Larchwood Inn: Denied Discharge Appeal Rights - CO
Larchwood Inn refused to allow Resident #2 to return from the hospital on July 31, 2025, after what administrators described as a "psychotic break" involving severe behaviors. The facility's nursing home administrator made the decision without reevaluating the resident while he was hospitalized.
"The facility felt that he had a psychotic break based on his severe behaviors on 7/31/25 and he became a different person," the administrator told state inspectors on August 20. She said the facility told the hospital they were "not prepared or equipped to deal with residents' psychotic episodes."
The administrator explained that the behavior "occurred so fast without any triggers with that type of dementia." She said the facility could not meet the resident's needs "if there was a chance his behaviors would escalate and be directed towards another resident."
Nobody told the resident's representative why he was being discharged.
A frequent facility visitor said she contacted the resident's representative after the facility refused readmission. "He was very upset because he was only told that Resident #2 went to the hospital but he was not told why or that he would not be permitted to return to the facility," she told inspectors. The representative "had to find out what happened from the hospital and not the facility."
The visitor said she repeatedly asked for the discharge notice but didn't receive it until August 1 — two days after the facility had already refused the resident's return.
Federal regulations require nursing homes to provide discharge notices and appeal rights directly to residents or their representatives. The facility failed to do either.
The assistant director of nursing said she emailed the discharge notice to the frequent facility visitor on August 1 at 1:32 p.m., but acknowledged the facility "did not provide the resident or the resident's representative with the discharge notice or the rights to appeal the discharge."
When inspectors asked about this violation, the administrator said the discharge was "emergent and the frequent facility visitor was involved, so it was assumed that the frequent facility visitor provided the representative with the notice and appeal rights."
She admitted this assumption was wrong. "It was not the responsibility or normal practice for the frequent visitor to give the notice," she told inspectors.
The frequent visitor confirmed she never provided the representative with the discharge notice or appeal rights information. She said "the facility should have provided the representative with the notice and rights."
The resident's representative came to collect belongings but said nothing about an appeal, according to the administrator. She noted he didn't request to appeal the discharge, but he had never been informed of his right to do so.
The administrator's decision was based partly on the hospital making "no medication changes" during the resident's stay. She said she "did not feel safe taking Resident #2 back" because the facility couldn't handle potential behavioral escalations.
"The facility did not want their nurses in danger," the frequent visitor explained, describing the administrator's reasoning for the refusal.
During the August 20 inspection interview, the administrator acknowledged the facility's error. "The facility should not have assumed the representative was already given the notices and appeal rights," she said. She told inspectors she "wanted to make sure Resident #2's representative knew his appeal rights."
The assistant director of nursing promised to send the required documents overnight.
The following morning, August 21, she provided inspectors with a priority mail receipt showing the discharge notice and appeal rights were being delivered to the resident's representative. According to the receipt, the documents would arrive on August 22 — exactly 22 days after the facility had discharged the resident.
By that point, the resident had been barred from returning for more than three weeks without his family knowing they had any legal recourse to challenge the decision.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Larchwood Inn from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Larchwood Inn in GRAND JUNCTION, CO was cited for violations during a health inspection on August 21, 2025.
The facility's nursing home administrator made the decision without reevaluating the resident while he was hospitalized.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.