Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Amethyst Health Of Algoma during CMS and state inspections, most recent first.
Food storage, cooling, sanitizing, and serving practices were not properly monitored. Staff did not complete cooling logs for multiple cooked foods, did not document sanitizer solution temperature, and used a reach-in cooler without an internal thermometer while the outside thermometer read 52°F. During meal service, an DM wore the same gloves throughout plating and handling food, touching utensils, surfaces, and resident meals. Room refrigerators also lacked temperature logs, and staff stated they did not monitor them.
Unqualified Infection Preventionist: The facility did not ensure that the designated IP completed specialized infection prevention and control training. An LPN had been serving as the IP and confirmed no specialized training had been completed, no other staff were IP certified, and the former DON/IP had left the facility. The DON and NHA both verified that the facility did not have a qualified IP.
Failure to Re-Weigh Residents and Notify Providers After Significant Weight Changes: The facility did not consistently monitor weights for five residents with conditions including obesity, malnutrition, dementia, heart failure, and diabetes. Records showed repeated weight changes greater than 5 lbs without re-weighing, provider/POA or guardian notification, or use of a consistent scale. Staff stated some residents were weighed on different devices, one scale was out of service, and the DON acknowledged missing weights and incomplete re-weights and notifications.
The facility failed to consistently follow EBP requirements during high-contact care. Surveyors observed staff assisting a resident with vomiting, working with a resident with a PICC line, transferring a resident with a Hoyer lift, and transferring a resident with a urinary catheter without wearing the required gown and gloves. Interviews showed staff were unclear about which residents were on EBP, and PPE was not consistently available outside resident rooms.
Failure to Document Vaccine Offers and Consent: The facility did not document consent or declination for influenza and/or pneumococcal vaccines for 5 sampled residents. Records showed residents with diagnoses including CHF, AFib, COPD, diabetes, malnutrition, and respiratory failure, with mixed cognitive status, while an LPN stated influenza vaccines were last offered previously and was not aware of CDC pneumococcal guidance. The DON said immunization records were being reviewed and vaccines would be offered as necessary.
Failure to Offer and Document COVID-19 Vaccine Status: The facility did not ensure that 5 of 10 sampled residents were offered the COVID-19 vaccine or that consent or declination was documented. The affected residents had varied medical histories including AFib, HF, COPD, diabetes, malnutrition, hepatic encephalopathy, and respiratory failure, and several had intact or moderately impaired cognition. The LPN and DON stated residents were last offered the vaccine and that immunization records were still being reviewed.
A resident with vascular dementia, diabetes, and right-side paralysis, and with severely impaired cognition and an activated POA for healthcare, was transferred to another SNF without prior notification or involvement of the POA in discharge planning, contrary to the facility’s own admission agreement and procedures. The resident’s record contained only a physician-signed discharge order with no resident or representative signature, no documented discharge communication, and no recapitulation of stay. The social services/discharge coordinator confirmed they did not contact the POA or obtain required signatures, and the administrator acknowledged the discharge process was not carried out according to facility policy.
A resident with dementia and severe cognitive impairment was prescribed Rexulti for behavior changes, but the medical record did not include monitoring for adverse reactions or side effects. The DON confirmed the facility typically documents psychotropic monitoring on the MAR/TAR and in the care plan, but no such documentation was present for the resident’s antipsychotic medication.
A resident with dementia, atrial fibrillation, prior stroke, prior DVT, and HTN missed four consecutive doses of warfarin when the medication was not added to the MAR and was not administered as ordered. The resident’s INR remained below the therapeutic range, and the DON leadership was unaware the doses had been missed.
A resident with severe cognitive impairment and a history of pressure ulcers developed a new stage 2 pressure injury that progressed to a stage 4 infected wound with osteomyelitis due to failures in timely wound assessment, documentation, care plan updates, and implementation of physician orders. Inadequate pressure-relieving devices and missed wound vac changes further contributed to the deficiency.
