Accel At Longmont Health And Rehab, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support.Findings include: I. Professional referenceAccording to the National Certification Council of Activity Professionals (NCCAP) (2023), retrieved on 9/15/25 from www.nccap.org, An activity director must meet specific qualifications in education, certification and/or experience.The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist; or an activities professional who is licensed or registered, if applicable, by the State in which practicing; and eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body; or has two years of experience in a social or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures.Specifically, the facility failed to ensure food was palatable and served at the appropriate temperature.Findings include:I. Facility policy and procedureThe Food Preparation Guidelines policy, implemented 4/11/25, was provided by the regional vice president of operations on 9/11/25 at 1:26 p.m. It read in pertinent part, It is the policy of this facility to prepare foods in a manner to preserve and enhance a resident's nutrition and hydration status. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include providing meals that are varied in color and texture, using spices or herbs to season food in accordance with recipes, serving hot foods/drinks hot and cold foods/drinks cold, addressing resident complaints about foods/drinks, and honoring resident preferences, as possible, regarding foods and drinks, food shall be provided in a form…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents received food prepared in a form designed to meet their needs per physician orders for one (#29) of one resident reviewed for a mechanically altered diet texture out of 36 sample residents.Specifically, the facility failed to serve Resident #29 with food that was altered to the correct texture.Findings include:I. Professional referenceCambridge University Hospital (2023) Minced and Moist Food IDDSI Level 5, retrieved from https://www.cuh.nhs.uk/patient-information/minced-moist-food-iddsi-level-5/ No regular bread due to high choking risk.II. Facility policy and procedureThe Food Preparation Guidelines policy, implemented 4/11/25, was provided by the chief nursing officer (CNO) on 9/11/25 at 1:27 p.m. It read in pertinent part: Food shall be provided in a form (regular, cut, chopped, ground, pureed) that meets each resident's individual needs in accordance with his or her assessment and care plan.III. Resident #29A.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure consent was obtained for the use of psychotropic medications for two (#47 and #3) of five residents reviewed for unnecessary medications out of 36 sample residents.Specifically, the facility failed to ensure informed consent, which included the reason for medication use, risks and benefits associated with the medication use and any black box warning (a safety warning, highlighting a drug's potential to cause serious, life-threatening adverse reactions, or to cause harm that could be prevented by specific prescribing practices) was obtained from the resident or the resident's representative prior to the resident's use of a psychotropic medication for Resident #47 and Resident #3.Findings include: I. Facility policy and procedureThe Use of Psychotropic Medication policy and procedure, revised 4/28/25, was provided by the regional vice president of operations on 9/8/25 at 4:34 p.m. It read in pertinent part, Prior to initiating or increasing a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to make immediate notification to the resident representative when the resident had a significant change in condition requiring a need to alter treatment, initiate a resident's transfer or discharge from the facility or when the resident was involved in an accident with an injury for one (#16) of 17 residents out of 36 sample residents.Specifically, the facility failed to ensure Resident #16's representative was notified when the resident experienced a choking episode that required the Heimlich maneuver (a first aid method used for choking) by staff.Findings include:I. Facility policy and procedureThe Notification of Changes policy, implemented on [DATE], was provided by the chief nursing officer on [DATE] at 12:14 p.m. The policy was to ensure the facility promptly informed the resident, consulted the resident's physician; and notified, consistent with his or her authority, the resident's representative when there was a change requiring notification.The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to maintain a system of documenting grievances and demonstrating prompt actions for one (#37) of two residents reviewed for grievances out of 36 sample residents.Specifically, the facility failed to effectively address, resolve and demonstrate a timely response to Resident #37's grievances.Findings include:I. Facility policy and procedureThe Grievance policy and procedure, implemented 4/11/25, was provided by the regional vice president of operations on 9/11/25 at 1:26 p.m. It read in pertinent part, It is the policy of this facility to support each resident's and family member's right to voice grievanceswithout discrimination, reprisal, or fear of discrimination or reprisal.The Grievance Officer is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to incorporate the recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation report into the assessment, care planning, and transition of care for one (#3) of four residents reviewed for PASRR out of 36 sample residents. Specifically, the facility failed to take steps to ensure services were provided as recommended in Resident #3's PASRR level II report.Findings include: I. Resident #3A. Resident status Resident #3, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included schizoaffective disorder (a mental health condition characterized by a combination of symptoms of schizophrenia - a disconnection from reality and a mood disorder like depression or mania), cerebral infarction (stroke) affecting the right