Accel At Longmont Health And Rehab, Llc

F-F686, Pressure Injuries.

C. Facility plan to remove immediate jeopardy

The facility submitted a plan to remove the immediate jeopardy on 8/28/24 at 6:17 p.m. The plan read:

All residents in the facility identified as high risk for skin breakdown based on their risk assessment score started and completed 8/28/24.

Identify responsible staff/what action taken:

Resident #85 is no longer in (the facility) and will not be assessed. Risk assessment for Resident #140 was not assessed due to being admitted to the hospital on 8/27/24.

The regional nurse consultant (RNC) immediately on 8/28/24 provided education to wound nurse on implementation of interventions based on risk scores.

All nurses and certified nurse aid(e)s scheduled today will be educated on implementation of pressure injury prevention interventions and will be completed by the end of 8/28/24.

A full facility skin sweep was conducted on 8/28/24 assessing current residents'skin conditions and will be documented as completed by 8/28/24.

Pressure Ulcer Risk assessments will be completed on current residents to identify those at high risk for skin breakdown and interventions put in place by the end of 8/28/24.

Interventions will be implemented on 8/28/24 to prevent the development of new wounds or deterioration of existing wounds.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0686 Interventions will be added to certified nurse aid(e)s Point of Care Device for documentation by the end of 8/28/24. Level of Harm - Immediate jeopardy to resident health or Minimum Data Set nurse is auditing care plans for residents identified as high risk for appropriate safety interventions and will make changes as necessary by the end of 8/28/24.

Residents Affected - Few Staff that have not received the education will be provided with education on implementation of pressure injury prevention interventions prior to the start of their next shift, and followed up on by the administrator.

Nurse will round on assigned residents twice per shift to verify interventions are being followed by staff and turn in the audit form to DON/designee at the end of their shift.

All newly admitted patients receive a skin assessment and Risk assessment completed on admission. Necessary interventions are put in place at the time a need is identified. The admission will be reviewed in

the next morning clinical meeting. Skin assessments are done weekly ongoing, and the risk assessment is completed weekly three times after admission then quarterly and with change of condition.

D. Removal of immediate jeopardy

The facility plan was accepted by the state survey agency on 8/28/24 at 6:17 p.m., based on the systemic changes outlined in the above plan to ensure pressure injuries would be immediately addressed through assessment, monitoring, and treatment. The immediate jeopardy situation was removed; however, the deficient practice remained at a G level, isolated, actual harm.

II. Professional references

A. Classification of pressure injuries

According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www. internationalguideline.com/guideline on 7/30/24, Pressure ulcer classification is as follows:

Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)

Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk).

Category/Stage 2: Partial Thickness Skin Loss

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0686 Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry Level of Harm - Immediate shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape jeopardy to resident health or burns, perineal dermatitis, maceration or excoriation. safety Category/Stage 3: Full Thickness Skin Loss Residents Affected - Few Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable.

Category/Stage 4: Full Thickness Tissue Loss

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable

Unstageable: Depth Unknown

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed.

Suspected Deep Tissue Injury: Depth Unknown

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

According to the Basic Nursing third edition, Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022), page 1214, Healthy people regularly shift position to maintain comfort. However, many patients are unable to move without assistance. They require a change of position at least every two hours to prevent skin breakdown, muscle discomfort, damage to superficial nerves and blood vessels, and contractures.

III. Facility policy

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0686 The Prevention of Pressure Injuries policy and procedure, revised July 2018, was received from the regional nurse consultant (RNC) on 8/27/24 at 12:27 p.m. It read in pertinent part: Level of Harm - Immediate jeopardy to resident health or Any significant abnormal findings are reported to the resident physician and resident or responsible party. safety Abnormal findings are to be documented in the medical record. Actions taken to be documented in the medical record, along with a summary of all notified with their responses. Care plans will be updated on a Residents Affected - Few routine basis and with significant changes in condition.

IV. Resident #85

A. Resident status on admission

Resident #85, age older than 65, was admitted to the facility on [DATE REDACTED] from the hospital. According to the November 2023 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus and chronic kidney disease.

The 11/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief

interview for mental status (BIMS) score of 12 out of 15. She required substantial to maximal assistance from two staff members for transfers.

The care plan for skin integrity was initiated on 11/7/23 with interventions to turn and reposition frequently, off-load heels, and position the resident properly.

The medication administration (MAR) and treatment administration records (TAR) for November 2023 revealed there were no treatment orders for the resident's heels.

A skin assessment completed on admission (11/7/23) revealed Resident #85 had a stage 2 coccyx/sacral wound; however, her skin was intact to her lower extremities, heels, and feet.

A review of the daily skilled nurse's notes revealed no documentation of any changes in the resident's skin

before 11/16/23 (see below). A review of daily skilled nurses notes for November 2023 mentioned that coccyx/sacral wound care was ordered; however, there was no mention of skin breakdown to the resident's heels from 11/8/23-11/11/23. There was no daily skilled note documented for 11/15/23.

B. Resident status following admission - Skin changes identified on 11/16/23 - development of a pressure injury to the resident's right heel - facility failures

1. Skin changes identified on 11/16/23

An occupational therapy note, dated 11/16/23, nine days after admission, read in pertinent part, bleeding right heel during therapy session.

A weekly skin assessment dated [DATE REDACTED] documented discoloration to bilateral heels and a laceration to the right foot.

A note by licensed practical nurse (LPN) #4 on 11/16/23 at 6:22 p.m. documented, Resident notified nurse of open skin area on right heel. Fluid filled blister broke, deep tissue injury (DTI) visible. Primary care physician (PCP) power of attorney (POA), wound nurse notified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0686 2. Facility failures

Level of Harm - Immediate The weekly skin assessment on 11/16/23 (see above) did not document the description and measurements jeopardy to resident health or of new skin wounds. (It also did not document how the resident obtained the laceration.) safety

The care plan was revised on 11/16/23 with a mention of heel discoloration and skin tear. Residents Affected - Few However, the care plan did not document the location (right or left heel) of the discoloration. Further, no additional interventions were added to the care plan to address the new pressure wound.

Review of the resident's record from admission on 11/7/23 to 11/16/23 revealed no evidence that the care plan intervention for off-loading (see above) was followed.

A review of the resident's record revealed that although the nurse's note documented the PCP was notified of the resident's right heel injury and skin tear on 11/16/23 (see above), there was no documentation of PCP follow-up or of additional attempts to notify the PCP of the resident's skin breakdown.

C. Discovery on 11/20/23 - development of additional pressure injuries and cellulitis - facility failures

1. On 11/20/23 at 7:15 p.m., a physician progress note written by PCP #1 documented in part:

[A]sked to see lesions on feet that may not wait for wound care. New wounds on feet have not been seen before. Resident #85 has DTI changes (approx 6 centimeters) to bilateral heels and lateral calcaneal (large bone at the end of the foot), ascending cellulitis on the right calf. Right calf is tender, mildly warm and red.

At risk for diabetic infection that may threaten life or limb. Ascending erythema (redness of skin) is also a concern for cellulitis (skin infection). Resident #85 to be sent to the emergency room for evaluation to rule out osteomyelitis (inflammation of the bone due to infection).

The admission hospital record, dated 11/21/23, revealed the resident was diagnosed with cellulitis and sepsis from cellulitis. Upon admission to the hospital, the following wounds were identified: trauma injury to

the right big toe measured 2.0 by 2.0 by 0.1 cm, stage 3 pressure injury on coccyx/sacrum 3.0 by 3.0 by 0.2 cm, unstageable (pressure injury) on right heel measured 5.5 by 15.5 cm, and unstageable (pressure injury)

on left heel measured 4.5 by 5.5 cm.

The hospital record revealed the resident was administered intravenous (IV) antibiotics and spent a week in

the hospital including one day in the intensive care unit (ICU).

2. Facility failures

A review of the resident's progress notes, daily skilled nurses's notes, and skin assessments revealed there was no further documentation of discoloration to the resident's heels after 11/16/23 until the physician's note above on 11/20/23. A review of the resident's November MAR and TAR revealed no orders addressing the skin breakdown of the resident's heels identified on 11/16/23.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0686 The resident's record revealed daily skin assessments were not completed with accuracy to ensure Resident #85's pressure injuries were timely managed. Further, the facility failed to ensure timely notification to the Level of Harm - Immediate PCP after the evidence of a DTI was identified on 11/16/23. jeopardy to resident health or safety D. Interviews

Residents Affected - Few 1. The facility's MD was interviewed on 8/28/2024 at 8:52 a.m. The MD said the pressure injuries Resident #85 developed had been facility-acquired and were preventable. She said pressure injury wounds developed when protocol and care plans were not being followed by staff. The MD further said the expectation was that any change of condition (in the resident's skin) would have been documented and reported the same day to either an on-site physician or the on-call team.

