Larchwood Inns

A complaint survey, prompted by #CO1923449 and #CO2586776 was conducted on 8/19/25 to8/21/25. Two deficiencies were cited. Based on record review and interviews, the facility failed to ensure one (#1) of three residents were provided the care and services necessary to ensure a safe discharge from the facility to the community out of seven sample residents. Specifically, the facility failed to:-Allow Resident #2 to return to the facility after an unplanned discharge to the hospital;-Provide documentation made by Resident #2’s physician, including the specific resident needs the facility could not meet, the facility’s efforts to meet those needs and the specific services the receiving facility would provide to meet the needs of the resident which could not be met at the current facility; and,-Reassess Resident #2 for readmission after he was stabilized at the hospital and ready to return to the facility.Findings include:I. Facility policy and procedureThe Transfer or Discharge, Facility-Initiated policy, revised October 2022, was provided by the assistant director of nursing (ADON) on 8/21/25 at 11:31p.m. The policy read in pertinent part, “Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. “Each resident will be permitted to remain in the facility and not be transferred or discharge.. Based on record review and interviews, the facility failed to revise and implement an effective discharge plan for one (#2) of three residents reviewed for discharge planning out of seven sample residents.Specifically, the facility failed to:-Ensure the discharge planning was process was documented, including the reason for discharge in Resident #2' s electronic medical record (EMR); -Notify Resident #2 and/or Resident #2' s representative, in writing, of the discharge, including the reason for the move, the effective date of discharge, the location where the resident was being discharged to, a statement of the resident' s appeal rights and the name, address and telephone number of the office of the state long term care ombudsman; and,-Notify the facility' s ombudsman of Resident #2' s discharge in writing in a timely manner.Findings include: I. Facility policy and procedureThe Transfer or Discharge, Facility-Initiated policy, revised October 2022, was provided by the assistant director of nursing (ADON) on 8/21/25 at 11:31p.m. The policy read in pertinent part,“Once admitted to the facility, residents have the right to remain in the facility. Facility initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. “Each resident will be permitted to remai..

A complaint survey, prompted by #CO39786 was conducted on 4/23/25 and 4/24/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure a copy of medical records were provided in a timely manner for one (#1) of three residents out of five sample residents.Specifically, the facility failed to ensure medical records were provided in a timely manner upon request for Resident #1 from his resident representative.Findings include:I. Facility policy and procedure The Release of Information policy, revised November 2009, was provided by the nursing home administrator (NHA) on 4/24/25 at 1:10 p.m. It read in pertinent part,"The resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed and dated request from the resident or representative."A resident may have access to his or her records within ____ hours (excluding weekends or holidays) of the resident' s written or oral request."-The facility did not indicate on the policy how many hours the facility had to provide the requested medical records. II. Resident representative interviewResident #1' s representative was interviewed on 4/23/25 at 3:45 p.m. via phone. She said she requested Resident #1' s medical records from the facility in February 2025 after he passed away. She said she did not receive the records for over two weeks.III. Record reviewThe request for access to health information was provided by the medical records director (MRD) on 4/24/25 at 11:30 a.m. The form was completed by Resident #1' s representative on 2/24/25 at 3:30 p.m. The form revealed the resident' s representative received the records on 3/13/25 at 11:58 a.m.-The representative did not receive the medical records for 12 weekdays after she requested them. IV. Staff interviewsThe MRD was interviewed on 4/24/25 at 10:20 a.m. The MRD said she did not know the time frame the facility had to provide the resident or the representative with the medical records after they were requested. She said Resident #1' s medical durable power of ..

A complaint survey, prompted by #CO38530, Incident #38573, Incident #39456, Incident #39457, Incident #39458 and Incident #39458 was conducted from 3/10/25 to 3/11/25. One deficiency was cited. Based on observations, record review and interviews, the facility failed to ensure three (#1, #8 and #6) of three residents were kept free from abuse out of nine sample residents. Specifically, the facility failed to:-Protect Resident #1 and Resident #8 from being sexually abused by Resident #2; and, -Protect Resident #6 from physical abuse by Resident #5. Findings include:I. Facility policy and procedureThe Abuse Prevention, Investigation and Reporting policy and procedure, revised November 2022, was provided by the nursing home administrator (NHA) on 3/11/25 at 5:14 p.m. It read in pertinent part, "To ensure to the extent possible, that every resident is free from abuse, neglect, misappropriation of resident property, and exploitation."The resident has the right to be free from abuse (including verbal, mental, sexual and physical), neglect, misappropriation of resident property and exploitation. This includes freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat a resident' s medical condition. Management will take specific steps to reduce the potential for abuse to occur at the facility including, but not limited to education, monitoring and investigating thoroughly if abuse, misappropriation, neglect, or exploitation is suspected."Sexual abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. "Physical abuse includes, but is not limited to, hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment."The admissions coordinator will do a pre-assessment on all potential admissions to see if there is a history of abusive behavior. If any potential admission has a history of abusive behavior, the admissions coordinator will notify the administrator and/or the director of nursing services. The administrator will make the final determination on whether or not to admit, upon consultation with the director of nursing services and/or other appropriate personnel."The facility will conduct assessment, care planning and monitor..

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag # K 000), are informational only and a representation of the facility' s general characteristics.The facility consists of two unattached structures, designated Building A-1 (Inns) and Building A-2 (PARC). The South structure, Building A-2, PARC building, is a type V (111) single-story structure with a c.. The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag # K 000) are informational only and represent the facility' s general characteristics.The facility consists of two unattached structures, designated Building A-1 (Inns) and Building A-2 (PARC). The North structure, Building A-1, is a type II (000) single-story structure with a complete automatic fire sup.. Through document review and observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. This was evidenced by1. Fire Sprinkler Semi-Annual: Not Provided2. Fire Sprinkler 5 Year: Not ProvidedBased on a record review, it was determined that the facility failed to maintain the fire sprinkler system components and devices in accordance with the Life Safety Code .. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by:1. Emergency Power Load bank test (Monthly)(110 8.4.1): Not Provided2. Emergency Power Generator fuel quality (annually) (110 8.3.8): Not ProvidedNFPA 110 8.4.1* EPSSs, including all appurtenant components, shall beInspected weekly and exercised under.. Through observation and document review during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101, NFPA 25, and NFPA 13. This was evidenced by:1. Fire Sprinkler Semi-Annual: Not Provided2. Fire Sprinkler 5 Year: Not Provided3. All three fire sprinkler antifreeze systems are over 250 PSI and have no overpressurization protection. There is also no overpressurization protection on.. Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:1. Salon needs door closure deemed a hazardous areaNFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing.This deficiency could affect occupants, including residents, staff, and visitors within the smoke compartment. Deficient items were discussed with the facilit.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 54. This was evidenced by:1. Gas valves on the dryer(s) not rated for more than 2000 feet elevation need high-elevation gas valvesNFPA 54 11.1.2 High Altitude.Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 80. This was evidenced by: 1. The door is dragging between the kitchen and dining room hall2. The 2nd door between the kitchen and dining hall closure is not operating properlyNFPA 101, 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, la..