Larkspur

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Residents #34, #66 and #71) and 2 of 7 staff (CNA A and CNA B) reviewed for infection control. 1. The facility failed to ensure CNA A followed EBP and proper infection control measures when providing direct care and handling soiled linens for Resident #66 on 6/08/2026. 2. The facility failed to ensure EBP was initiated and followed for Residents #34 and #66 on 6/08/2026 and 6/09/2026. 3. The facility failed to ensure CNA B followed EBP when providing direct care to Resident #71 on 6/09/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident (Resident #52) reviewed for enteral nutrition. The facility failed to ensure staff followed facility policy to label the formula label with date, time and initials of nurse when formula bag was started. This failure could affect residents by placing them at risk of dehydration and weight loss.

Inspectors wroteBased on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 3 of 3 days reviewed for 3 of 3 days reviewed (06/08/2026, 06/09/2026 and 06/10/2026) for nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 06/08/2026, 06/09/2026 and 06/10/2026. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 1 of 8 residents reviewed for ADLs (Resident #2)The facility failed to ensure Resident #2 received timely incontinent care on 10/29/2025. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs, which could result in poor care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls for 1 of 7 residents (Resident #3) reviewed for pharmacy services. The facility failed to ensure a tube of diclofenac sodium topical gel 1% (primary use for pain relief) was not in the room of Resident #3 on 10/28/2025. This failure could place residents at risk for adverse effects and reduced therapeutic effects of medication.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #2) reviewed for infection control. The facility failed to ensure CNA C changed her gloves, washed or sanitized her hands, and placed clean items on dirty linens when providing care to Resident #2 on 10/29/2025. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 2 of 6 residents reviewed for ADLs (Residents #23 and Resident #24) 1. The facility failed to clean/groom Resident #23's fingernails. Resident #23 had long fingernails that were about an inch in length with a yellow-brown substance underneath them on 4/21/2025 and 4/22/2025. 2. The facility failed to clean/groom Resident #24's fingernails that had a black substance underneath them on 4/21/2025 to 4/23/2025. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 6 residents (Resident #32) reviewed for accidents/hazards. The facility failed to remove worn and damaged mechanical lift slings from service from 04/21/2025 through 04/23/2025. This failure could place residents at risk of a loss of quality of life due to injuries.