2. The wound care physician (WCP) was interviewed on 8/28/24 at 4:13 p.m. The WCP said she had initially observed Resident #85 on 11/8/23 to have only a stage 2 coccyx/sacral wound. She said she was unaware

the resident had been hospitalized on [DATE REDACTED] due to a wound infection.

The WCP said she had no reason to believe Resident #85 was at risk of developing heel wounds as she was not bed-bound. She concluded that the resident's heel wounds were unavoidable because the resident had a diagnosis of diabetes.

-However, see above. The resident entered the facility without any pressure injuries to her heels, review of

the resident's record revealed daily skin assessments were not completed with accuracy, there was no evidence the resident was turned and repositioned as care planned, and new interventions were not considered when the resident's bilateral heel discoloration,/DTI was identified.

3. Physician assistant (PA) #1 was interviewed on 8/29/24 at 9:40 a.m. PA #1 said that the pressure injuries Resident #85 developed were facility-acquired and had proper interventions been completed the injuries should not have developed.

V. Resident #140

A. Resident record review, observations, and interview

Resident #140, age older than 65, was admitted to the facility from the hospital on 8/10/24. According to the August 2024 CPO, his diagnoses included sacral fracture, peripheral vascular disease, and idiopathic neuropathies.

According to the 8/16/24 MDS assessment, the resident was alert and oriented with a BIMS score of 15 out of 15.

Resident #140 was interviewed on 8/27/24 at 9:20 a.m. Resident #140 said he developed multiple wounds

on his right foot after he was admitted to the facility. Resident #140 said he had not had anything wrong with his foot before being admitted . Resident #140 said he developed a wound on his right heel from his feet being pushed against the footboard of the bed. (Per the MDS assessment, the resident's height was 6 feet 4 inches.) The resident said he also developed sores on his toes because the staff did not help him move.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0686 Resident #140 said the staff was not consistent with dressing changes. He said staff routinely told him that

he would see a WCN or physician, but he had not seen either the wound nurse or the physician when he Level of Harm - Immediate asked to see them to answer his questions. jeopardy to resident health or safety Observations revealed Resident #140 lying in the bed with his feet touching the footboard. His right heel was covered with a blue foam boot. There was a purple discoloration on the tip of his right first toe and a white Residents Affected - Few piece of tape on his right second toe labeled with a nurse's initials, dated 8/25.

B. Resident status on admission

A skin assessment completed on admission on 8/10/24 revealed Resident #140's skin was intact, except for

a skin tear and hematoma to his left elbow.

A care plan for physical mobility, initiated on 8/10/24, revealed the resident had impaired mobility due to a history of stroke and history of cardiovascular disease. Interventions included to provide an appropriate level of assistance. The 8/16/24 MDS assessment revealed the resident's level of assistance was substantial to maximal assistance and two staff assistance for transfers.

A care plan for skin breakdown was initiated on 8/10/24, revealing that the resident was at risk for actual skin breakdown due to a history of stroke and cardiovascular disease and a history of bruising and skin tears.

-Although the care plan noted the resident was confined to a chair most of the time, required extensive assistance with bed mobility and transfers, and had left-sided weakness, he was assessed at mild risk for skin breakdown.

-Interventions initiated on admission 8/10/24 included off-loading heels, positioning the resident properly, inspecting skin and completing a head-to-toe assessment every week and documenting results, as well as inspecting skin daily with care and bathing, and reporting any changes to the nurse.

C. Resident status after admission - development of pressure injury on the resident's right heel, right first toe - facility failures

1. Skin breakdown 8/12/24

On 8/12/24, two days after admission, a WCN assessment read in part, blister to right foot, DTI.

On 8/12/24, the care plan was updated to add a new blister.

-However, the location and the cause were not documented and the update did not reference DTI. Further, no new interventions were added to the care plan, and the resident's orders were not updated with any new treatments until 8/14/24 when the wound care physician (WCP) assessed the resident (see below).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0686 On 8/14/24, the WCP documented an unstageable DTI to the right great toe, measuring 1.0 by 0.5 centimeters (cm), and trauma injury to the right second toe. The WCP recommended to cleanse the wound Level of Harm - Immediate daily, apply skin prep, off-load, and avoid constrictive footwear, and the orders for daily wound care were jeopardy to resident health or entered on the MAR. safety Notwithstanding the above documentation by nursing and the WCP of skin breakdown, the August 2024 Residents Affected - Few daily skilled nurse's notes section revealed no documented skin concerns from 8/12/24 to 8/16/24. Further, there were no documented daily skilled nurse's notes on 8/15/24 and 8/17/24.

