Accel at Longmont: Immediate Jeopardy Wounds - CO

The violations were so serious that inspectors declared an immediate jeopardy situation on August 28, meaning residents faced imminent risk of serious injury or death.

Resident 85, a cognitively intact woman over 65 with diabetes, entered the facility in November 2023 with intact skin on her feet and heels. Nine days later, staff discovered bleeding on her right heel during a therapy session. Within four days, she had developed deep tissue injuries on both heels measuring up to 6 centimeters across, plus cellulitis that spread up her right calf.

"At risk for diabetic infection that may threaten life or limb," her physician wrote on November 20, ordering immediate transfer to the emergency room to rule out bone infection.

The hospital found trauma injury to her right big toe, a stage 3 pressure injury on her tailbone, and unstageable pressure injuries on both heels. She spent a week hospitalized, including one day in intensive care, receiving intravenous antibiotics for cellulitis and sepsis.

Resident 140, a 6-foot-4-inch man admitted in August 2024 after a sacral fracture, developed similar wounds despite entering with intact skin except for an elbow injury. Two days after admission, staff noted a blister on his right foot. By August 21, he had developed an unstageable deep tissue injury on his right heel measuring 3.0 by 6.0 centimeters.

During the inspection, Resident 140 told investigators he developed multiple wounds on his right foot after admission. He said he had nothing wrong with his foot before entering the facility. He developed a wound on his right heel from his feet being pushed against the footboard of the bed, and sores on his toes because staff did not help him move.

"The staff was not consistent with dressing changes," he said. "Staff routinely told him that he would see a wound care nurse or physician, but he had not seen either when he asked to see them to answer his questions."

On August 27, during the federal inspection, Resident 140 developed a fever of 100.7 degrees and low blood pressure. He was transferred by ambulance to the emergency department, where doctors found cellulitis of his right lower limb, severe sepsis, and purulent drainage along his heel with streaking redness. He was admitted to intensive care and treated with antibiotics.

When inspectors observed him that day, his feet were touching the footboard of his bed despite his height, and he had purple discoloration on his right big toe.

The facility's own medical director told inspectors the pressure injuries both residents developed were facility-acquired and preventable. She said pressure wounds develop when protocol and care plans are not followed by staff, and any skin changes should be documented and reported the same day.

"Had proper interventions been completed, the injuries should not have developed," a physician assistant told inspectors.

For Resident 85, staff failed to follow the care plan intervention to off-load her heels from admission through the development of wounds. Although nurses documented notifying her primary care physician about the heel injury on November 16, there was no record of physician follow-up or additional attempts to reach the doctor.

Daily skin assessments were not completed accurately, and no additional interventions were added to her care plan when bilateral heel discoloration was first identified. Staff documented heel discoloration on November 16 but provided no further documentation until the physician's note four days later describing the extensive wounds and cellulitis.

Resident 140's case revealed similar failures. Despite care plan requirements to turn and reposition him frequently, staff interviews indicated it was unclear how often this should occur. The resident said staff did not help him move.

His care plan noted he was confined to a chair most of the time, required extensive assistance with bed mobility and transfers, and had left-sided weakness, yet he was assessed at only mild risk for skin breakdown. None of the care plan updates after admission considered his height and the footboard on his bed.

When a wound care physician ordered liquid protein supplement for wound healing, the resident frequently refused it, preferring a protein shake from his family. But staff never communicated these refusals and preferences to his primary care physician.

Daily skilled nursing notes revealed gaps in documentation, with no entries on August 15 and August 17, despite ongoing wound care needs.

The wound care nurse told inspectors that Resident 140's heel tissue had been intact during her first assessment on August 12. Therefore, his heel wound would be considered facility-acquired.

Beyond the pressure injury failures, inspectors found a medication error rate of 16.67 percent during observations. A licensed practical nurse applied a lidocaine patch to a resident's neck instead of the prescribed sacral area, documented giving medications that were refused, and administered a Parkinson's medication 50 minutes outside the allowed window.

"Of all medications, Parkinson's medications should be given on time," a physician assistant told inspectors. "Even small delays could cause a significant increase in Parkinson's disease symptoms, such as tremors or difficulty swallowing."

Staff also failed basic infection control practices, skipping hand hygiene before and after patient contact and not cleaning monitoring equipment between residents.

The facility submitted a plan to remove the immediate jeopardy on August 28, promising immediate education for all nursing staff, facility-wide skin assessments, and twice-per-shift monitoring rounds. State inspectors accepted the plan that evening, removing the immediate jeopardy designation while keeping the violation at the level of actual harm.

But the damage to both residents had already been done. Resident 85 was no longer at the facility by the time of the inspection. Resident 140 remained hospitalized with severe sepsis as inspectors completed their work.

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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