Amethyst Health of Algoma

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 38 residents residing in the facility. The facility did not monitor and document food cooling temperatures. The facility did not test the Quaternary sanitizing solution per manufacturer's instructions. The facility did not ensure each refrigerator contained an internal thermometer to monitor safe food cooling temperatures. The facility did not practice safe food handling processes while serving food. The facility did not monitor the temperature of residents' room refrigerators.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 38 residents residing in the facility. Licensed Professional Nurse (LPN)-C was the facility's designated IP. LPN-C did not complete specialized infection prevention and control training.

Inspectors wroteBased on staff interview and record review, the facility did not ensure appropriate weight monitoring was provided for 5 residents (R) (R20, R29, R26, R24, and R15) of 6 sampled residents. R20, R29, R26, R24 and R15 were not re-weighed for weight loss or gain greater than 5 pounds (lbs). R20, R29, R26, R24, and R15's providers and/or representatives were not notified regarding weight loss or gain greater than 5 lbs. In addition, R20, R29, R26, R24 and/or R15's weights were not obtained using a consistent device.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 4 residents (R) (R44, R3, R35, R5) of 4 sampled residents. R44, R3, R35, and R5 were on enhanced barrier precautions (EBP). Staff did not wear the appropriate personal protective equipment (PPE) during high-contact resident cares. Findings Include: The facility's Enhanced Barrier Precautions policy, dated 3/25/24, indicates: It is the policy of this facility to implement Enhanced Barrier Precautions (EBP) for the prevention of transmission of multi drug-resistant organisms. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 5 residents (R) (R18, R22, R24, R30, and R33) of 10 sampled residents were offered influenza/pneumococcal vaccines as indicated. R18 was admitted to the facility on [DATE]. The facility did not obtain R18's consent or declination for the influenza and pneumococcal vaccine. R22 was admitted to the facility on [DATE]. The facility did not obtain R22's consent or declination for the pneumococcal vaccine. R24 was admitted to the facility on [DATE]. The facility did not obtain R24's consent or declination for the influenza and pneumococcal vaccine. R30 was admitted to the facility on [DATE]. The facility did not obtain R30's consent or declination for the influenza and pneumococcal vaccine. R33 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 5 residents (R) (R18, R22, R24, R30, and R33) of 10 sampled residents were offered the COVID-19 vaccine. R18 was admitted to the facility on [DATE]. The facility did not obtain R18's consent or declination to receive a COVID-19 vaccine. R22 was admitted to the facility on [DATE]. The facility did not obtain R22's consent or declination to receive a COVID-19 vaccine. R24 was admitted to the facility on [DATE]. The facility did not obtain R24's consent or declination to receive a COVID-19 vaccine. R30 was admitted to the facility on [DATE]. The facility did not obtain R30's consent or declination to receive a COVID-19 vaccine. R33 was admitted to the facility on [DATE]. The facility did not obtain R33's consent or declination to receive a COVID-19 vaccine.

Inspectors wroteBased on staff interview and record review, the facility did not ensure adequate monitoring of psychotropic medication was provided for 1 resident (R) (R5) of 5 sampled residents. R5 was prescribed Rexulti (an atypical antipsychotic medication) 0.5 milligrams (mg) once daily for dementia with agitation beginning on 12/18/25. R5's medical record did not include monitoring for adverse reactions or side effects of the antipsychotic medication. The facility's Psychotropic Medication Use policy, dated 8/1/25, indicates antipsychotic medications require monitoring for adverse effects which can include cardiovascular, neurological, and psychosocial effects. On 3/25/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including dementia, diabetes, kidney disease, and hypertension. [...]