On 8/15/24, the resident was ordered to receive sugar-free liquid protein (Prostat) 30 milliliters (ml) by mouth two times a day for wound healing (unstageable DTI).

-Although a review of the resident's MAR for August 2024 revealed the Prostat was documented as routinely given, an interview with LPN #1 on 8/27/24 at 8:48 a.m. revealed the resident frequently refused the liquid protein, preferring a protein shake provided by his family. (A refusal was observed on 8/27/24 at 8:48 a.m.)

-However, the resident's record revealed no evidence that the resident's refusals and preference for another protein supplement were communicated to the PCP.

On 8/17/24, the resident's care plan was updated again to turn and reposition the resident frequently.

-However, despite the resident's mobility limitations, there was no evidence that repositioning was offered to

the resident, and staff interviews (see below) indicated it was unclear how frequently it was to be done. See also the resident interview above; Resident #140 said that the staff did not help him move.

2. Skin breakdown 8/21/24

On 8/21/24, the WCP documented Resident #140 still had an unstageable DTI to the right great toe that measured at 0.9 by 1.0 dcm, trauma injury to the right second toe, but also a new pressure wound unstageable DTI on the right heel that measured 3.0 x 6.0 cm. Orders were entered for right heel wound care every three days, cleanse with wound cleanser, and pat dry. Apply foam dressing and off-load while in bed.

On 8/22/24, the care plan was updated with interventions to off-load heels as allowed and apply boot to the right foot when out of bed.

-However, none of the care plan updates after admission indicated staff had considered the resident's height and the footboard on his bed. See resident interview and observation above.

On 8/25/24, the daily skilled nurses note documented concerns for a right heel wound, right second toe wound, and bruising to the right fourth toe with new right foot swelling (edematous +3 and painful to touch).

3. Change of condition 8/27/24

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0686 On 8/27/24 (during the survey), the care plan was updated with an intervention to document weekly treatments and to include measurements for every wound. However, on this date, the resident experienced a Level of Harm - Immediate change in condition and was transferred to the hospital. Specifically: jeopardy to resident health or safety On 8/27/24 at 3:19 p.m., LPN #1 documented that during therapy it was observed that Resident #140 was altered from baseline and unable to complete tasks normally. Vital signs were taken and revealed that Residents Affected - Few Resident #140 had a fever (100.7 F) and hypotension (a low blood pressure of 97/65). The physician was notified of Resident #140's status and the resident was sent to the emergency department via ambulance.

The hospital emergency room records dated 8/27/24 at 8:24 p.m. read in pertinent part, cellulitis of right lower limb, severe sepsis without septic shock, purulent (pus-like drainage which is a sign of infection) drainage along heel with streaking erythema superiorly. Resident #140 was admitted to the ICU and treated with antibiotics.

D. Interviews

1. The WCN was interviewed on 8/27/24 at 2:29 p.m. The WCN said she conducted a skin assessment on newly admitted residents but was not aware of a timeframe for her assessment to occur. She said Resident #140's heel tissue had been closed during the first skin assessment she conducted on 8/12/24. Therefore,

the resident's heel wound would be considered facility-acquired. The WCN said the WCP mentioned the toe wounds may have bee[TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 48112 potential for actual harm Based on record review and interviews, the facility failed to complete a performance review of every nurse Residents Affected - Few aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for two of five certified nurse aides (CNA) reviewed.

Specifically, the facility did not complete a performance review for CNA #1 and CNA #2.

Findings include:

I. Record review

CNA #1 was hired on 2/28/23. A request for a performance review was made on 8/27/24.

-The facility was unable to provide documentation indicating a performance review for CNA #1 was completed in the past 12 months.

CNA #2 was hired on 11/29/22. A request for a performance review was made on 8/29/24.

-The facility was unable to provide documentation indicating a performance review for CNA #2 was completed in the past 12 months.

II. Staff interviews

The human resources director (HRD) was interviewed on 8/29/24 at 4:28 p.m. The HRD said each department lead was responsible for completing an annual performance review for their staff. She said a performance review was not completed for CNA #1 and CNA #2.