The facility failed to store and prepare food in a sanitary manner, affecting all residents. Surveyors found food items without use-by dates and improper cooling logs, with staff unaware of correct procedures. The Dietary Manager and other staff lacked knowledge of food storage and cooling policies.
The facility failed to serve meals at palatable temperatures, affecting four residents. Meals, including breakfast and coffee, were served cold, with food temperatures recorded below FDA guidelines. Operational issues, such as delayed breakfast service and lack of a documented policy on meal serving, contributed to the deficiency.
A resident with a urinary catheter was observed with their catheter drainage bag uncovered and in contact with the floor, contrary to the facility's policy. The resident, who was not cognitively impaired, reported that staff had assisted with transferring the catheter bag, but it was left on the floor by an unknown staff member. A CNA and the Director of Nursing confirmed that the catheter bag should be hung below the bladder level and not touch the floor to prevent infections.
A resident with severely impaired cognition and at risk for elopement exited a facility unsupervised due to a malfunctioning door alarm and lack of Wanderguard sensor. The resident was found outside by a housekeeper and returned without injury. The facility's failure to ensure the alarm system was functioning and to provide adequate supervision created immediate jeopardy, which was later corrected.
The facility's governing body failed to manage finances effectively, resulting in unpaid vendor accounts, delayed staff paychecks, and lapses in health insurance coverage. Essential services like food supply, medical records, and emergency power were disrupted, impacting resident care. Staff faced financial strain due to late payments, and the facility struggled with vendor relations and service continuity.
Food Storage, Cooling, Sanitizing, and Serving Practices Not Properly Monitored
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards. During kitchen observations, pre-cooked and cooled foods were found in the reach-in cooler and walk-in freezer, including chicken soup, hamburgers, goulash, beef stew, and another container of chicken soup. The same foods were still present during a later kitchen observation the next day. The facility also maintained a food cooling log that showed multiple cooked items with incomplete cooling documentation, including meatloaf, baked beans, pureed eggs, carrots, potato soup, stroganoff, broccoli, mashed potatoes, shepherd's pie, chicken, vegetables, egg puree, and chicken soup. Several entries showed only initial temperatures or temperatures after one or two hours, with no further cooling temperatures documented. The facility did not document the temperature of the quaternary sanitizing solution used in sanitizing buckets and the three-compartment sink. The sanitizer log contained the time the sink and buckets were filled and the PPM, but it did not include the solution temperature. The Dietary Manager confirmed staff did not obtain or document the temperature of the sanitizing solution, and stated the log could be amended to include it. The Hydrion Quaternary test strip instructions required the solution to be between 65 and 75 degrees Fahrenheit at the time of testing. The reach-in cooler used for food storage did not contain an internal thermometer. The Dietary Aide who inspected the cooler confirmed the absence of an internal thermometer, and the Dietary Manager stated staff used the outside thermometer instead. The outside thermometer on the cooler showed 52 degrees Fahrenheit. During breakfast service, the Dietary Manager wore the same gloves throughout meal service, touched plates, serving utensils, the steam table, and countertops, tore a waffle with gloved hands, and continued plating food for resident consumption without removing the gloves. In resident rooms, personal refrigerators were observed in several rooms, but no temperature logs were present. Housekeeping staff stated they did not check refrigerator temperatures or monitor food in the refrigerators, and residents reported staff did not monitor or maintain their room refrigerators.
Unqualified Infection Preventionist
Penalty
Summary
The facility did not ensure that the staff person designated as the Infection Preventionist (IP) completed specialized infection prevention and control training. Licensed Practical Nurse (LPN)-C had been functioning as the facility’s IP since March 2025, but verified that no specialized infection prevention and control training had been completed and that no other staff in the facility were IP certified. LPN-C stated that the role was limited to completing resident and staff vaccinations and the antibiotic line list, and that there was not much time to complete other IP tasks. The former DON had been certified but no longer worked at the facility. The DON and NHA both confirmed that the facility did not have a qualified IP, and the NHA stated that the former DON and IP had ended employment and LPN-C had assumed the IP role.