dominant side, chronic kidney disease, major depressive disorder, and anxiety disorder. The 9/8/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services and assistance for bathing for two (#29 and #33) of 17 residents reviewed for ADLs out of 36 sample residents.Specifically, the facility failed to provide Resident #29 and Resident #33, who were dependent upon staff assistance for ADLs, with timely incontinence care.Findings includeI. Facility policy and procedureThe Activities of Daily Living (ADLs) policy, implemented 4/11/25, was provided by the chief nursing officer on 9/11/25 at 1:27 p.m. It read in pertinent part, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care; transfer and ambulation;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure received treatment and care in accordance with professional standards of practice for two (#33 and #32) of four residents out of 36 sample residents. Specifically, the facility failed to:-Ensure staff followed physician's orders for Resident #32's toe wound dressing; and, -Ensure medications were not documented as being administered prior to the medications being administered to Resident #33.Findings include: I. Failed to ensure staff followed physician's orders for Resident #32's toe wound dressing A. Resident status Resident #32, age greater than 65, was admitted on [DATE]. According to the September 2025 computerized physician's orders (CPO), diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side (a stroke affecting the left side of the body), depression and narcolepsy. The 8/1/25 minimum data set (MDS) assessment revealed Resident #32 had moderate cognitive impairment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent the occurrence or recurrence of pressure injuries for one (#25) of three residents reviewed out of 36 sample residents.Specifically, the facility failed to ensure appropriate interventions were in place to prevent Resident #25 from developing a non-blanchable (skin that does not turn white when pressure is applied to the area) wound to his left outer ankle.Findings include:I. Professional referenceAccording 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 on 9/19/25 from https://www.internationalguideline.com/guideline, Pressure ulcer classification is as follows:Category/Stage 1: Nonblanchable Erythema (discoloration of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents were free from accidents or hazards for two (#11 and #42) of four residents reviewed out of 36 sample residents. Specifically, the facility failed to ensure resident safety when using a Hoyer lift (mechanical lift) to complete transfers for Resident #11 and Resident #42.Findings include:I. Professional reference According to the Food and Drug Administration's (FDA) Safety Guide For Patient Lifts pp. 6, retrieved on 9/17/25 from https://www.fda.gov/files/medical%20devices/published/Patient-Lifts-Safety-Guide.pdf, Move lift base legs near or around the patient's device. Base legs are usually more stable in full open position. Ensure there is space for lift to pivot and move freely to the receiving area. Ensure lift is able to fit under or around the receiving surface and through doorways.II. Facility policy and procedureThe Safe Resident Handling/Transfers policy, revised April 2025, was provided by the chief nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide respiratory services for one (#42) of two residents reviewed out of 36 sample residents. Specifically, the facility failed to:-Ensure Resident #42's bilevel positive airway pressure (BiPAP) machine was set up in order for the resident to utilize it at night; and,-Ensure the resident's care plan included the use of a BiPAP machine.Findings include:I. Resident #42A. Resident statusResident #42, age less than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included quadriplegia (loss of motor function from the neck down), neurogenic bowel, neuromuscular dysfunction of the bladder and narcissistic personality disorder. The 8/21/25 minimum data set (MDS) assessment revealed Resident #42 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required moderate assistance to roll side to side, and required substantial assistance with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#7) of two residents out of 36 sample residents. Specifically, the facility failed to: -Ensure an assessment was completed to identify potential trauma behaviors for Resident #7, who had a diagnosis of post-traumatic stress disorder (PTSD); -Identify triggers for Resident #7's trauma behaviors related to past childhood trauma; -Identify and document resident-specific care approaches that addressed Resident #7's past history of trauma and triggers, which may cause re-traumatization, and train staff on the resident's trauma and triggers; and, -Ensure Resident #7's trauma care plan included resident-specific interventions for the resident.Findings…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure two (#47 and #3) of five residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 36 sample residents. Specifically, the facility failed to:-Ensure a complete, thorough and timely assessment, including non-pharmacological interventions and a documented rationale for prescribing antipsychotic and antidepressant medications was completed for Resident #47 and Resident #3; -Ensure hours of sleep were monitored for Resident #47 and Resident #3 while they were on antidepressant medications, known to cause drowsiness and; -Identify and implement effective interventions when Resident #47 and Resident #3 refused psychotropic medications.Findings include: I. Facility policy and procedure The Use of Psychotropic Medication policy and procedure, revised 4/28/25, was provided by the regional vice president of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure all drugs and biologicals were properly stored, secured and labeled in accordance with accepted professional standards. Specifically, the facility failed to: -Ensure topical medications were not left on Resident #8's bathroom counter; and,-Ensure medicated wound