Accel at Longmont Health and Rehab, LLC

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#11) of six residents were provided the care and services necessary to ensure a safe discharge from the facility to the community out of 22 sample residents. Specifically, the facility failed to coordinate a safe discharge for Resident #11. On 4/12/26, the facility issued Resident #11 a one hour notice to pack her belongings and leave the facility due to an uninvestigated allegation that Resident #11 was providing other residents with opioids (a class of powerful drugs that carry a high risk of dependence and overdose). The facility failed to coordinate services needed to meet her medical needs, failed to ensure the resident was discharged with her prescribed medications, and failed to ensure the resident was discharged to a safe location. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for five (#10, #13, #14, #24 and #8) of six residents reviewed for grievances out of 22 sample residents. Specifically, the facility failed to provide timely follow-up on grievances reported by Resident #10, Resident #13, Resident #14, Resident #24 and Resident #8 or their representatives.

Inspectors wroteBased on record review, and interviews, the facility failed to provide written notification of room changes and roommate changes for one (#15) of three residents reviewed for notifications out of 22 sample residents. Specifically, the facility failed to provide timely written notification of room changes to Resident #15 and/or the resident's representative in a language the resident could understand.

Inspectors wroteBased on record review and interviews, the facility failed to notify the resident's next of kin when there was a significant change in the resident's condition for one (#12) of three reviewed out of 22 sample residents. Specifically, the facility failed to notify the resident's next of kin in a timely manner when Resident #12 passed away.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#4 and #16) of six residents reviewed for abuse out of 22 sample residents were kept free from abuse. Specifically, the facility failed to:-Protect Resident #4 from verbal abuse by Resident #5; and,-Protect Resident #16 from sexual abuse by Resident #4.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide the necessary services to maintain personal hygiene to two (#10 and #22) of four residents reviewed for services to maintain the highest practicable quality of life out of 22 sample residents. Specifically, the facility failed to ensure:-Resident #10 received timely incontinence care; and,-Resident #22 received his scheduled bed baths.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents were free from significant medication errors for two (#13 and #8) of four residents reviewed for medication errors out of 22 sample residents. Specifically, the facility failed to ensure physician orders were transcribed correctly for Resident #13 and Resident #8.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (#7) of three residents reviewed for change of condition assessments out of 25 sample residents. Resident #7, who was diagnosed with alcoholic polyneuropathy (nerve damage that causes pain, tingling, and numbness in the limbs), history of traumatic brain injury, congestive heart failure (CHF), type 2 diabetes mellitus, alcoholic cirrhosis of liver without ascites (liver disease without fluid in the abdomen), hypertension (high blood pressure), long term use of anticoagulants (blood thinners), and alcohol use with unspecified alcohol-induced disorder was admitted from the hospital to the facility on 7/17/25. Specifically, on 1/27/26 Resident #7 signed out of the facility at 8:30 a.m. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#9) of three residents reviewed for medication errors out of 25 sample residents. Resident #9 readmitted to the facility after being hospitalized from [DATE] to [DATE]. Upon return to the facility, the facility failed to ensure that metolazone (a diuretic), which was entered into the electronic medical record (EMR) as a daily scheduled order instead of as needed (PRN), was not administered to Resident #9. The resident received the medication scheduled daily over eight days instead of PRN (based upon a weight gain of five pounds (lbs) over baseline). [...]

Inspectors wroteBased 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 current DON was reassigned to be the temporary emergency licensed nursing home administrator (NHA) on 12/30/25 to 3/30/26. Cross-reference F684: The facility failed to provide quality care by not assessing, monitoring, documenting, and communicating a resident's change in condition when indicated, resulting in the death of the resident.

Inspectors wroteBased on interviews and record review, 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 care by not assessing, monitoring, documenting, and communicating a resident's change in condition when indicated that rose to the level of immediate jeopardy and created a situation where a serious adverse outcome occurred and caused harm.

Inspectors wroteBased on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of three units. Specifically, the facility failed to: -Ensure staff performed hand hygiene after emptying the resident's catheter and prior to providing incontinence care for Resident #4;-Ensure staff followed appropriate infection control guidelines and ensured the facility's shower chair was cleaned after use and not covered in stool prior to being used by Resident #4; and,-Ensure the facility's hot water heater was functioning appropriately in order to launder residents' clothes and linens at the appropriate water temperature.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#5) of three residents out of nine sample residents. Specifically, the facility failed to ensure an assessment was conducted to determine whether the self-administration of medications was clinically appropriate for Resident #5.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that clean linens were provided in sufficient quantities for residents in two of three linen storage closets. Specifically, the facility failed to ensure there were enough clean linens for residents.