Failure to Re-Weigh Residents and Notify Providers After Significant Weight Changes
Penalty
Summary
The facility did not ensure appropriate weight monitoring for five residents, including failure to re-weigh residents after weight changes greater than 5 pounds, failure to notify providers and/or representatives of those changes, and use of inconsistent weighing devices. The facility policy stated that resident weights are to be monitored for unintended loss or gain, that any weight change of 5% or more is to be retaken the next day for confirmation, and that verified significant changes are to be reported to the dietitian and tracked by the interdisciplinary team. For one resident with morbid obesity and type 2 diabetes, the record showed multiple weekly weights with changes greater than 5 pounds, including a loss of 7.8 pounds and 8.2 pounds, but the resident was not re-weighed and the provider and activated POA were not notified. A nurse stated the resident should have been re-weighed on those occasions and that notification should have occurred. The resident’s weights were obtained with a mechanical lift scale, and staff reported that the stand-up scale had been out of service in February before a new scale was obtained in March. For another resident with dementia, heart failure, and multiple sclerosis, the record showed weight changes greater than 5 pounds, including a loss of 5.3 pounds and gains of 6.5 pounds and 7 pounds, but the resident was not re-weighed and the provider and POA were not notified. Staff documented that the resident could not safely balance on the standing scale and refused weighing in the Hoyer lift, and no other functioning scale was available at that time. A nurse stated the resident should have been re-weighed and that weekly weights were expected on the resident’s bath day. A third resident with obesity and type 2 diabetes had weight changes including a loss of 13.3 pounds and 7.4 pounds, but the record did not show re-weighing or provider/guardian notification for those changes. The resident’s weights were taken on both standing and wheelchair scales, and one weight entry was later disputed and reassessed by the Registered Dietitian. A fourth resident with moderate protein-calorie malnutrition and type 2 diabetes had weight changes including a loss of 7.6 pounds and a gain of 9.2 pounds, but the resident was not consistently re-weighed or monitored using a functioning scale when the wheelchair/standing scale was unavailable; staff documented that the resident was a bilateral amputee and a mechanical lift scale was later ordered. A fifth resident with protein-calorie malnutrition, dementia, Alzheimer’s disease, and anorexia had multiple weight changes greater than 5 pounds, including a loss of 7 pounds, a loss of 6 pounds, and a gain of 20 pounds, but the resident was not re-weighed consistently and staff did not use a consistent scale after the facility obtained a new scale. The DON stated that residents’ weights were missing, staff were not documenting weights, and re-weights and provider/resident representative updates were not being completed as required.
Failure to Use EBP During High-Contact Resident Care
Penalty
Summary
The facility did not maintain an infection prevention and control program to prevent the development and transmission of communicable disease and infection for residents on Enhanced Barrier Precautions (EBP). The facility’s EBP policy stated that gown and glove use was required during high-contact resident care activities, including transferring and providing hygiene, and that PPE should be available near or outside the resident’s room. However, surveyors observed that PPE carts were not outside residents’ rooms during the survey period, and staff interviews showed inconsistent understanding of which residents required EBP and when PPE was needed. R44 had diagnoses including peritoneal abscess, enterotoxigenic E. coli infection, and type 2 diabetes, and had a PICC line with an order for EBP. Surveyors observed a CNA enter R44’s room to assist with vomiting without hand hygiene or PPE and later observed a PTA working with R44 without PPE, only applying gloves after the interaction had begun. The DON stated R44 should have been on EBP because of the midline IV and that staff should use PPE during cares, while an LPN stated R44 was not on EBP. The PTA later stated they were not aware R44 was on EBP until noticing the sign on the wall. R3 had end stage renal disease and was dependent on hemodialysis with a permacath, but the medical record did not contain an EBP order at the time of review. R3 stated staff did not wear gowns during high-contact cares and only used gloves on occasion, and surveyors did not observe an EBP sign or gowns in the room. R35 had an EBP order, and surveyors observed two CNAs transfer R35 into bed with a Hoyer lift and adjust linens without gowns or gloves. R5 had an EBP order and a care plan noting increased infection risk related to a urinary catheter; surveyors observed two CNAs transfer R5 from a recliner to a wheelchair and handle the catheter bag and blanket without PPE, despite an EBP sign posted above the bed.