treatment supplies were not stored in an unlocked drawer in Resident #7's bedside table.Findings include: I. Resident #8A. Resident status Resident #8, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included vascular dementia, end-stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus and cellulitis of the chest wall. The 7/13/25 minimum data set (MDS) assessment revealed that the resident was cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. She required a wheelchair. She required set up assistance with eating and oral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure accurate medical records were kept for one (#42) of two residents out of 36 sample residents reviewed. Specifically, the facility failed to maintain accurate records for Resident #42 of urine output and suprapubic catheter care in the electronic medical record (EMR).Findings include:I. Professional referenceAccording to [NAME], P.A. and [NAME], A.G. et.al., (2021), Fundamentals of Nursing, 10 edition, pp 366 Documentation is an important professional responsibility. To limit liability, your documentation needs to follow organizational standards, which include a clear description of individualized and goal-directed nursing care you provide based on your nursing assessment. Always document patient care in a timely manner following agency standards. Documenting all aspects of the nursing process is a critical nursing responsibility that limits nursing liability by providing evidence that you maintained or exceeded practice standards…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease.Specifically, the facility failed to ensure staff performed appropriate hand hygiene when assisting residents in the dining room.Findings includeI. Professional referenceAccording to The Centers for Disease Control and Prevention's (CDC). Clean Hands: About Handwashing 2/16/24), retrieved on 9/18/25 from https://www.cdc.gov/clean-hands/about/index.html, Many diseases and conditions are spread by not washing hands with soap and clean, running water. If soap and water are not readily available, use a hand sanitizer with at least 60% alcohol to clean your hands. Key times to wash hands: before, during, and after preparing food, and before and after eating food. Washing hands can keep you healthy and prevent the spread of respiratory and diarrheal infections. Germs can spread from person to person or from surfaces to people when you…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to ensure residents had the right to secure and confidential personal and medical records.Specifically, the facility failed to ensure residents' medical records were stored securely. Findings include:I. Facility policy and procedureThe Health Insurance Portability and Accountability Act (HIPPA) Sanctions policy, implemented 4/11/25, was provided by the regional vice president of operations (RVPO) on 7/23/25 at 12:13 p.m. The policy revealed this facility would apply sanctions against employees who fail to comply with all policies and procedures regarding the protection of our residents' personal identifiable health information. The facility, as a covered entity under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), would implement policies and procedures to prevent, detect, contain, and correct any HIPAA violations. All employees were expected to comply with all policies and procedures regarding the protection of personal identifiable health information of our residents. All employees would be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility ensure residents had a right to make choices about aspects of his or her life in the facility that were significant to the resident for two (#6 and #11) of 10 residents out of 11 sample residents.Specifically, the facility failed to ensure Resident #6 and Resident #11 received showers according to their preferences. Findings include:I. Facility policy and procedureThe Resident Showers policy, implemented on 6/1/25, was provided by the regional vice president of operations (RVPO) on 7/23/25 at 2:03 p.m. The policy revealed this facility assisted residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents would be provided showers as per request or as per facility schedule protocols and based upon resident safety.II. Resident #6A. Resident observation and interviewsThe resident and his wife were interviewed on 7/23/25 at 1:36 p.m. The resident sat in a wheelchair in his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis. Specifically, the facility did not designate an RN to serve as the DON on a full-time basis, after the former DON resigned. Findings include: I. Record review The review of the facility staffing list and facility assessment on 8/27/24 revealed there was no full time DON in the building. II. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 8/29/24 at 4:30 p.m. LPN #2 said the facility did not have a DON and there was no charge nurse on duty. She said all questions were deferred to the wound care nurse (WCN) and the minimum data set (MDS) nurse. She said both nurses were LPNs, but since they had worked in the building for a long time they were a good resource. The MDS coordinator (MDSC) was interviewed on 8/29/24 at 4:45 p.m. The MDSC said the staff asked her for assistance in different nursing matters because she was available and had worked in the building for some time. She said she was not a charge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews, the facility failed to ensure it was free of a medication 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored according to professional standards of practice in one of one medication storage rooms and two of two medication carts. Specifically, the facility failed to: -Ensure multi-dose medications were dated when they were first opened; -Ensure medications were stored in clean and sanitary conditions; -Maintain medications in a way that the medications were accessible only to designated staff; -Dispose of unused, wasted or damaged medication in a way to prevent diversion or accidental exposure; and, -Maintain sanitary conditions