The regional nurse consultant (RNC) was interviewed on 8/29/24 at 4:36 p.m. The RNC said a performance

review was not completed for CNA #1 and CNA #2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 51160 potential for actual harm Based on observations, record review and interviews, the facility failed to ensure it was free of a medication Residents Affected - Some error rate of five percent (%) or greater.

Specifically, the medication administration observation error rate was 16.67%, or five errors out of 30 opportunities for error.

Findings include:

I. Facility policy and procedure

The Medication Guidelines On Clinical Practice policy and procedure, revised January 2020, was provided by the regional nurse consultant (RNC) on 8/29/24 at 4:30 p.m. It read in pertinent part, Staff will provide medications in accordance with standard practice guidelines.

II. Medication error observations

On 8/27/24 at 8:38 a.m. licensed practical nurse (LPN) #1 was observed preparing and administering medications for Resident #5. The resident had a physician's order for Aspercreme (lidocaine) (a medication used for pain) 4 % topical patch, one time per day, apply one patch to left knee for pain due to fall.

-LPN #1 documented that he gave the medication, however, he did not apply the patch to Resident #5's left knee.

On 8/27/24 at 8:48 a.m. LPN #1 was observed preparing and administering medications for Resident #140.

The resident had physician's orders for the following medications:

-Lidocaine 4 % topical patch one time per day, apply one patch to the sacrum;

-Metoprolol tartrate (a blood pressure medication) 25 milligrams (mg) tablet one tablet by mouth two times per day. Hold if systolic BP (blood pressure) is less than 100 millimeters of mercury (mmHg), hold if pulse less than 60 beats per minute (bpm); and,

-Prostat sugar-free liquid protein 30 milliliters (ml) by mouth two times per day, for wound healing.

LPN #1 attempted to place the lidocaine patch on Resident #140's knee. Resident #140 said he did not want

the patch on his knee because his neck hurt. LPN #1 proceeded to apply the lidocaine patch to the resident's left lateral neck.

-However, the physician's order was for the lidocaine patch to be applied to Resident #140's sacrum.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0759 -LPN #1 failed to verify Resident #140's heart rate or blood pressure prior to administration of the metoprolol tartrate. Level of Harm - Minimal harm or potential for actual harm -Additionally, LPN #1 documented the resident's heart rate was 62 bpm, however, the morning vital signs obtained by a certified nurse aide (CNA) were documented as a heart rate of 80 bpm and a blood pressure Residents Affected - Some reading of 147/80.

-Resident #140 refused the Prostat liquid protein, however, LPN #1 documented the medication was given.

On 8/28/24 at 9:50 a.m. LPN #2 was observed preparing and administering medications for Resident #15.

The resident had a physician's order for carbidopa ER (extended release) 25 mg-levodopa 100 mg tablet, two tablets by mouth three times per day (8:00 a.m., 12:00 p.m. and 4:00 p.m.) for Parkinson's disease.

-The medication was administered to Resident #15 at 9:50 a.m., 50 minutes after the allowed medication administration window.

III. Staff interviews

LPN #2 was interviewed on 8/28/24 at 10:00 a.m. LPN #2 said she had a two hour window to administer medications from their ordered timeframe. She said Resident #15's carbidopa-levodopa medication was ordered at 8:00 a.m. and could be given between 7:00 a.m. and 9:00 a.m.

-However, the medication was administered at 9:50 a.m., outside the two- hour medication administration window (see observation above).

Physician assistant (PA) #1 was interviewed on 8/29/24 at 9:40 a.m. PA #1 said of all medications, Parkinson's medications should be given on time. PA#1 said that it was extremely important to administer carbidopa/levodopa on time. PA #1 said the reason it was important was because of the half-life (the time it takes for the amount of a drug's active substance in your body to reduce by half) of the medication. PA #1 said even small delays could cause a significant increase in Parkinson's disease symptoms, such as tremors or difficulty swallowing. PA #1 said administering the 8:00 a.m. dose at 9:50 a.m. had been a medication error.

PA #1 said if a lidocaine patch was prescribed for the sacral area it should not be applied to a different area. PA #1 said a different physician's order would be required to place a lidocaine patch on a different area of

the body. PA #1 said if a medication was refused or not given it should not be documented as given. PA #1 said any medication refusals required notification of a provider.