Failure to Document Vaccine Offers and Consent
Penalty
Summary
The facility did not ensure that influenza and pneumococcal vaccines were offered and documented for 5 of 10 sampled residents. R18, R24, R30, and R33 did not have consent or declination documented for influenza vaccination, and R18, R24, R30, and R33 also lacked consent or declination documentation for pneumococcal vaccination. R22 did not have consent or declination documented for the pneumococcal vaccine. The facility’s vaccine policy stated that residents are to be assessed upon admission and annually, educated on vaccine benefits and risks, and that informed consent is to be obtained prior to vaccination. Record review showed that the affected residents had varying medical histories and cognitive status. R18 had atrial fibrillation, heart failure, and type 2 diabetes, with a BIMS score of 14 indicating intact cognition. R22 had atrial fibrillation, heart failure, and a cardiac pacemaker, with a BIMS score of 13; the record showed prior pneumococcal vaccines but no current pneumococcal consent or declination. R24 had frostbite with tissue necrosis of both feet, malnutrition, and type 2 diabetes, with a BIMS score of 14. R30 had hepatic encephalopathy, chronic hepatitis C, and COPD, with a BIMS score of 9 and no history of pneumococcal vaccines. R33 had heart failure, COPD, emphysema, and respiratory failure with hypoxia, with a BIMS score of 12; the record showed prior influenza and pneumococcal vaccines but no current consent or declination documentation. During interview, the LPN stated the last time residents were offered influenza vaccine was 10/21/25 and was not aware of CDC pneumococcal vaccination guidelines, while the DON stated immunization records were being reviewed and that the facility would offer vaccines as necessary.
Failure to Offer and Document COVID-19 Vaccine Status
Penalty
Summary
The facility did not ensure that 5 of 10 sampled residents were offered the COVID-19 vaccine and did not obtain consent or declination documentation for those residents. The residents identified were R18, R22, R24, R30, and R33. The facility’s Vaccine Policy, revised 10/6/25, states that nursing staff will assess each resident’s vaccination status upon admission and annually, provide education on the risks, benefits, and potential side effects of recommended vaccines, and maintain accurate vaccine records and immunization logs. Record review showed that R18, R22, R24, R30, and R33 each had medical records that lacked a COVID-19 vaccine consent or declination. R18 had diagnoses including atrial fibrillation, heart failure, and type 2 diabetes, with a BIMS score of 14/15 and a prior COVID-19 vaccine on 10/8/24. R22 had atrial fibrillation, heart failure, and a cardiac pacemaker, with a BIMS score of 13/15 and a prior COVID-19 vaccine on 10/28/22. R24 had frostbite with tissue necrosis of both feet, moderate protein-calorie malnutrition, and type 2 diabetes, with a BIMS score of 14/15 and no history of COVID-19 vaccines. R30 had hepatic encephalopathy, chronic viral hepatitis C, and COPD, with a BIMS score of 9/15 and a prior COVID-19 vaccine on 5/11/22. R33 had heart failure, COPD, emphysema, and respiratory failure with hypoxia, with a BIMS score of 12/15 and a prior COVID-19 vaccine on 12/13/21. During interview, the LPN and DON stated residents were last offered the COVID-19 vaccine on 10/21/25 and that they were reviewing immunization records; the LPN also stated she was in the process of offering and obtaining consent for all residents, including these five.