in the medication storage room. Findings include: I. Facility policy and procedure The Medication Storage policy and procedure, revised January 2020, was provided by the regional nurse consultant (RNC) on 8/29/24 at 4:30 p.m. It documented in pertinent part, Staff will store medications in accordance with standard practice guidelines. II. Manufacturer's guidelines According to the Anoro Ellipta manufacturer's guidelines, retrieved on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life and quality of care. Findings include: I. Facility policy and procedure The facility's QAPI policy was requested from the nursing home administrator (NHA) on [DATE] at 6:10 p.m. -The policy was not received by the end of the survey on [DATE]. II. Repeat deficiencies Review of the facility's regulatory record revealed it failed to operate a QAPI program in a manner to prevent repeat deficiencies. F759 Medication administration error rate above five (%) percent During a recertification survey on [DATE], F759 was cited at an E level…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to follow proper infection prevention practices during 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure the residents' right to make choices about aspects of their lives that were important to them for two (#7 and #2) of five residents reviewed out of 24 sample residents. Specifically, the facility failed to: -Provide assistance scheduling a wound care appointment for Resident #7 at his preferred wound clinic; and, -Provide Resident #2 a shower schedule based on her preferences. Findings include: I. Facility policy and procedure The Residents' Rights policy and procedure, dated August 2022, was provided by the regional nurse consultant (RNC) on 8/29/24 at 4:30 p.m. It read in pertinent part, Staff will abide by and protect resident rights in accordance with state and federal guidelines. The administrator will pursue appropriate action regarding resident rights. II. Resident #7 A. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to prevent misappropriation of property for one (#12) of two residents reviewed for missing property out of 24 sample residents. Specifically, the facility failed to protect Resident #12's electric tricycle from being stolen from behind a locked gate at the facility. Findings include: I. Facility policy and procedure The Resident Rights policy and procedure, dated August 2022, was provided by the regional nurse consultant (RNC) on 8/29/24 at 4:30 p.m. It read in pertinent part, The staff will abide by and protect resident rights in accordance with state and federal guidelines. In the event a resident rights issue is observed or alleged, staff will report the issue to the administrator. The administrator will pursue appropriate action which may include grievance investigation, customer service recovery, discussion with the resident. II. Resident #12 A. Resident status Resident #12, age greater than 65, was admitted on [DATE] and discharged to another long…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure the comprehensive care plan was reviewed and revised timely to include the instructions needed to provide effective and personalized care for one (#27) of one resident out of 24 sample residents. Specifically, the facility failed to revise Resident #27's care plan to address the resident's pattern of repeated refusals of physician-ordered medications and treatments. Findings include: I. Facility policy and procedure The Care Plan Process policy, revised 3/27/23, was provided by the nursing home administrator (NHA) on 8/29/24 at 3:00 p.m. It read in pertinent part, The team directs care planning toward attaining and maintaining the highest optimal physical, psychosocial, functional status. The plan of care identifies the date, problem, measurable and realistic goals, time frames for achievement, discipline-specific service interventions, resolution and discharge option. II. Resident #27 A. Resident status Resident #27, age [AGE], was admitted on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for one (#134) of five residents reviewed for ADLs out of 24 sample residents. Specifically, the facility failed to ensure Resident #134 received showers per her preference Findings include: I. Facility policy and procedure The Bathing policy and procedure, revised 2/12/2020, was provided by the nursing home administrator (NHA) on 8/29/24 at 3:00 p.m. It revealed in pertinent part, Staff will provide bathing services for residents within standard practice guidelines. Residents have the right to choose if they want to be bathed at certain times and with certain methods in accordance with the care plan. II. Resident #134 A. Resident status Resident #134, age less than 65, was admitted on [DATE]. According to the August 2024 computerized physician order (CPO), diagnoses included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#84) of five residents reviewed for quality of care out of 24 sample residents. Specifically the facility failed to: -Ensure nursing staff did not remove Resident #84's peripherally inserted central catheter (PICC) line (a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart utilized for intravenous (IV) medication administration) prior to the completion of a physician prescribed course of antibiotics; and, -Provide care of Resident #84's PICC line per physician's orders and professional standards. Findings include: I. Facility policy and procedure The Peripherally Inserted Central Line Catheter (PICC) policy and procedure, dated August 2021, was provided by the regional nurse consultant (RNC) on 8/29/24 at 4:30 p.m. -The policy did not include information…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to complete a performance review of every nurse 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to develop, implement and maintain an effective 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,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure one (#2) resident reviewed out of three sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to for Resident #2: -Ensure