Health inspection·August 21, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to accurately document an incident of maggots in Resident #42's tracheostomy in the medical record. This affected one resident (#42) out of three residents reviewed for tracheostomy care. The facility census was 58. Findings include: Review of the medical record for the Resident #42 revealed an admission date of 12/07/22 and a readmission date of 05/25/22. Diagnoses included end stage renal disease, dependence on respirator, epilepsy, major depressive disorder, glomerular disease in systemic lupus, dependence on renal dialysis, and cerebral infarction. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had moderately impaired cognition. The resident required extensive assistance with two staff for mobility, total dependence of two staff for transfers, extensive assistance of one staff for personal hygiene, and supervision with set-up help only for eating. Review of the physician's order for August 2023 revealed Resident #42 had an order for tracheostomy care every shift. Interview on 08/21/23 at 9:34 A.M. with the Director of Nursing (DON) revealed that on 07/27/23 at 6:30 P.M. she received a call from Licensed Practical Nurse (LPN) #212 said there was a maggot on Resident #42's tracheostomy and one on the bedside table. LPN #212 got Respiratory Therapist (RT) #209 to provide tracheostomy care. Resident #42 would only let RT #209 change out her split sponge and briefly suction. LPN #212 contacted the Nurse Practitioner and Respiratory Pulmonary Nurse Practitioner (RPNP) #210. RPNP #210 stated that she would be in the next day and change out the tracheostomy. On the morning of 07/28/23, Wound Doctor #213 came in and stated that he saw no maggots. The DON stated that she did a soft file on the maggots; there was no documentation regarding the maggots in Resident #42's medical record. RPNP #210 came in the next day, changed the tracheostomy and there were no signs of maggots. RPNP #210 did education with Resident #42 and attempted to call the resident's mother and mother hung up on RPNP #210. The DON stated that there were no issues with maggots since. Phone interview on 08/21/23 at 3:07 P.M. with RT #209 revealed that she was an as needed (PRN) RT and earlier that day Resident #42 refused to be suctioned and would only let her change the split pad. If she remembers correctly, Resident #42 was combative, and there was a bug on the tray table, but she could not identify it. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 366359 Printed: 05/15/2026 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 366359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Larchwood Care 4110 Rocky River Drive Cleveland, OH 44135 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)