Amethyst Health Of Algoma

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

involved with Resident R2's wound progression. DON-B acknowledged there were missing weekly wound evaluations and verified the evaluations did not contain the location of the wound. When asked about treatment orders for Resident R2's coccyx, sacrum, etc., DON-B indicated the facility did not have assessments for each of the treatment areas. DON-B verified Resident R2's care plan was not updated until 9/26/25 but should have been updated upon discovery of the gluteal cleft wound on 8/5/25. When asked to check Resident R2's wound clinic order from 9/16/25, DON-B verified the order entered on 9/17/25 did not match the wound clinic order. When informed about WCP-D's concern for Resident R2's wheelchair cushion, DON-B verified interventions should have been addressed and updated as soon as the wound was noted. DON-B also confirmed a Braden Scale assessment was not completed with Resident R2's Significant Change of Condition MDS assessment. DON-B indicated photos were not obtained due to iPad issues when the facility changed ownership.On 10/28/25 at 3:53 PM, Surveyor observed Resident R2 in bed and noted Resident R2's air mattress was set at 400 pounds. Of note: Resident R2's weight on 10/28/25 was 228.8 pounds.On 10/29/25 at 12:50 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-G via phone. Surveyor noted Resident R2 had a stage 2 pressure injury on the gluteal cleft on 8/5/25; however, a weekly skin check on 8/19/25 indicated Resident R2 had a wound on the coccyx. When asked if the physician was notified, LPN-G indicated it was probably the same area and stated Resident R2 had three areas that were discovered at approximately the same time. Each wound progressed differently and more than likely merged into one wound with healed tissue in between. At one point, staff completed three different treatments. When asked if a wound assessment should have been completed for each area since each area had different orders, LPN-G indicated staff looked at the wound as one area. LPN-G verified accurate and thorough assessments should have been completed and should have contained the location of the wound. LPN-G verified there were issues with an iPad used for wound assessments and indicated assessments were likely missed. LPN-G entered an order for staff to document wound measurements in a progress note (which was not completed). When asked if staff could enter an assessment in Resident R2's medical

record without a photo, LPN-G indicated that was possible. LPN-G also indicated Braden Scale assessments and care plan updates may have been missed. LPN-G indicated Resident R2 could have used a ROHO cushion for longer than Resident R2's medical record indicated. Resident R2 had a Broda chair which was too big to use for transport. LPN-G indicated Resident R2 used a smaller wheelchair for transport to the wound clinic and stated the ROHO cushion may not have been put in the wheelchair. LPN-G confirmed Resident R2's medical record did not indicate Resident R2 had a ROHO cushion prior to 9/16/25. When informed that Resident R2's bed was set to 400 pounds, LPN-G indicated the bed should be set to Resident R2's weight. LPN-G indicated staff enter an order to ensure the mattress is checked for functioning, however, the order does not usually contain a weight setting. LPN-G verified Resident R2 did not have orders for either. When asked if Resident R2's wound vac was changed on 10/22/25, LPN-G indicated if the wound vac was not changed, staff should have entered a note to indicate why.The failure to ensure a resident received the appropriate care and treatment for a stage 2 facility-acquired pressure injury that progressed to a stage 4 infected pressure injury created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The immediate jeopardy was removed on 10/29/25. The deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement the following action plan: Educated staff on

the facility's skin and wound assessment process, timely transcription and implementation of physician orders, what to do if supplies are unavailable, care plan updates, and Braden Scale assessments Wound physician to round weekly with facility staff devoted to wound care. Implemented new skin and wound assessment forms.Implemented skin impairment/new pressure area audits twice weekly for 6 weeks.

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