Amethyst Health of Algoma

In the surveyor’s words

From the most serious findings on record at Amethyst Health of Algoma, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Nov 3, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Jun 11, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Mar 25, 2026

  Based 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.Findings include:On 3/23/26, Dietary Manager (DM)-F confirmed the facility follows the Food and Drug Administration (FDA) Food… […]

• No harm, potential for more than minimal, widespreadF882Mar 25, 2026

  Based 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.Findings include:On 3/24/26 at 1:51PM, Surveyor interviewed LPN-C who stated LPN-C had been functioning as the facility's IP since March of 2025. LPN-C verified LPN-C did not complete specialized infection prevention and control training and stated no other staff in the facility are IP certified. […]

• No harm, potential for more than minimal, widespreadF812Jan 8, 2025

  Based 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. Findings include: On 1/6/25 at 8:44 AM, Surveyor interviewed Dietary Manager (DM)-D who was unsure which food code the facility followed. […]