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 2 medication rooms (Bluebonnet) reviewed for pharmacy services. The facility failed to dispose of expired medications from the medication room for Bluebonnet on 4/22/2025 which included: *Resident #35 had a foil package of albuterol 0.083% (nebulized medication that helps with breathing) that expired February 2025. *Resident #24 had a box of albuterol 0.083% that expired February 2025. *Resident #191 had 1 box of ipratropium/albuterol 0.5 mg/3 mg (nebulized medication that helps with breathing) that expired October 2024 and 3 boxes of ipratropium/albuterol 0.5 mg/3 mg that expired February 2025. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls for 1 of 18 rooms (room [ROOM NUMBER]) reviewed for pharmacy services. The facility failed to ensure a syringe of normal saline 0.9% (a solution used to maintain hydration) and 1 syringe of heparin 500 units per 5 ml (blood thinner) was were not on a bedside table in an unoccupied room (room [ROOM NUMBER]) on 4/21/2025. These failures could place residents at risk for adverse effects and reduced therapeutic effects of medication.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #20) and 1 of 5 staff (CNA D) reviewed for infection control. CNA D failed to wear appropriate PPE for contact isolation precautions when providing care to Resident #20 on 4/21/2025. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from misappropriation of resident property for 1 of 2 residents (Resident #1) reviewed for misappropriation. The facility failed to prevent misappropriation of property when CNA A took money via cash app from Resident #1 in the amount of $106.00 dollars. The noncompliance was identified as PNC. The noncompliance began on 05/10/2024 and ended on 05/10/2024. The facility had corrected the noncompliance before the survey began. This failure could affect residents by putting them at risk for not being able to meet financial needs and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 16 residents (Resident #2) reviewed for infection control. The facility failed to ensure CNA D and CNA E wore appropriate PPE for enhanced barrier precautions when providing catheter care to Resident #2 on 1/6/25. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free from sexual abuse for 2 of 15 residents (Resident #1 and Resident #2) reviewed for abuse. 1. The facility failed to prevent sexual abuse for Resident #1 witnessed by CNA A on 06/08/2024 at approximately 2:00 p.m. to be in her room covered with a sheet and lying in bed with the Floor Tech. 2. The facility failed to prevent sexual abuse for Resident #2 that reported to CNA B on 06/08/2024 at 2:15 p.m. that the Floor Tech approximately two weeks prior had touched her hip, rubbed his penis against her while clothed, and asked if she was interested while making sexual body gestures. The noncompliance was identified as PNC. The IJ began on 06/08/2024 and ended on 06/08/2024. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility failed to date six packages of white cake mix and two packages of gelatin mix that were in the dry storage area on 3/4/2024. The facility failed to ensure the DM and [NAME] wore a hairnet effectively to cover all of their hair on 3/5/2024. These failures could place residents at risk for food-borne illnesses.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident and the resident's representatives the right to participate in the development and implementation of his or her person-centered plan of care for 1 of 6 residents (Resident #4) reviewed for care plans. The facility failed to invite and include the input of the resident responsible party as members of the interdisciplinary team after the completion of the comprehensive assessment for Resident #4. This failure could place the residents at risk for decreased quality of life and not having their needs met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of 4 residents reviewed for misappropriation of property. (Resident #124). The facility failed to prevent a diversion (misappropriation) of Resident #124's Zofran tablets (used to treat nausea and vomiting) a total of 4 tablets. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity.

Inspectors wroteBased on interview and record review, the facility failed to assess each resident quarterly (every 3 months or 92 days) using the MDS (minimum data set) form specified by the state and approved by CMS (Centers for Medicare & Medicaid Services) for 1 of 6 residents (Resident # 271) reviewed for quarterly assessments. The facility failed to ensure Resident # 271 had a quarterly MDS assessment completed within 3 months or 92 days from the previous assessment that was completed on 07/26/2023. This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #63) reviewed for indwelling catheters. The facility failed to prevent Resident #63's urinary catheter drainage bag from touching the floor. These failures could place residents at risk for inappropriate placement of indwelling catheters, discomfort or injury, and urinary tract infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided care, consistent with professional standards of practices for 2 of 13 residents reviewed for respiratory care (Residents #7 and #122). 1. The facility failed to ensure Resident #7's nebulizer mask was changed per the facility's policy. 2. The facility failed to ensure Resident #122's humidifier bottle and tubing for the oxygen concentrator were changed per the facility's policy and Physician orders. These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress.

Inspectors wroteBased on interviews and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 1 of 12 months (January 2024) reviewed for pharmacy services. The facility failed to properly inventory drugs at time of disposal on 1/31/24. This failure could put residents at risk for misappropriation and drug diversion.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #271) and 1 of 7 staff (CNA E) reviewed for infection control. CNA E failed to perform hand hygiene while performing incontinent care to Resident #271 on 03/05/2024. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 1 of 6 residents reviewed for call lights. (Resident #4). The facility failed to ensure Resident #4's emergency call light in the bathroom had a cord enabling it to be reachable from the floor. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision and assistance to prevent accidents for 1 of 7 residents reviewed for accidents/supervision (Resident #1). The facility failed to ensure Resident #1's wheelchair was locked during a transfer causing the resident to slide out of the wheelchair and fall. Resident #1 sustained an acute comminuted fracture (when a bone breaks into 3 or more pieces) of the right femur (bone above the knee). The noncompliance was identified as PNC. The Immediate Jeopardy began on 10/24/23 and ended on 10/26/23. The facility had corrected the noncompliance before the survey began. This failure could place all residents at risk of severe injuries or death.