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) agreed to a discharge or was notified when 1 resident (R) (R49) of 3 sampled residents was transferred to another skillled nursing facility. R49 was transferred to another skilled nursing facility on 1/7/26. R49's POAHC (POAHC-M) was not notified or contacted prior to the transfer. In addition, R49's medical record did not contain a recapitulation of stay.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R11) of 5 sampled residents was free from a significant medication error. R11 did not receive warfarin (a blood-thinning medication) 2.5 milligrams (mg) as ordered from 1/15/26 through 1/18/26 for a total of four missed doses. The facility's Administering Medications policy, revised April 2019, indicates: Medications are to be administered in accordance with prescriber orders .Medication errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to inform process changes and/or the need for additional staff training. On 3/24/26, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including dementia, atrial fibrillation, history of stroke, history of deep vein thrombosis, and hypertension. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the necessary care and services to prevent pressure injuries from developing and/or promote healing for 1 Resident (R) (R2) of 2 sampled residents. On 8/5/25, R2 developed a facility-acquired stage 2 pressure injury on the gluteal cleft. R2 also had treatment orders for coccyx and sacral wounds. On 9/16/25, R2 was seen at the wound clinic. A provider note indicated R2 did not have an adequate wheelchair cushion when R2 arrived. The pressure injury was classified as a stage 4 and was infected. The facility did not ensure weekly wound assessments were completed timely or accurately for each of R2's wounds. The gluteal cleft pressure injury was not added to R2's care plan until 9/26/25. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 34 residents residing in the facility. The facility did not store food in a manner to ensure food safety and did not use proper food dating practices. The facility did not follow safe food cooling protocols.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure food was served at a palatable temperature for 4 residents (R) (R24, R32, R87, and R239) of 14 sampled residents. R24, R32, R87, and R239 indicated hot food was not always served hot. During the breakfast meal on 1/7/25, food items were not served at a palatable temperature.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R87) of 2 sampled residents received appropriate care and services to prevent urinary tract infections (UTIs). The facility did not ensure R87 received catheter care in a manner that decreased the risk of infection. On 1/7/25, R87's uncovered catheter drainage bag was observed on the floor of R87's room.

Inspectors wroteBased on staff interview and record review, the facility did not ensure adequate supervision was provided for 1 resident (R) (R1) of 3 residents reviewed for elopement. R1 was assessed to be at risk for elopement after exiting the building without supervision on 3/5/24. A Wanderguard (a security device that triggers an alarm if the wearer exits the facility) was placed on R1's right ankle. On 4/27/24 at 1:35 PM, Housekeeper (HK)-C observed R1 outside the facility near the staff parking lot. Staff were unaware R1 had left the facility and redirected R1 back into the facility. An assessment indicated R1 had no injuries. An investigation determined R1 had exited the facility through a door that did not have a Wanderguard sensor installed. The door through which R1 exited had a door alarm that was not functioning and did not alarm and alert staff when R1 exited the building. [...]

Inspectors wroteBased on staff interview and record review, the facility's governing body did not ensure safe and efficient management of the facility by ensuring adequate funds were provided to pay vendors who supplied services to the facility. In addition, the facility did not ensure staff received their health insurance benefits and paychecks on a timely basis. This practice had the potential to affect all 34 residents residing in the facility. The governing body did not maintain current payment status with multiple vendors which resulted in past due balances, account holds, disconnection notices, or lapses in service for supplies, food, staff, medical record management, waste removal, lawn maintenance, and the emergency generator. The corporation's failure to keep service vendor contracts in good standing had the potential to negatively impact residents' quality of care and quality of life. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 38 residents residing in the facility. The facility did not monitor and document food cooling or cooked temperatures.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure nutritional needs were met for 6 Residents (R) (R4,R5, R7, R21, R24 and R79) of 6 residents reviewed who had an order for a carbohydrate-controlled diet. The facility did not follow physician ordered therapeutic carbohydrate-controlled diets when residents were served full carbohydrate meals, including full servings of dessert.

Inspectors wroteBased on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 Residents (R) (R21 and R15) of 2 residents reviewed. The facility did not report a resident-to-resident physical altercation involving R21 and R15 to the State Agency (SA).

Inspectors wroteBased on staff interview and record review, the facility did not ensure a resident-to-resident altercation was thoroughly investigated for 2 Residents (R) (R21 and R15) of 2 residents reviewed. The facility did not thoroughly investigate a resident-to-resident altercation involving R21 and R15.

Inspectors wroteBased on staff interview and record review, the facility did not ensure neurological checks were completed per policy for 2 Residents (R) (R24 and R9) of 5 residents reviewed for falls. Staff did not complete neurological checks after R24 fell on 9/14/23 and 9/22/23. Staff did not consistently complete neurological checks after R9 fell on 9/12/23.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R21) of 5 sampled residents was offered a pneumococcal vaccine as indicated. R21 was eligible for pneumococcal vaccination, but was not offered a pneumococcal vaccine.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish procedures to ensure the availability of water in the event of a loss of its normal water supply. This had the potential to affect all 24 residents residing in the facility. The facility did not have an emergency water plan that included a contract with a vendor to provide water to the facility in case of an emergency. In addition, the facility did not maintain the appropriate amount of drinking water on hand in case of an emergency.