LONGMONT, CO - Federal inspectors issued an immediate jeopardy citation to Accel at Longmont Health and Rehab following an August 2024 investigation that revealed systematic failures in preventing and treating pressure injuries, resulting in two residents developing life-threatening infections requiring intensive care.
Resident Develops Sepsis Nine Days After Admission
A resident admitted in November 2023 for rehabilitation arrived at the facility with intact skin on her lower extremities and feet, though she had a stage 2 pressure injury on her coccyx. The resident had diabetes and kidney disease, conditions that placed her at moderate risk for developing additional pressure injuries.
Nine days after admission, a weekly skin assessment documented discoloration on both heels. Despite this documented finding, the resident's primary care physician did not become aware of the deteriorating skin condition until four days later, on November 20, 2023.
When the physician finally examined the resident, the documentation noted deep tissue injuries to both heels and cellulitis ascending on the right calf. The physician's note specifically stated the wounds were "new" and "have not been seen before," indicating a significant communication breakdown between nursing staff and medical providers.
The resident was immediately transferred to the hospital, where physicians diagnosed cellulitis, sepsis from the cellulitis, a trauma injury to the right big toe, a stage 3 pressure injury on her coccyx, and unstageable pressure injuries on both heels. The infection had progressed to the point that the resident required intravenous antibiotics and spent one day in the intensive care unit during her week-long hospitalization.
Understanding Pressure Injury Progression
Pressure injuries develop when sustained pressure on the skin restricts blood flow to tissues. For individuals with diabetes, this risk increases significantly due to compromised circulation and reduced sensation in the extremities. Deep tissue injuries represent damage to underlying muscle and tissue that may not be immediately visible on the skin surface.
The progression from initial skin discoloration to unstageable pressure injuries with systemic infection represents multiple failures in preventive care. Stage 3 pressure injuries involve full-thickness skin loss, while unstageable injuries have so much dead tissue that the depth cannot be determined without surgical removal of the damaged tissue.
Cellulitis, a bacterial skin infection, can spread rapidly through tissue planes. When it enters the bloodstream, it causes sepsis, a life-threatening condition where the body's response to infection damages its own tissues. The medical record noted the resident faced a "diabetic foot infection that could threaten life or limb."
Systematic Failures in Care Implementation
Federal inspectors identified multiple points where the facility's care system broke down. The resident's care plan, initiated on November 7, 2023, included specific interventions for turning and repositioning frequently and off-loading heels to prevent pressure injuries. However, documentation showed insufficient evidence these interventions were actually performed.
Off-loading refers to techniques that eliminate pressure on vulnerable areas, such as using pillows to elevate heels off the bed surface or specialized boots that distribute pressure away from bony prominences. These interventions are considered standard care for patients at risk of pressure injuries.
When staff discovered bilateral heel discoloration on November 16, the finding should have triggered an immediate reassessment and intensification of preventive measures. Instead, the care plan remained unchanged, and no additional interventions were implemented despite the documented deterioration.
The medication and treatment administration records showed orders for treating the existing coccyx wound but contained no treatment orders for the newly identified heel injuries throughout November 2023. This gap meant no formal wound care protocol was in place as the injuries worsened over multiple days.
Second Resident Develops Infected Heel Wound
In August 2024, another resident admitted for sacral fracture rehabilitation experienced a similar cascade of preventable complications. This resident had peripheral vascular disease and neuropathy, conditions that significantly impair circulation and sensation in the extremities, creating elevated risk for pressure injuries.
The resident arrived with intact skin on the lower extremities. Two days after admission, during a wound care nurse assessment on August 12, staff documented a blister on the right foot classified as a deep tissue injury. Nine days later, on August 21, the wound care physician documented a large deep tissue injury on the right first toe and right heel.
By August 25, nursing notes described the right foot as edematous and painful to touch, with bruising to the fourth toe and new swelling. Two days later, on August 27, the resident developed altered mental status, fever, and chills - classic signs of systemic infection.
The resident was transferred to the hospital and diagnosed with cellulitis from an infected right heel wound. The infection was severe enough to require one night in the intensive care unit and intravenous antibiotic treatment.
Documentation Failures Masked Deteriorating Conditions
Federal inspectors found that daily skilled nursing notes failed to accurately document the resident's actual skin condition as it deteriorated. This documentation gap meant physicians reviewing the medical record would not have a clear picture of how rapidly the wounds were progressing.
The care plan included heel off-loading as an intervention, yet reviewers found no evidence in the medical record that staff actually implemented this critical preventive measure. Without proper off-loading, heels remain in constant contact with the mattress surface, creating sustained pressure that damages underlying tissue even when skin appears intact on the surface.
Staff also failed to ensure physicians received timely notification of changes in the resident's condition. This delay meant medical interventions such as specialized wound care orders, antibiotic prophylaxis, or enhanced monitoring protocols were not initiated when they could have been most effective.
Medical Director Deems Injuries Avoidable
During the investigation, the facility's medical director stated that all pressure-related injuries were avoidable if appropriate care had been provided. The medical director emphasized that when residents develop pressure injuries, it indicates prevention interventions were not followed.
Significantly, the medical director noted that even though both residents had comorbidities - diabetes for the first resident and vascular disease for the second - all the pressure injuries that developed were avoidable with proper care implementation.
This assessment aligns with current medical standards, which recognize that while certain conditions increase pressure injury risk, facilities can prevent these injuries through consistent implementation of evidence-based protocols including regular repositioning, pressure redistribution surfaces, skin assessment, nutrition support, and immediate intervention when early warning signs appear.
Immediate Jeopardy Determination
Federal regulations allow inspectors to cite immediate jeopardy when a facility's practices have caused or are likely to cause serious injury, harm, impairment, or death to a resident. On August 28, 2024, at 11:30 a.m., inspectors notified the nursing home administrator of the immediate jeopardy determination.
The citation reflected the systemic nature of the failures across multiple residents and the severity of outcomes, including sepsis requiring ICU-level care. Immediate jeopardy citations require facilities to implement corrective actions immediately to remove the threat to resident safety.
The inspection documented failures in multiple interconnected systems: care planning, care plan implementation, physician communication, wound assessment and treatment, documentation accuracy, and quality oversight. This pattern indicated problems extending beyond individual staff errors to fundamental gaps in the facility's care delivery systems.
Industry Standards for Pressure Injury Prevention
Professional guidelines from organizations including the National Pressure Injury Advisory Panel emphasize that most pressure injuries are preventable through systematic assessment and intervention. Standard protocols include risk assessment at admission and with condition changes, individualized prevention plans, repositioning schedules typically every two hours, pressure-redistributing support surfaces, skin inspection at least daily, moisture management, and nutritional support.
For residents with diabetes, peripheral vascular disease, or other conditions affecting circulation and healing, guidelines recommend enhanced monitoring and more aggressive preventive interventions. Heel injuries are particularly concerning because heels have limited soft tissue padding over bone, making them highly vulnerable to pressure damage.
When early signs of pressure injury appear, such as the skin discoloration documented in both cases, immediate intervention is required. This includes completely eliminating pressure to the affected area, assessing for infection, notifying physicians for treatment orders, and revising the care plan to address the changed condition.
The inspection findings reveal these fundamental protocols were not consistently followed at Accel at Longmont, resulting in preventable suffering and life-threatening complications for vulnerable residents.
For complete details of the inspection findings and the facility's corrective action plan, the full federal inspection report is available through the Medicare.gov Nursing Home Compare website.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accel At Longmont Health and Rehab, LLC from 2024-08-29 including all violations, facility responses, and corrective action plans.
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