The RNC was interviewed on 8/29/24 at 4:30 p.m. The RNC said medication should be administered as it was prescribed. The RNC said a lidocaine patch should be placed on the part of the body specified in the physician's order, not just anywhere on a resident's body. The RNC said timed and extended release medications should be administered within a two hour window of the prescribed administration time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51160 potential for actual harm Based on observations and interviews, the facility failed to follow proper infection prevention practices during Residents Affected - Some patient care and medication administration.

Specifically, the facility failed to:

-Perform appropriate hand hygiene during medication administration; and,

-Clean multi-resident use vitals monitoring equipment in between residents.

Findings include:

I. Professional reference

The Centers for Disease Control and Prevention (CDC) (2024), Clinical Safety: Hand Hygiene for Healthcare Workers, was retrieved on 9/9/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html. It read in pertinent part,

Perform hand hygiene before touching a patient, after touching a patient or their surroundings, immediately

after glove removal.

According to Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022.) Basic Nursing: Thinking, Doing and Caring, (Third edition), pages 1601, 1604-1605, Use standard precautions to prevent the transmission of infection. Implement measures to prevent healthcare-associated infections (HAIs). HAIs are the leading complication of healthcare and one of the ten leading causes of death in the United States. Hand hygiene can remove transient flora (microbes acquired by touching objects or people).

II. Observations

On 8/27/24 at 8:38 a.m. medication administration was observed in the presence of licensed practical nurse (LPN) #1. LPN #1 did not perform hand hygiene prior to entering the resident room. LPN # 1 donned gloves and administered eye drops into both of Resident #5's eyes.

-After administering the eyedrops, LPN #1 removed her gloves, did not perform hand hygiene, and proceeded to administer oral medications to Resident #5.

During the medication administration, LPN #1 attempted to take Resident #5's heart rate with a facility pulse oximeter (finger probe that measures heart rate and oxygen level). The equipment was not working properly. LPN #1 left the resident's room to obtain his personal pulse oximeter.

-LPN #1 did not perform hand hygiene upon exiting or re-entering the room.

-LPN #1 did not clean the facility equipment or his own before or after use on Resident #5.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0880 On 8/27/24 at 8:48 a.m. medication administration was observed in the presence of LPN #1. LPN #1 walked from Resident #5's room to medication cart #1 and prepared medications for Resident #140 without Level of Harm - Minimal harm or performing hand hygiene. potential for actual harm -LPN #1 entered Resident #140's room without performing hand hygiene. An opened cup of applesauce was Residents Affected - Some on the dresser with the lid open and a spoon resting in the cup. LPN #1 handed the resident the cup of applesauce and spoon to use to take the medications. LPN #1 completed administration of the oral medications, then placed a lidocaine patch on Resident #140's neck.

-LPN #1 exited the room without performing hand hygiene and proceeded to medication cart #1.

On 8/28/24 at 9:50 a.m. medication administration was observed in the presence of LPN #2. LPN #2 prepared medications for Resident #15 without performing hand hygiene. LPN #2 entered Resident #15's room without performing hand hygiene, then proceeded to administer oral medications.

On 8/28/24 at 9:23 a.m. medication cart #2 was observed in the presence of LPN #6. While LPN #6 was standing at medication cart #2, a staff member walking down the hallway stopped and picked up a pill off the floor near the medication cart. LPN #6 took the pill from the staff member and threw it into a trash can attached to the medication cart.

-After disposing of medication from the floor, LPN #6 proceeded to prepare medications for residents without performing hand hygiene.

III. Staff Interview

The wound care nurse (WCN), who was also overseeing the facility's infection control program was interviewed on 8/29/24 at 12:56 p.m. The WCN said hand hygiene should be used prior to administering resident care. The WCN said hand hygiene should be used prior to administering medications, especially eye drops, to prevent the spread of infection. The WCN said hand hygiene should occur after the removal of gloves and prior to providing care for a different resident.

The WCN said vital signs monitoring equipment (blood pressure cuffs, pulse oximeters) should be cleaned

after each resident with cavi wipes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 37166

Residents Affected - Many Based on record review and interviews, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control which had the potential to affect all residents residing in the facility at the time of the survey.

Specifically, the facility failed to have a qualified ICP involved with the facility's infection prevention and control program.

Findings include:

I. Professional reference

The Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, (updated 5/8/23) was retrieved on 9/4/24 from https://www.cdc. gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html-read in pertinent part,

Nursing homes should assign one or more individuals with training in infection prevention and control (IPC) to provide on-site management of the IPC program. Smaller facilities should consider staffing the IPC program based on the resident population and facility service needs identified in the IPC risk assessment.

