facility, and a fracture requiring a transfer to a higher level of care. The findings included: The facility policy Fall Management Program origination 3/8/17 (revised 11/22) documented, The Falls Management Program is an interdisciplinary quality improvement program that provides resident fall processes and outcomes. […]

• No harm, potential for more than minimal, widespreadF812Sep 21, 2022

  Based on record review, observations, and interviews, the facility failed to ensure food was served in a sanitary manner by not taking the temperatures of food prior to serving and by wet nesting pots on the self with clean pots. The findings included: Review of the documented Trayline Taste & Temperature Log from 9/1/22 to 9/21/22 showed: The food temperature was not documented for breakfast on 9/1/22, 9/2/22, 9/3/22, 9/4/22, 9/5/22, 9/6/22, 9/7/22, 9/8/22, 9/11/22, 9/14/22, 9/15/22, 9/16/22 and 9/21/22. The food temperature was not documented for lunch on 9/6/22, 9/8/22, 9/11/22, 9/15/22, and 9/16/22. The food temperature was not documented for the supper meal on 9/3/22, 9/5/22, 9/6/22, 9/7/22, 9/11/22, 9/12/22, 9/15/22, and 9/16/22. […]