Failure to Notify POA and Document Discharge Planning for Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify and involve a resident’s activated Power of Attorney for Healthcare (POAHC) in the discharge and transfer process, and the absence of required discharge documentation, including a recapitulation of stay. The resident had vascular dementia, diabetes, and right-side paralysis from a cerebral infarction, with a BIMS score of 5/15 indicating severely impaired cognition, and an activated POAHC to assist with medical decisions. The facility’s admission agreement stated that all transfers or discharges would comply with federal and state regulations, that discharges would occur only under specified procedures, and that the facility would provide preparation and orientation involving the resident and representative in discharge planning and post-discharge care arrangements. Despite this, the resident was transferred to another skilled nursing facility via transportation service, with no family or POAHC present, and without documented involvement of the POAHC in discharge planning. Record review showed a physician-signed discharge order, but the section for the resident or resident representative signature was blank, and there was no documentation of discharge communication or a recapitulation of stay in the medical record. The POAHC reported not being included in any discharge planning meetings, not initiating the transfer, and not being informed of any potential transfer during the months preceding the move; the POAHC only learned of the transfer after it had already occurred and did not receive or sign any transfer paperwork. The Social Services and Admission/Discharge Coordinator acknowledged that they are responsible for working with the resident or representative during discharge planning, ensuring care plan updates, obtaining signatures, and documenting communication, but confirmed that they did not contact the POAHC, did not obtain the POAHC’s signature, and that the record lacked discharge communication. The Nursing Home Administrator acknowledged that the discharge process for this resident did not occur in accordance with facility policy.
Lack of Monitoring for Psychotropic Medication
Penalty
Summary
The facility did not ensure adequate monitoring of psychotropic medication for one resident, R5, who was prescribed Rexulti 0.5 mg by mouth once daily for dementia with agitation beginning on 12/18/25. R5 was admitted to the facility with diagnoses including dementia, diabetes, kidney disease, and hypertension, and the most recent MDS assessment dated 2/14/26 showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. The medication was administered as ordered through the date of the survey. On 3/25/26, the surveyor reviewed R5’s medical record, including physician orders, the MAR, and the care plan, and found no documentation of monitoring for adverse reactions or side effects of the antipsychotic medication. The facility’s Psychotropic Medication Use policy states that antipsychotic medications require monitoring for adverse effects, including cardiovascular, neurological, and psychosocial effects. The DON verified that adverse reaction and side effect monitoring is typically documented on the MAR or TAR and in the care plan, and confirmed that R5’s record did not contain such monitoring for Rexulti.
Missed Warfarin Doses
Penalty
Summary
R11 was not free from a significant medication error when warfarin 2.5 mg was not administered as ordered for four consecutive days. R11 was admitted with diagnoses including dementia, atrial fibrillation, history of stroke, history of deep vein thrombosis, and hypertension, and the MDS assessment showed severe cognitive impairment with a BIMS score of 7 out of 15. The care plan identified anticoagulant therapy related to atrial fibrillation and directed staff to administer anticoagulant medication as ordered and obtain and report lab results. The January 2026 MAR showed warfarin 2.5 mg was given as ordered through 1/14/26, but the medication was not added to the MAR and was not administered from 1/15/26 through 1/18/26. The 1/15/26 INR was 1.1, below the therapeutic range of 2 to 3, and a physician fax ordered warfarin 2.5 mg daily with a repeat INR on 1/19/26. The 1/19/26 INR was 1.0, and a nursing progress note documented that R11 had not received warfarin since 1/14/26. The Assistant Director of Nursing verified the missed doses, and the Nursing Home Administrator was not aware that four doses had been missed.