II. Record review

The infection preventionist's (IP) certification for training specific to infection prevention and control was requested on 8/26/24 from the nursing home administrator (NHA) for the wound care nurse (WCN), who was

the acting IP.

-The facility was unable to provide documentation that the wound care nurse had completed specialized training in infection prevention and control (see interviews below).

III. Staff interviews

The WCN was interviewed on 8/29/24 at 5:10 p.m. The WCN said she was the acting IP but she had not yet completed her certification. She said she was enrolled in a training program but had not completed it yet.

The regional nurse consultant (RNC) was interviewed on 8/29/24 at 5:30 p.m. The RNC said she was providing assistance in the building since the director of nursing (DON) quit a few days prior. She said she was not aware that the WCN had not completed her IP training.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 065429

F-F867 (Quality Assurance and Performance Improvement).

RESIDENT #85

Resident #85, who had a diagnosis of diabetes, kidney disease, and generalized muscle weakness, was admitted to the facility on [DATE REDACTED] for rehabilitation and strengthening. Resident #85 was assessed on admission with intact skin of the lower extremities, feet, and heels, and a stage 2 pressure injury to her coccyx/sacrum. She was evaluated at moderate risk of developing pressure injuries due to a history of previous pressure injury and stroke.

On 11/16/23, nine days after admission, a weekly skin assessment documented bilateral heel discoloration. However, the resident's primary care physician (PCP) did not become aware of the resident's skin condition until 11/20/23. In a note that day, the PCP documented the resident had deep tissue injury (DTI) changes to both heels and right lower extremity cellulitis (skin infection), ascending on the right calf. The resident was sent to the hospital where she was diagnosed with cellulitis and sepsis from cellulitis, as well as a trauma injury to the right big toe, a stage 3 pressure injury on her coccyx/sacrum, and unstageable pressure injuries to her right and left heel. She was treated with intravenous (IV) antibiotics and spent a week in the hospital, including one day in the intensive care unit (ICU).

Record review revealed the facility failed to provide the resident with timely and necessary services to prevent the development of the resident's heel wounds and to promote the healing of her coccyx/sacral wound. Specifically:

-While an 11/16/23 assessment revealed discoloration to bilateral heels and a nursing note the same day documented the physician was notified of the resident's DTI injuries, a change of condition assessment was not completed, and a PCP note on 11/20/24, four days later, indicated the physician was unaware of the heel wounds, citing new wounds on feet have not been seen before.

-While the resident's care plan for skin integrity was initiated on 11/7/23, and included interventions to assist

the resident in turning and repositioning frequently and to off-load heels, there was insufficient evidence

these interventions were implemented. Further, the discovery of bilateral heel discoloration on 11/16/23 did not trigger the facility to consider new interventions to prevent further skin breakdown despite being noted as

a problem on the care plan.

-While a review of the medication and treatment administration records (MAR and TAR) revealed orders for

the resident's coccyx/sacral wound, there was no treatment order for the resident's heels in November 2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0686 RESIDENT #140

Level of Harm - Immediate Resident # 140, who had a diagnosis of sacral fracture, peripheral vascular disease, and idiopathic jeopardy to resident health or neuropathies, was admitted to the facility on [DATE REDACTED]. Resident #140 was admitted to the facility with intact safety skin on the lower extremities, feet, and heels. At the time of admission, he was assessed at mild risk for pressure injuries due to a history of skin tears, stroke, and left-sided weakness. Residents Affected - Few

On 8/12/24, two days after admission and during the wound care nurse (WCN) assessment, a blister to the right foot, DTI was noted. On 8/21/24, nine days later, the wound care physician assessed the resident and documented the resident had a large DTI on his right first toe and right heel. On 8/25/24, the daily skilled nurse's note read the resident's right foot had become edematous and painful to touch with bruising to the right fourth toe and new right foot swelling with edema and pain.

On 8/27/24, Resident #140 developed altered mental status, fever, and chills and was sent to the hospital where he was diagnosed with cellulitis due to an infected right heel wound. He spent one night in the ICU and was administered IV antibiotics.

Record review revealed the facility failed to provide the resident with timely and necessary services to prevent and manage the resident's pressure injuries. Specifically:

-Record review revealed no evidence the resident's heels were off-loaded, even though heel off-loading was documented on his admission care plan.

