Larkin Chase Center

Inspectors wroteBased on observations, interview, and record review, it was determined that the facility failed to ensure that staff interacted with residents in a courteous, respectful and responsive manner. This was evident for 1 (Resident #71) of 1 Resident monitored for a dignified existence and 1 (Resident #2) of 2 residents investigated for abuse.

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate an allegation of verbal abuse for 1 (Resident #2) of 2 residents reviewed for abuse investigations.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to promptly notify the provider of a critical and abnormal laboratory test values for 1 (Resident #7) of 3 sampled residents reviewed for a change in condition. On [DATE], Resident #7 experienced a change in condition and a nurse practitioner (NP) ordered STAT (a Latin word, statim, which meant immediately or without delay) laboratory tests to rule out pneumonia and assess for other possible underlying causes of the resident's change in condition. The blood specimen was collected for the laboratory tests, which revealed the resident had a high critical sodium level of 161 millimoles per liter (mmol/L). This critical laboratory value was communicated to the facility nursing staff on [DATE]; however, the provider was unaware of the results until [DATE]. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a STAT (a Latin word, statim, which meant immediately or without delay) chest x-ray was completed as ordered and timely provider notification of a critical and abnormal laboratory test values for 1 (Resident #7) of 3 sampled residents reviewed for a change in condition. On [DATE], Resident #7 experienced a change in condition and a nurse practitioner (NP) ordered a STAT chest x-ray and STAT laboratory tests to rule out pneumonia and assess for other possible underlying causes of the resident's change in condition. The STAT chest x-ray was not completed on [DATE]. The blood specimen was collected for the laboratory tests, which revealed the resident had a high critical sodium level of 161 millimoles per liter (mmol/L). [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure there was an order to perform wound care when Resident #6 was identified to have an in-house acquired Stage 2 pressure ulcer. The facility further failed to ensure an order to perform wound care was transcribed and implemented for Resident #9's in-house acquired Stage 3 pressure ulcer; notify the Lead Registered Dietician of the resident's new pressure ulcer; and ensure there was not inconsistencies in how the resident's pressure ulcer was assessed and documented. These failures affected 2 (Resident #6 and Resident #9) of 3 sampled residents reviewed for pressure ulcer/injury.

Inspectors wroteBased on interview and record review, the facility failed to obtain consent prior to the use of psychotropic medications for 2 (Resident #6 and Resident #7) of 14 sampled residents.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to timely report an allegation of abuse to the state survey agency for 1 (Resident #5) of 8 sampled residents reviewed for abuse.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to ensure staff assigned to care for a resident was interviewed once the resident voiced an allegation of neglect for 1 (Resident #1) of 8 sampled residents reviewed for abuse.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) for 1 (Resident #9) of 3 sampled residents reviewed for pressure ulcer/injury.

Inspectors wroteBased on observation and staff interviews, the facility failed to protect residents private information during medication administration. This had the potential to affect 14 of 73 residents information. During observation on 2/19/26, a medication cart was observed between rooms [ROOM NUMBERS] from 9:55 am until 9:59 am, with the Electronic Health Records visible on the computer screen for 14 of 73. Several visitors and staff members were seen walking along the hallways past the medication cart. Licensed Practical Nurse (LPN) 23 walked out of room [ROOM NUMBER], approached the medication cart, and locked it, but did not close the Electronic Health Records (EHR). During the interview on 2/19/23 at 9:59 am, LPN #23 confirmed s/he was the nurse responsible for the medication cart and that s/he had left the EHR visible, with resident information displayed. [...]

Inspectors wroteBased on observation, staff interviews, and review of facility policy titled 'Medication Storage-Storage of Medications', the facility failed to ensure 1 of 4 medications carts was locked when not in use. Review of facility policy titled 'Medication Storage-Storage of Medications' dated 01/25 revealed 'Procedures 3. To limit access to prescription medication, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medication (such as medication aides) may access medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by people with authorized access.'During observation on 2/19/26, a medication cart was observed between rooms [ROOM NUMBERS], unlocked and unattended from 9:55 am until 9:59 am. Several visitors and staff members were seen walking along the hallways past the medication cart. [...]

Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure: 1) food items were stored properly and 2) staff practiced appropriate use of gloves. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on observations and interviews it was determined the facility failed to ensure resident rooms were kept in a home like environment. This was found to be evident for 2 (Resident #72 and #87) out of 8 resident rooms observed during the re-certification survey.

Inspectors wroteBased on medical record review, the facility failed to notify the Ombudsman and Responsible Party in writing that Resident # 75 was sent to the hospital. This was evident for 1 out of 1 resident reviewed for hospitalization.

Inspectors wroteBased on review of minimum data set (MDS) assessment information and interview with facility staff, it was determined that the facility failed to transmit an MDS assessment within 14 days after completion. This was evident for 1 (Resident #1) of 1 resident reviewed for the Resident Assessment.

Inspectors wroteBased on Medical Record Review Resident # 53 did not have a care plan written for the use of a urinary cather and multiple UTI (Urinary Tract infections). This was evident for 1 out of 1 residents.

Inspectors wroteBased on observation, the facility failed to put dates on the oxygen tubing and tracheostomy tubing, and gastrostomy tubing for Resident # 100. This was evident for 1 out of 1 resident without dated tubing.

Inspectors wroteBased on observation it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of insects. This was found to be evident for the kitchen.

Inspectors wroteBased on medication cart observations and staff interviews it was determined that facility staff failed to ensure that medical records were kept in a confidential manner. This was evident in 2 out of 2 medication carts involving Resident's (R#10, R#14, R#28, R#93 and R#120).

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that residents or resident representatives were notified in writing that they are being transferred out of the facility to a hospital and the reason why the facility is transferring the resident out. This was found to be evident for 3 out of 3 residents' (Resident's #48, #81, and #92) reviewed for a complaint during the investigative portion of the survey.

Inspectors wroteBased on surveyor observation, environmental rounds and interview with the Maintenance Director it was determined that the facility failed to maintain clean, intact walls in resident rooms.

Inspectors wroteBased on staff interview and review of medical records and other pertinent documentation, it was determined the facility failed to ensure that Resident #73 was free of abuse from a staff member. This was evident for 1 of 47 residents reviewed during the survey.

Inspectors wroteBased on observation and interviews with facility staff, it was determined that food service employees failed to ensure that equipment was maintained and safe food handling practices were followed to reduce the risk of foodborne illness.

Inspectors wroteBased on observation, medical record review and staff interview it was determined the facility failed to ensure that personal hygiene equipment items meant for individual use were not mixed together for roommates, Residents #70 and #101 and roommates, Residents #6 and #71. This was evident for 4 of 47 residents investigated during the survey.

Inspectors wroteBased on observation and interviews of facility staff, it was determined the facility failed to ensure that garbage and refuse was disposed of properly.

Inspectors wroteBased on observation and interview of staff, it was determined that facility staff failed to maintain equipment and prepare foods in a manner that ensures a safe and sanitary food service.

Inspectors wroteBased on interview and medical records review, it was determined that facility staff failed to follow doctor's orders and arrange a psychiatric evaluation of a resident who qualified for a professional evaluation from psychiatric services.