Larchwood Inn: Veteran Denied Return After Escape - CO
Resident #2 attempted to elope from the facility on July 31, 2025. The nursing home administrator told federal inspectors she would not readmit him because his behaviors would escalate and be directed towards other residents.
"She said she did not feel safe taking Resident #2 back," inspectors wrote in their August report.
The administrator said the hospital had assigned a caregiver to stay with the resident around the clock. She told inspectors that having a caregiver always with Resident #2 was not an option at the facility.
But facility managers had missed warning signs for ten days before the elopement attempt.
Resident #2 had expressed his desire to leave the facility and go to the VA on July 21, 2025. The nursing home administrator told inspectors she was not aware the resident had requested to leave. She acknowledged his desire to go to the VA "could have been a potential trigger to his behaviors on 7/31/25."
The facility failed to conduct required safety assessments after the resident expressed his desire to leave. Federal regulations require nursing homes to evaluate residents for elopement risk and update those assessments when circumstances change.
The assistant director of nursing confirmed that Resident #2 did not receive an elopement assessment until after his escape attempt on July 31. "The ADON said if the facility had known he had signs of wanting to leave, they would have looked at a safety plan," inspectors found.
The administrator said all residents were supposed to be evaluated for elopement on admission to establish a baseline and risk level. She acknowledged the resident should have been assessed again after he reported wanting to leave on July 21.
Resident #2 had no history of elopement, exit-seeking, or aggressive behaviors before July 31, according to the administrator. She said she didn't know what triggered his behaviors that day.
When the facility decided not to readmit him, administrators took no steps to help him find alternative care. The nursing home administrator said the facility did not send referrals to other facilities after determining they would not take Resident #2 back.
"She said she did not send out referrals because she did not know what was wrong with him so she did not feel comfortable referring him to anyone else," the inspection report states.
The administrator told inspectors that if she had known Resident #2 was expressing that he wanted to leave, she would have spoken to his representative and explored why he wanted to go to the VA instead of remaining at the facility.
The case illustrates how communication breakdowns between staff can leave vulnerable residents without proper safety planning. The resident's desire to leave the facility and seek care at the VA went unrecognized by administrators for ten days, despite federal requirements that nursing homes assess and address elopement risks.
Federal inspectors cited the facility for failing to provide adequate supervision and assistive devices to prevent accidents. The violation was classified as causing minimal harm or potential for actual harm to few residents.
The facility's decision to refuse readmission left the veteran in an uncertain situation, with administrators acknowledging they provided no assistance in finding him appropriate alternative care despite their obligation to ensure continuity of services.
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.
Resident #2 attempted to elope from the facility on July 31, 2025.
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.