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Complaint Investigation

Larchwood Inn

August 21, 2025 · Grand Junction, CO · 2845 N 15th St
Citations 2
CMS Rating 2/5
Beds 130
Provider ID 065331
Healthcare Facility
Larchwood Inn
Grand Junction, CO  ·  View full profile →
Inspection Summary

Larchwood Inn in GRAND JUNCTION, CO — inspection on August 21, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0627
Resident Rights Deficiencies
Potential for More Than Minimal Harm

behaviors would escalate and be directed towards a resident.

She said she did not feel safe taking Resident #2 back.

The NHA said the hospital had a caregiver stay with the resident.

She said a caregiver always being with Resident #2 was not an option at the facility.

She said if the hospital had adjusted the resident's medication, she might have taken him back.The NHA said the facility did not send out referrals to other facilities when they determined that they were not going to 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 NHA said she did not know what triggered his behaviors on 7/31/25.

She said Resident #2 did not have elopement, exit seeking or aggressive behaviors prior to 7/31/25.

She said she was not aware that he had requested to leave the facility and go to the VA.

She said his desire to leave the facility and go to the VA could have been a potential trigger to his behaviors on 7/31/25.

The NHA said all residents were evaluated for elopement on admission so the facility could establish a baseline and risk.

The NHA said the resident should have been assessed on admission and again after he reported a desire to leave the facility on 7/21/25.

The NHA said if she knew 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 in the facility.The ADON said Resident #2 did not have an elopement assessment until after his attempt to elope on 7/31/25.

The ADON said if the facility had known he had signs of wanting to leave, they would have looked at a safety plan.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Larchwood Inn

2845 N 15th St Grand Junction, CO 81506

SUMMARY STATEMENT OF DEFICIENCIES

According to the receipt, the discharge notice and appeal rights were to be delivered to Resident #2's representative on 8/22/25 (22 days after the resident was discharged from the facility).

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GRAND JUNCTION, CO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Larchwood Inn or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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