-Record review revealed the resident's daily skilled notes failed to accurately reflect the resident's skin condition.

-Record review revealed staff failed to ensure the physician was timely notified of resident changes in condition.

The facility's systemic failure to provide Resident #85 and Resident #140 with timely interventions and necessary treatment and services to prevent and manage pressure injuries created an immediate jeopardy situation with the likelihood of serious harm to other residents with similar conditions.

Findings include:

I. Immediate Jeopardy

A. Findings of immediate jeopardy

RESIDENT #85

The facility failed to prevent the development of pressure injuries for Resident #85. The resident was admitted to the facility on [DATE REDACTED]. She was identified to be at moderate risk for pressure injuries due to her diagnosis of diabetes and kidney disease. Although she had a stage 2 coccyx/sacral wound, she did not have any injuries on her legs, feet, or heels.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0686 However, an 11/16/23 assessment revealed discoloration to bilateral heels, and on 11/20/23, a physician's note revealed the nurse asked the physician to see lesions on the resident's feet. The note read the resident Level of Harm - Immediate had new deep tissue injury DTI) wounds to both heels and ascending cellulitis to the right calf. The physician jeopardy to resident health or wrote that the resident is a diabetic and was at risk for diabetic foot infection that could threaten life or limb. safety The resident was sent to the emergency room for further evaluation.

Residents Affected - Few While in the hospital, the resident was diagnosed with cellulitis and sepsis from cellulitis as well as a trauma injury to the right big toe, a stage 3 coccyx/sacral pressure injury, and unstageable pressure injuries on her right and left heel. The resident was hospitalized for a week but her wounds did not heal and she was admitted to hospice on 11/28/23.

Record review revealed the facility failed to provide the resident with timely and necessary services to prevent the development of the resident's heel wounds and to promote the healing of her coccyx/sacral wound. Specifically:

-While an 11/16/23 assessment revealed discoloration to bilateral heels and a nursing note the same day documented the physician was notified of the assessment, a change of condition assessment was not completed, and a physician note on 11/20/24, four days later, indicated the physician was unaware of the heel wounds, citing new wounds on feet have not been seen before.

-While the resident's care plan for skin integrity was initiated on 11/7/23, and included interventions to assist

the resident in turning and repositioning frequently and to off-load heels, there was insufficient evidence

these interventions were implemented. Further, the discovery of bilateral heel discoloration on 11/16/23 did not trigger the facility to consider new interventions to prevent further skin breakdown despite being noted as

a problem on the care plan.

-While a review of the medication and treatment administration records (MAR and TAR) revealed orders for

the resident's coccyx/sacral wound, there was no treatment order for the resident's heels in November 2023.

RESIDENT #140

Resident #140 was admitted to the facility on [DATE REDACTED]. He did not have any wounds on his legs and feet. On 8/12/24, the WCN completed a skin assessment and noted a blister to right foot, DTI.

On 8/21/24 the wound care physician (WCP) documented the resident had an unstageable deep tissue injury (DTI) to the right first toe, and unstageable DTI to the right heel.

Record review revealed the facility failed to provide the resident with timely and necessary services to prevent the development of the resident's pressure injuries. Specifically:

-Record review revealed no evidence the resident's heels were off-leaded, even though heel off-loading was documented on his admission care plan.

-Record review revealed the resident's daily skilled notes did not accurately reflect the condition of the resident's skin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 23 065429 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065429 B. Wing 08/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accel at Longmont Health and Rehab, LLC 1960 S Fordham St Longmont, CO 80503

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 0686 -Record review revealed staff failed to ensure the physician was timely notified of resident changes in condition. Level of Harm - Immediate jeopardy to resident health or The medical director (MD) was interviewed about Resident #85's and #140's DTIs that developed after safety admission. The MD said that all pressure-related injuries were avoidable if appropriate care had been provided. She said if residents developed pressure-related injuries it meant interventions for prevention were Residents Affected - Few not followed. She further said, even though both residents had comorbidities, such as diabetes for Resident #85 and vascular disease for Resident #140, all developed pressure injuries were avoidable.

The facility's systemic failure to provide Resident #85 and Resident #140 with timely interventions and necessary treatment and services to prevent and manage pressure injuries created an immediate jeopardy situation with the likelihood of serious harm to other residents with similar conditions.

B. Notice of immediate jeopardy

On 8/28/24 at 11:30 a.m., the nursing home administrator (NHA) was informed of the findings of immediate jeopardy under