Inspectors wroteBased on observations, record review interviews, the facility failed to ensure residents were kept free from abuse, as one (#2) of four residents reviewed for abuse out of the nine sample residents. Specifically, the facility failed to protect Resident #2 from abuse by Resident #3.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide respiratory services for two (#4 and #5) of three residents reviewed out of nine sample residents. Specifically, the facility failed to:-Ensure Resident #4's bilevel positive airway pressure (BiPAP) machine was set up and monitored and adjusted by the physician in order for the resident to utilize it at night; -Ensure Resident #4's care plan included the use of a BiPAP machine and settings; and, -Ensure Resident #5's physician's orders included application of his continuous positive airway pressure (CPAP) machine at night.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for two (#15 and #42) of seventeen residents out of 36 sample residents. Specifically, the facility failed to:-Ensure Resident #15 was administered pain medication as ordered;-Implement effective interventions to prevent Resident #15 from running out of her medication; and,-Offer and administer scheduled and as-needed medication for pain as ordered for Resident #42. RESIDENT #15Resident #15 was admitted to the facility on [DATE] with a diagnosis of acute and chronic respiratory failure, schizoaffective disorder (mental illness), bipolar disorder (mental illness), muscle weakness, frequent pain and limited range of motion. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards for two (#8 and #7) of two residents reviewed for dialysis out of 36 sample residents. Resident #8 was admitted on [DATE] for long-term care with diagnoses of end-stage renal disease, dependence on renal dialysis and type 2 diabetes mellitus. The 6/3/25 dialysis communication form (a form used for communication between the facility and the dialysis center) revealed the resident's central venous catheter (CVC) site (dialysis access site) was bloody and the resident pulled on the catheter line. The form documented that the dialysis center requested that the facility contact them. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents and their representatives had a right to participate in the development and implementation of their person-centered plan of care for three (#13, #18 and #46) of 17 residents out of 36 sample residents. Specifically, the facility failed to invite Resident #13, Resident #18 and Resident #46 and/or their representatives to participate in the initial care conferences to develop the resident's plan of care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to honor resident choices for five ( #1, #25, #42, #17 and #38) of 17 residents out of 36 sample residents. Specifically, the facility failed to honor the preferred shower days and/or preferred number of showers per week for Resident #1, Resident #25, Resident #42, Resident #17 and Resident #38.

Inspectors wroteBased on record review and interviews, the facility failed failed to ensure meaningful activities designed to support residents physical, mental and psychosocial well-being were provided for six ( #1, #32, #42, #29, #38 and #18) of 17 residents reviewed for activities out of 36 sample residents. Specifically, the facility failed to:-Provide a meaningful activity program for Residents #1, #32, #42, #29, #38 and #18; and,-Ensure an initial activity assessment was completed for Resident #18.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents, family members and legal representatives had full access to review the results of the facility's most recent survey findings, including the survey results, certifications, complaint investigations and plans of correction in effect for the preceding three years. Specifically, the facility failed to:-Ensure the residents knew where the survey results binder was located; and,-Ensure the survey results binder was accessible for review by residents and visitors.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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

Inspectors wroteBased 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.

Inspectors wroteBased on interviews, record review, and observations, the facility failed to provide two of five residents (#85 and #140) out of 24 sample residents, with the timely and necessary treatment and services to prevent and manage facility-acquired deep tissue pressure injuries (DTI) that resulted in the development of infection and sepsis, and required hospitalization. Cross-reference F880 (Infection Prevention and Control), F882 (Infection Preventionist) and 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] 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the resident environment was free from accident hazards and adequate supervision was provided for three (#3, #5 and #6) of four residents reviewed out of 11 sample residents. Resident #3 was a known fall risk and the facility failed to consistently implement interventions to prevent her falls. After the resident had a fall on 11/12/23 in the morning, the facility implemented gripper socks/shoes. Subsequently, the resident had another fall on 11/12/23 due to her slipping on the floor and did not have appropriate footwear. The facility failed to initiate and complete neurological assessments, STAT (urgent, rush) x-rays ordered timely to the service provider, communicate to nursing staff/providers the resident had significant pain levels with movement and investigate the root cause. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.