Failure to Prevent and Manage Pressure Injury Progression
Penalty
Summary
A resident with a history of cerebral palsy, severe cognitive impairment, and prior pressure ulcers developed a new stage 2 pressure injury on the gluteal cleft while in the facility. The facility failed to provide necessary care and services to prevent the progression of this wound, as evidenced by incomplete and untimely weekly wound assessments, lack of accurate documentation regarding wound location, and failure to update the care plan promptly when the new wound was identified. The resident's Braden Scale assessment, which should have been completed upon a significant change of condition, was not performed as required by facility policy. The resident's wounds were not consistently or accurately assessed, with missing measurements and unclear documentation about the specific locations of each wound. Orders for wound care were not always transcribed or implemented correctly, and there were discrepancies between physician and wound clinic orders. The resident did not have an adequate wheelchair cushion for offloading pressure, and the specialty bed was not set to the correct weight, both of which are critical interventions for pressure injury prevention and management. Additionally, the wound vac was not changed as ordered due to supply issues, and there was no documentation of follow-up with the wound clinic when this occurred. Staff interviews revealed confusion regarding the number and location of wounds, with some staff treating multiple wounds as a single area and failing to complete separate assessments for each. There were also missed care plan updates and Braden assessments, and issues with obtaining wound photos due to equipment problems. These failures resulted in the resident's stage 2 pressure injury progressing to a stage 4 infected wound with osteomyelitis, requiring advanced interventions including wound vac therapy, antibiotics, and a urinary catheter.
Removal 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 with facility staff devoted to wound care
- Implemented new skin and wound assessment forms
- Implemented skin impairment/new pressure area audits
Deficiency in Food Storage and Cooling Practices
Penalty
Summary
The facility failed to ensure food was stored and prepared in a sanitary manner, potentially affecting all 34 residents. During a kitchen tour, surveyors observed various food items in the cooler, freezer, and dry storage areas that were not labeled with use-by dates, contrary to the facility's policy and the FDA Food Code. The Dietary Manager (DM) was unaware of the specific food dating policy and did not know how long food could be stored, indicating a lack of knowledge and adherence to proper food storage practices. Additionally, the facility did not follow safe food cooling protocols. The cooling logs reviewed by the surveyor showed that out of 50 food entries, only 6 items were cooled to 41 degrees or less within the required 6-hour time frame. The remaining entries were incomplete or contained temperatures above the safe cooling thresholds. The DM misunderstood the cooling log directions, and other staff members, including a cook and a dietary aide, were unclear about the correct food cooling steps and temperatures. Interviews with the kitchen staff revealed a lack of awareness and understanding of the facility's food storage and cooling policies. The Dietary Manager and other staff members were unable to correctly identify the appropriate procedures for food storage and cooling, which contributed to the deficiency. The Nursing Home Administrator expected the kitchen staff to be knowledgeable about these procedures, but the observations and interviews indicated otherwise.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable temperature for four residents, as observed during a survey. Residents reported that their meals, including breakfast and coffee, were served cold, which affected their dining experience. The surveyor noted that meal trays were not kept in a heated serving cart, and food temperatures were recorded significantly below the recommended levels. For instance, eggs were served at 98.2 degrees Fahrenheit, sausage at 93.5 degrees Fahrenheit, and waffles at 89.9 degrees Fahrenheit, all of which are below the FDA guidelines for safe and palatable food temperatures. The deficiency was further compounded by operational issues within the facility. The Dietary Manager indicated that breakfast was delayed due to a lack of communication about the reopening of the dining room, and the Director of Nursing noted that meal delivery was slowed by the need for staff to don protective gear due to illness. Despite these challenges, the facility did not provide a policy on meal serving and food temperatures when requested by the surveyor, indicating a lack of procedural guidance. The Nursing Home Administrator expected kitchen staff to adhere to existing policies, but the absence of a documented policy suggests a gap in ensuring food safety and quality.
