Accel At Longmont Health And Rehab, Llc

F-F686: The facility failed to ensure pressure injuries were assessed and interventions were implemented timely to prevent worsening of the wounds and infection.

The facility failed to ensure wound treatment was implemented as ordered for a resident who developed a wound infection with sepsis. The facility's failure to assess and treat pressure injuries created an immediate jeopardy (IJ) situation with actual serious harm.

Cross-reference

F-F727: The facility failed to employ a full time director of nursing (DON), resulting in a F level citation, no actual harm with potential for more than minimal harm, widespread.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 18 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 0867 IV. Interviews

Level of Harm - Minimal harm or The medical director (MD) was interviewed on [DATE REDACTED] at 9:57 a.m. The MD said she was not aware that potential for actual harm Resident #85 was hospitalized due to her infected wounds. She said pressure injuries were avoidable injuries when all necessary precautions were in place. She said the fact that residents developed pressure Residents Affected - Some injuries indicated that appropriate interventions were not implemented.

The NHA was interviewed on [DATE REDACTED] at 5:30 p.m. The NHA said he was new to the building and he had participated in one QAPI meeting since he started the position. He said he was not aware of the pressure injury, medications administration and medication storage concerns that were identified at the time of the survey. He said he was not able to locate any investigations or notes completed by the previous administrator, however he would continue to look and provide anything that was relevant.

V. Facility follow up

On [DATE REDACTED] at 6:47 a.m. the NHA submitted additional documentation via email. Specifically, the NHA provided a QAPI plan of correction for the identified medication error concerns identified at the time of the survey. According to the plan of correction, the date the problem was identified by the facility was [DATE REDACTED]. Listed interventions included education to all nurses and audits for expired, discontinued or missing medications were to be completed monthly for the next two months (through [DATE REDACTED]).

-However, the NHA did not provide documentation that education had been provided to nursing staff regarding expired, discontinued or missing medications.

-Additionally, the NHA did not provide documentation of the audits that were to have been conducted for expired, discontinued or missing medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 18 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Level of Harm - Minimal harm or 48112 potential for actual harm Based on record review and interviews, the facility failed to develop, implement and maintain an effective Residents Affected - Few training program for staff based on the facility assessment and resident population for two of five certified nurse aides (CNA) reviewed.

Specifically, the facility failed to:

-Ensure CNA #1 and CNA #2 received training in abuse, dementia management, behavioral health management, infection control, communication, quality assurance and quality improvement (QAPI), compliance and ethics, and resident rights; and,

-Ensure CNA #1 and CNA #2 received at least 12 hours of annual in-service training.

Findings include:

I. Record review

A request for abuse, dementia management, behavioral health management, infection control, communication, QAPI, compliance and ethics and resident rights training from the past 12 months and the 12 hours of in-service training was made on 8/27/24 for CNA #1 and CNA #2.

CNA #1 was hired on 2/28/23. The facility was unable to provide documentation indicating CNA #1 had completed training for abuse, dementia management, behavioral health management, infection control, communication, QAPI, compliance and ethics and resident rights training in the past 12 months and attended at least 12 hours of in-service training.

CNA #2 was hired on 11/29/22. The facility was unable to provide documentation indicating CNA #1 had completed training for abuse, dementia management, behavioral health management, infection control, communication, QAPI, compliance and ethics and resident rights training in the past 12 months and attended at least 12 hours of in-service training.

II. Staff interviews

The human resources director (HRD) was interviewed on 8/29/24 at 4:28 p.m. The HRD said abuse, dementia management, behavioral health management, infection control, communication, QAPI, compliance and ethics and resident rights training was completed when the CNAs were first hired and then annually through an electronic learning management program. She said CNA #1 and CNA #2 did not complete abuse, dementia management, behavioral health management, infection control, communication, QAPI, compliance and ethics and resident rights training in the past 12 months.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 18 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 0940 The HRD said there was an annual skills clinic training completed in May 2024 that was approximately six hours of training. The HRD said she was unable to locate any documentation that CNA #1 and CNA #2 Level of Harm - Minimal harm or attended the May 2024 skills clinic training. The HRD said there were monthly hour-long staff meetings that potential for actual harm included training. She was unable to locate the agendas for what was covered in the staff meetings and could not say if CNA #1 and CNA #2 attended the staff meetings. The HRD said she was unable to confirm Residents Affected - Few and show documentation CNA #1 and CNA #2 had completed the required annual trainings and 12 hours of inservice.

The regional nurse consultant (RNC) was interviewed on 8/29/24 at 4:36 p.m. The RNC said annual training was completed through an online training system. She said CNA #1 and CNA #2 did not complete abuse, dementia management, behavioral health management, infection control, communication, QAPI, compliance and ethics and resident rights training in the past 12 months. The RNC said it was difficult to have staff complete the required annual training.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 18 065429

F-F759 was cited at an E level scope and severity, pattern, no actual harm with potential for more than minimal harm, pattern.

F 880 Infection control

During a recertification survey on [DATE REDACTED],

F-F880 was cited at an E level scope and severity, pattern, no actual harm with potential for more than minimal harm, pattern.

III. Cross-referenced citations

Cross-reference