Larchwood Inn

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Larchwood Inn

2845 N 15th St Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to himself and others and the facility did not want their nurses in danger.The visitor said she contacted Resident #2's representative and 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 said he had to find out what happened from the hospital and not the facility. She said she was not provided a notice of discharge for Resident #2 until 8/1/25, two days after the facility refused to allow him to return to the facility, and after she had to continue to ask for the notice. The frequent facility visitor was interviewed again on 8/20/25 at 5:05 p.m. The visitor said she did not provide Resident #2's representative with the notice of discharge and the resident's appeal rights. She said the facility should have provided the representative with the notice and rights. The visitor said the representative did not contact her to help with the discharge appeal.The NHA and the assistant director of nursing (ADON) were interviewed together on 8/20/25 at 4:01 p.m. The NHA said the facility did not reevaluate Resident #2 while he was at the hospital. The NHA said

she made the decision not to allow Resident #2 to return to the facility because the hospital made no medication changes. She said the facility felt that he had a psychotic break based on his severe behaviors

on 7/31/25 and he became a different person. She said that the facility told the hospital that they were not prepared or equipped to deal with residents' psychotic episodes. She said the behavior occurred so fast without any triggers with that type of dementia. The NHA said the facility could not meet Resident #2's needs if there was a chance his behaviors would escalate and be directed towards another resident. She said she did not feel safe taking Resident #2 back.The ADON said the discharge notice was emailed to the frequent facility visitor on 8/1/25 at 1:32 p.m. The ADON said the frequent facility's visitor and the hospital told Resident #2's representative that Resident #2 was not coming back to the facility. The ADON said she did not know if the frequent facility visitor provided the resident's representative with the discharge notice or information on the appeal process. The ADON said the facility did not provide the resident or the resident's representative with the discharge notice or the rights to appeal the discharge. The NHA said Resident #2's representative did not request to appeal the discharge. She said he came to the facility and collected the resident's belongings but did not say anything about an appeal. The NHA said the discharge of Resident #2 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 said it was not the responsibility or normal practice for the frequent visitor to give the notice.The NHA said the facility should not have assumed

the representative was already given the notices and appeal rights. The NHA said she wanted to make sure Resident #2's representative knew his appeal rights. The NHA said she would make sure the resident's representative received the discharge notice and the rights to appeal.The ADON said she would send out

the discharge notice and the rights to appeal process overnight (on 8/20/25).VI. Facility follow-up The ADON provided a priority overnight mail receipt for Resident #2's discharge notice and appeal rights on 8/21/25 at 10:50 a.m. 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).

Event ID:

Facility ID:

If continuation sheet