Inadequate Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a resident received appropriate catheter care to prevent urinary tract infections. The resident, who had a urinary catheter due to benign prostatic hyperplasia, was observed with their catheter drainage bag uncovered and in contact with the floor. This observation was made while the resident was seated in a recliner, and the catheter bag was not placed in a dignity bag as required by the facility's policy. The resident, who was not cognitively impaired, indicated that staff had assisted with transferring the catheter bag during a move from the bed to the recliner, but the bag was left on the floor by an unknown staff member. A Certified Nursing Assistant (CNA) confirmed that the catheter bag should not be on the floor and should be hung below the level of the bladder. The Director of Nursing also confirmed that catheter bags should be hung below the bladder level and should not touch the floor. The facility's policy, dated November 2023, clearly states that catheter tubing and drainage bags must be kept off the floor to prevent urinary tract infections, yet this protocol was not followed in the case of this resident.
Failure to Prevent Resident Elopement Due to Malfunctioning Alarm
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as being at risk for elopement. The resident, who had a history of stroke, vascular dementia, and severely impaired cognition, was assessed to be at risk for elopement after previously exiting the building without supervision. Despite being equipped with a Wanderguard, the resident was able to leave the facility through a door that lacked a Wanderguard sensor and had a malfunctioning door alarm. This allowed the resident to exit the building unnoticed by staff. On the day of the incident, a housekeeper observed the resident outside near the staff parking lot, unsupervised and without a wheelchair. The resident was redirected back into the facility without difficulty and was assessed to have no injuries. However, the investigation revealed that the door alarm system was disarmed, which contributed to the resident's unsupervised exit. The resident's care plan had previously identified the need for a Wanderguard due to poor impulse control and impaired safety awareness. The facility's failure to ensure the door alarm system was functioning and to provide adequate supervision for the resident created a situation of immediate jeopardy. The resident's severely impaired cognition and high risk for falls, combined with the environmental hazards outside the facility, posed a reasonable likelihood of serious harm. The deficiency was identified as past non-compliance, as the immediate jeopardy was removed and corrected on the same day of the incident.
Removal Plan
- Initiated supervision for R1
- Posted staff at each doorway to ensure no other residents left unsupervised
- Interviewed and assessed other residents for elopement risk
- Educated all staff on the alarm system and elopement
- Completed an elopement drill and tested both alarm systems
Financial Mismanagement Leads to Service Disruptions
Penalty
Summary
The facility's governing body failed to ensure the safe and efficient management of the facility by not providing adequate funds to pay vendors and staff. This resulted in multiple accounts being placed on hold, disconnection notices, and lapses in services essential for resident care, such as supplies, food, and medical record management. The facility's accounts with various suppliers, including janitorial, medical, and food services, were on hold due to nonpayment, leading to shortages and disruptions in service. Additionally, the facility's emergency generator was at risk of repossession due to unpaid invoices. Staff members experienced delays in receiving their paychecks and health insurance benefits, causing financial strain and lapses in coverage. The Nursing Home Administrator (NHA) and Director of Nursing (DON) reported receiving numerous calls from vendors and contractors regarding unpaid bills, and the facility frequently changed vendors, complicating operations. The facility's financial instability also affected its ability to maintain essential services, such as lawn maintenance and garbage pickup, further impacting the quality of life for residents. The facility's financial mismanagement extended to its inability to pay the Medical Director, who had not been compensated since starting in January 2023. Despite attempts to prioritize critical areas like food, payroll, and medical record access, the facility struggled to maintain consistent service and faced challenges in staff retention and resident care. The NHA and DON expressed concerns about the facility's capacity to care for new admissions, given the ongoing financial difficulties and the potential for staff burnout.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Algoma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kewaunee Health Services | 11.2 mi | ★★★★★ | 4 | 0 |
| Door County Memorial Hospital Snf | 16.4 mi | ★★★★★ | 3 | 0 |
| Sturgeon Bay Health Services | 16.5 mi | ★★★★★ | 8 | 0 |
| Brown Cty Comm Treatment Ctr-bayshore Village | 23.8 mi | ★★★★★ | 8 | 0 |
| Edenbrook Of Green Bay | 24.5 mi | ★★★★★ | 5 | 0 |
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