Federal inspectors found immediate jeopardy violations at Amethyst Health of Algoma in November, citing the facility's failure to provide appropriate wound care that allowed a treatable injury to deteriorate into a serious infection requiring advanced treatment.
The problems began on August 5 when staff discovered a stage 2 pressure injury in the resident's gluteal cleft. But the facility's response was marked by confusion, missed assessments, and equipment failures that compounded the resident's deteriorating condition.
Two weeks later, during a skin check on August 19, nursing staff documented a wound on the resident's coccyx. Licensed Practical Nurse LPN-G later told inspectors this was "probably the same area" and said the resident actually had three wounds that were discovered around the same time.
Each wound progressed differently and likely merged into one larger injury with healed tissue between the damaged areas. At one point, staff were completing three different treatments simultaneously.
But the facility's wound assessment system was breaking down. Director of Nursing DON-B acknowledged to inspectors that weekly wound evaluations were missing entirely. The evaluations that did exist failed to specify the location of wounds, making it impossible to track which injuries were healing and which were worsening.
The resident's care plan wasn't updated until September 26 - nearly two months after the initial wound discovery. DON-B confirmed the plan should have been revised immediately when the gluteal cleft wound was first noted on August 5.
Equipment problems compounded the care failures. LPN-G told inspectors there were "issues with an iPad used for wound assessments" and said assessments were likely missed as a result. DON-B said photos of the wounds weren't obtained because of iPad problems that occurred when the facility changed ownership.
When inspectors observed the resident on October 28, they found the patient's air mattress was set to 400 pounds. The resident's actual weight that day was 228.8 pounds - meaning the therapeutic mattress was calibrated to nearly double the correct setting.
LPN-G confirmed to inspectors that the bed should be set to the resident's actual weight. The nurse said staff typically enter orders to ensure the mattress is checked for proper functioning, but those orders usually don't specify weight settings. In this case, the resident had no orders for either mattress checks or weight calibration.
The wheelchair situation was equally problematic. The resident had a Broda chair that was too large for transport to medical appointments. When traveling to the wound clinic, staff used a smaller wheelchair that may not have included the resident's ROHO pressure-relieving cushion.
LPN-G told inspectors the resident "could have used a ROHO cushion for longer than the medical record indicated." The nurse confirmed the resident's medical record showed no ROHO cushion use prior to September 16 - more than a month after the initial wound discovery.
A wound care physician who examined the resident on September 16 expressed concerns about the wheelchair cushion, but DON-B acknowledged that interventions should have been addressed and updated as soon as the wound was first noted in August.
The facility also failed to complete required risk assessments. DON-B confirmed that a Braden Scale assessment - used to evaluate pressure injury risk - was not completed when the resident had a significant change of condition that should have triggered the evaluation.
Treatment orders added to the confusion. When the wound clinic issued orders on September 16, the facility's entry the following day didn't match what the clinic had prescribed. DON-B verified the discrepancy when inspectors pointed it out.
LPN-G told inspectors that staff should have completed accurate and thorough assessments containing the specific location of each wound. Instead, nursing staff "looked at the wound as one area" even though each area had different treatment orders requiring separate documentation.
The nurse said staff could enter wound assessments in the medical record without photos, but acknowledged that both Braden Scale assessments and care plan updates "may have been missed."
When asked about a wound vacuum treatment that should have been changed on October 22, LPN-G said if the device wasn't changed as scheduled, staff should have documented why. No such documentation existed.
The cascade of missed assessments, equipment problems, and documentation failures allowed what should have been a manageable pressure injury to progress to a stage 4 infected wound requiring intensive treatment.
Federal inspectors determined the deficient care created "a reasonable likelihood for serious harm" and issued an immediate jeopardy finding - the most serious citation possible for nursing home violations.
The immediate jeopardy designation was removed on October 29 after the facility implemented corrective measures. But inspectors found the deficient practices continued at a level with "potential for more than minimal harm."
The facility's response included educating staff on skin and wound assessment processes, timely implementation of physician orders, procedures for when supplies are unavailable, care plan updates, and Braden Scale assessments.
Management arranged for a wound physician to conduct weekly rounds with facility staff devoted to wound care. The facility also implemented new skin and wound assessment forms and began conducting skin impairment audits twice weekly for six weeks.
But for the resident whose stage 2 pressure injury became an infected stage 4 wound, the corrective measures came too late. The case illustrates how seemingly routine care failures - missed assessments, wrong equipment settings, delayed care plan updates - can compound into serious medical complications that threaten resident safety and require intensive intervention to correct.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Amethyst Health of Algoma from 2025-11-03 including all violations, facility responses, and corrective action plans.