urinalysis laboratory results were received timely, with timely follow up; -Ensure intravenous (IV) fluid hydration was documented as administered; and, -Ensure PRN (as needed) medications included the reason the medication was administered and the effectiveness of the medication. Findings include: I. Facility policy and procedure The policies for the laboratory process for specimens and obtaining results and PRN (as needed) medications were requested from the nursing home administrator (NHA) three times between 8/3/23 and 8/7/23. The NHA did not provide the policies. II. Resident #2 status Resident #2, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included multiple sclerosis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically, the facility failed to: -Ensure holding temperatures were at appropriate temperatures; -Ensure proper food storage practices; -Ensure expired food was discarded; and, -Ensure food items removed from its original packaging had a dating system. Findings include: I. Food temperatures of cold and hot food items were not held at the proper temperature to reduce the risk of food-borne illness. A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, The food shall have an initial temperature of 41ºF (fahrenheit) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control. (Retrieved 6/22/23).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality for one of two dining areas. Specifically, the facility failed to ensure meals were provided in a timely manner. Findings include: I. Resident interviews Resident #15 were interviewed on 6/12/23 at 10:41 a.m. The resident said breakfast was late today. She had breakfast around 10:00 a.m. and she said she was hungry. Resident #41 was interviewed on 6/12/23 at 12:13 p.m. The resident said breakfast was late. She said she had low blood sugar so if she did not have her meals on time, it would cause her to be dizzy. II. Meal times The meal times were provided by the nursing home administrator (NHA) on 6/13/23 at 11:45 am. It documented as follows: -Breakfast was from 8:00 a.m. to 9:00 a.m. -Lunch was from 12:00 p.m. to 1:00 p.m. -Dinner 5:00 p.m. to 6:00 p.m. Meals were served from a serving unit that was in the main kitchen with one central dining…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 12% or three errors out of 25 opportunities. Findings include: I. Facility policy The Medication Administration policy, dated May 2016, was requested and received on 6/13/23. The policy read in pertinent part: Medications are to be administered within 60 minutes of scheduled times, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established administration schedule for the nursing center. II. Observations and record review Licensed practical nurse (LPN) #4 was observed on 6/13/23 at 9:20 a.m. during medication pass. Resident #12 had the following orders that were not administered timely: Physician's order: amlodipine (antihypertensive) 10 mg (milligrams) tablet ordered for 8:00 a.m. The medication was administered at 11:04 a.m., which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to maintain a sanitary environment to prevent the transmission of communicable disease and infection in two of three units. Specifically, the facility failed to: -Label resident specific medical supplies and ensure the medical supplies were changed out routinely; and, -Assist and encourage residents to perform hand hygiene at meals. Findings include: I. Facility policy The 2023 Infection Prevention and Control Plan was requested and received on 6/12/23. The plan read in pertinent part: Program goals for 2023 included: Monitor for infections related to medical equipment, devices, and supplies. Develop processes to reduce infection related to medical equipment, devices and supplies if the need arises. Improve compliance with hand hygiene guidelines. II. Observation and interview A. Supplies labeling On 6/11/23 at 5:44 p.m., unlabeled tube feeding supplies were observed in the bathroom of room [ROOM NUMBER]. There was a 60 cubic centimeter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to ensure biologicals were labeled and stored in accordance with accepted professional standards. Specifically, the facility failed to discard expired biologicals from the supply room. Findings include: I. Facility policy The Storage of Medications, dated [DATE], was requested and received on [DATE]. The policy read in pertinent part: Biologicals are stored properly, following manufacturer's recommendations, to maintain their (sic) integrity and to support safe effective drug administration. Outdated items are immediately removed from stock, disposed of according to procedures. II. Seqirus manufacturer guidelines The influenza vaccine package insert was retrieved electronically on [DATE] from https://labeling.seqirus.com/PI/US/Afluria/EN/Afluria-Prescribing-Information-TIV.pdf and the inserted read in pertinent part: Once the stopper of the multi-dose vial has been piered the vial must be discarded within 28 days. III. Observations On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide food that accommodated resident allergies, intolerances and preferences for one (#97) of three residents reviewed out of 31 sample residents. Specifically, the facility failed to honor Resident #97's diet preferences. Findings include: I. Resident #97 Resident #97 age [AGE], was admitted on [DATE]. According to June 2023 clinical physician orders (CPO) diagnoses included type 2 diabetes mellitus with hyperosmolarity, gastro-esophageal reflux disease, essential (primary) hypertension, pain and presence of left artificial knee joint. The minimum data set (MDS) assessment was not completed. II. Resident interviews and observations Resident #97 was observed on 6/11/23 at 6:00 p.m. She was in bed in her room. A dinner meal tray was on a bedside table in front of her. She said she was hungry. She said she tried to eat her supper (fried chicken sandwich and potato salad) however she had just a few bites of the chicken. She said she was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.