Alamo Nursing Home Inc

and removed the catheter securement device from the resident's leg.

Observed Resident #108's buttocks with a large non-blanchable area in the middle and a large open wound on the right buttocks.

The wound on the right buttocks had an area of eschar (dead tissue) and a bright red linear (line) open wound approximately 4 inches long that was actively bleeding. CNA Y reported that the red wound was new. CNA Y performed incontinence care, rolled up the wet pad underneath the resident and then pulled it out from under the resident's butt. CNA Y obtained a tube of barrier cream that was sitting on the resident's nightstand and applied the cream over the wounds. CNA Y reported that the day before the barrier cream was missing, but normally the CNA's apply cream to wounds during incontinence care. CNA Y reported that Resident #108 did not use incontinence briefs and was always continent of bowel and bladder. It was observed that CNA Y and LPN OO did not maintain EBP and wear a gown prior to providing direct care. In an interview on 9/17/25 at 9:12 AM, LPN OO reported that she frequently worked Resident #108's hall but had not observed Resident #108's wound on her buttocks. In an interview on 9/17/25 at 10:06 AM, Unit Manager (UM) X reported she had assessed Resident #108's wound on 9/16/25 along with the wound provider; Resident #108's wound on her right buttocks was superficial but had worsened since the previous assessment. UM X reported that the wound is not being covered with a bandage, but that the CNA's have a barrier cream in the room to use as needed. Resident #108's wound was observed at 10:10 AM along with UM X who reported the wound looked much worse than the day before. UM X pointed out a small superficial round wound on the lower right buttock that she was aware of and reported that the area of eschar and the bright red linear wound were new. UM X reported that staff should not pull the linens, pads or briefs out from under the resident due to potential for shearing (skin on the surface is pulled away from underlying tissue when linen is pulled across skin). UM X reported that Resident #108 required EBP due to wounds and catheter, but that it was not posted at the door. In an interview on 9/17/25 at 10:39 PM, Director of Nursing (DON) B reported that Resident #108 was cognitively intact and would be able to verbalize events related to her care. DON B reported that all wound care treatment orders should be administered by nursing staff so that the nurse was observing the wound routinely. In an interview on 9/17/25 at 12:27 PM, CNA DD reported working with Resident #108 the previous night shift. CNA DD reported that Resident #108 had a painful wound on her bottom, CNA DD used a spray wound cleanser, applied barrier cream, and change the resident's brief once that night. CNA DD reported that the wound was red, elongated and had yellow open areas. In an interview on 9/17/25 at 12:31 PM, LPN BB reported that she had not seen Resident #108's wound; that hall is very busy and difficult to get through medication pass. In an interview on 9/17/25 at 1:50 PM, UM X reported that she had spoken to the provider and Resident #108 wound orders have been changed to Medi Honey (a topical medication that promotes a moist wound environment and debridement (removes dead, infected, or damaged tissue from a wound) and will be covered with a bandage. UM X had applied the new wound dressing.Review of Resident #108's Physician Orders start dated 9/18/25 revealed, Right gluteal unstageable (pressure injury where the depth cannot be determined due to slough (dead tissue) or eschar) wound, cleanse with wound cleanser apply Medi Honey and collagen (maintains moist environment) cover with border gauze in the morning for wound care.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/22/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Alamo Nursing Home Inc

8290 W C Ave Kalamazoo, MI 49009

SUMMARY STATEMENT OF DEFICIENCIES

Review of Resident #108's Physician Orders start date 8/26/25 revealed, Enhanced barrier precautions r/t (related to) foley (urine catheter) and pressure wounds.Review of Resident #108's Kardex (direct care guide) revealed, Gloves and Gowns (enhanced barrier precautions/EBP) Required for following: dressing, bathing, showering, changing of briefs or toileting, personal hygiene, transferring, changing linens, device and/or wound care .Review of Resident #108's Wound Note dated 9/16/25 revealed, right gluteal (buttock) Stage 3, 6.0 (centimeters) x 2.9 x 0.1.scant amount of serosanguineous (containing blood) drainage, area fragile and declined. It was noted that the wound significantly increased in size between assessments.

During an observation on 9/17/25 at 8:45 AM in Resident #108's room with CNA Y and LPN OO. CNA Y and LPN OO did not don gowns prior to care. Resident #108 was reporting that her pants are soaking wet.

Observed catheter tubing twisted on Resident #108's leg and tubing full of urine. LPN OO reported that the resident's urine was flowing back to her bladder because the placement of the catheter tubing is not below her bladder and therefore overflowing onto the bed. LPN OO adjusted the catheter and removed the catheter securement device from the resident's leg.

Observed Resident #108's buttocks with a large non-blanchable area in the middle and a large open wound on the right buttocks. CNA Y performed incontinence care, rolled up the wet pad underneath the resident and then pulled it out from under the resident's butt. CNA Y obtained a tube of barrier cream that was sitting on the resident's nightstand and applied the cream over the wounds. It was observed that CNA Y and LPN OO did not maintain EBP and wear a gown prior to providing direct care. In an interview on 9/17/25 at 10:06 AM, Unit Manager (UM) X reported she had assessed Resident #108's wound on 9/16/25 and it had worsened since the previous assessment. Resident #108's wound was observed at 10:10 AM along with UM X who reported the wound looked much worse than the day before. UM X was not wearing a gown while she assisted the resident to reposition in bed for the observation. UM X reported that Resident #108 required EBP due to wounds and catheter, but that it was not posted at the door.

Facility ID: