Algoma, WI

Amethyst Health Of Algoma

2-star overall rating with 2-star inspections with $8,152 in total fines with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

1510 Fremont St, Algoma, WI

(920) 487-5511

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1994-06-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.98

Registered nurse staffing · state 0.97 · national 0.68

LPN hours / resident day

0.46

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

2.01

Nurse aide staffing · state 2.59 · national 2.35

Total nurse hours

3.45

All reported nurse hours · state 4.20 · national 3.89

Licensed hours

1.45

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.15

Weekend nurse staffing · state 3.72 · national 3.43

Weekend RN hours

0.58

Weekend registered nurse coverage · state 0.66 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

1.03

CMS adjusted RN staffing hours

Adjusted total hours

3.63

CMS adjusted total nurse staffing hours

Case-mix index

1.30

Higher values indicate more complex resident acuity

RN turnover

71%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

63%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,497

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

56.22

Composite VBP score used to determine payment impact.

Payment multiplier

1.0113

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

7.69

Performance 32.26% · Measure score 7.69 · Achievement 7.69 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

3.56

Baseline 4.28 hours · Performance 4.09 hours · Measure score 3.56 · Achievement 3.56 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.01%	10.72% 1.7 pts better	No Different than the National Rate · Eligible stays 52 · Observed rate 1.92% · Lower 95% interval 5.27%
Discharge to community	52.64%	50.57% 2.1 pts better	No Different than the National Rate · Eligible stays 46 · Observed rate 47.83% · Lower 95% interval 41.09%
Medicare spending per beneficiary	0.8	1.02 0.2 pts better
Drug regimen review with follow-up	80.95%	95.27% 14.3 pts worse	Numerator 17 · Denominator 21
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 21
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 21 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	4.65%	8.2% 3.5 pts worse	Numerator 4 · Denominator 86
Staff flu vaccination coverage	50.56%	42% 8.6 pts better	Numerator 45 · Denominator 89
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.3%	95.7% 2.6 pts better	93.4% 4.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 93.3% · 4Q avg 98.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.0% 5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	3.2% 3.2 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.9%	5.0% 4.1 pts better	11.4% 10.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9%
Percentage of long-stay residents who lose too much weight	5.7%	4.9% 0.8 pts worse	5.4% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 12.5% · Q3 3.7% · Q4 3.6% · 4Q avg 5.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	5.7%	16.6% 10.9 pts better	19.6% 13.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.0% · Q3 3.7% · Q4 10.7% · 4Q avg 5.7%
Percentage of long-stay residents who received an antipsychotic medication	8.0%	16.7% 8.7 pts better	16.7% 8.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 4.8% · Q3 8.3% · Q4 4.5% · 4Q avg 8.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	24.1%	21.1% 3 pts worse	16.3% 7.8 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 24.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	28.9%	17.3% 11.6 pts worse	14.9% 14 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 47.8% · Q3 33.3% · Q4 22.2% · 4Q avg 28.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	2.3% 1.4 pts better	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.7%	3.0% 1.3 pts better	1.7% About the same	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.7% · 4Q avg 1.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	21.3%	25.5% 4.2 pts better	19.8% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 12.3% · Q3 22.1% · Q4 23.7% · 4Q avg 21.3%
Percentage of long-stay residents with pressure ulcers	3.1%	5.5% 2.4 pts better	5.1% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 2.7% · Q3 0.0% · Q4 2.4% · 4Q avg 3.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	73.8%	86.8% 13 pts worse	81.7% 7.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 64.3% · Q3 63.6% · Q4 76.5% · 4Q avg 73.8%
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	72.1%	82.2% 10.1 pts worse	79.7% 7.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 72.1%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-08 · Fire 2025-01-08

4 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2023-11-08 · Fire 2023-11-08

7 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

18 fire-safety deficiencies

Top issue: Smoke (8 deficiencies)

Cycle 3 Health 2022-10-12 · Fire 2022-10-12

5 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

7 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-08

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-02-07

F · Potential for more than minimal harm 2025-01-08

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-02-07

F · Potential for more than minimal harm 2025-01-08

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2025-02-07

F · Potential for more than minimal harm 2025-01-08

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-02-07

F · Potential for more than minimal harm 2025-01-08

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-03-01

E · Potential for more than minimal harm 2025-01-08

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2025-02-07

D · Potential for more than minimal harm 2025-01-08

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-02-07

D · Potential for more than minimal harm 2025-01-08

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-02-07

F · Potential for more than minimal harm 2023-11-08

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2023-12-22

F · Potential for more than minimal harm 2023-11-08

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-01-12

F · Potential for more than minimal harm 2023-11-08

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-12-22

F · Potential for more than minimal harm 2023-11-08

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-09-03

F · Potential for more than minimal harm 2023-11-08

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-12-22

F · Potential for more than minimal harm 2023-11-08

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Not marked corrected

E · Potential for more than minimal harm 2023-11-08

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2023-12-22

E · Potential for more than minimal harm 2023-11-08

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-12-22

E · Potential for more than minimal harm 2023-11-08

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-12-22

E · Potential for more than minimal harm 2023-11-08

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2023-12-22

E · Potential for more than minimal harm 2023-11-08

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2024-08-26

E · Potential for more than minimal harm 2023-11-08

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-08-29

E · Potential for more than minimal harm 2023-11-08

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-11-08

K255 · Egress Deficiencies

Fire Safety

Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.

Corrected 2024-08-23

D · Potential for more than minimal harm 2023-11-08

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-11-08

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-08-26

D · Potential for more than minimal harm 2023-11-08

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-05-02

D · Potential for more than minimal harm 2023-11-08

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-12-22

F · Potential for more than minimal harm 2023-10-13

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2023-11-13

F · Potential for more than minimal harm 2023-10-13

K500 · Services Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2023-11-13

E · Potential for more than minimal harm 2023-10-13

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2023-11-13

F · Potential for more than minimal harm 2022-10-12

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-10-28

F · Potential for more than minimal harm 2022-10-12

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-11-01

E · Potential for more than minimal harm 2022-10-12

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-11-15

E · Potential for more than minimal harm 2022-10-12

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2022-10-24

Inspection history

Recent health citations

J · Immediate jeopardy 2025-11-03

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-11-04

F · Potential for more than minimal harm 2025-01-08

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-02-07

E · Potential for more than minimal harm 2025-01-08

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-02-07

D · Potential for more than minimal harm 2025-01-08

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-02-07

J · Immediate jeopardy 2024-06-11

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-04-27

F · Potential for more than minimal harm 2024-06-11

F837 · Administration Deficiencies

Health

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Corrected 2024-07-01

F · Potential for more than minimal harm 2023-11-08

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-12-22

E · Potential for more than minimal harm 2023-11-08

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-11-08

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-11-08

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-11-08

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-11-08

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2023-12-22

C · Minimal harm 2023-11-08

F922 · Environmental Deficiencies

Health

Have enough backup water supply for essential areas of the nursing home.

Corrected 2023-12-22

F · Potential for more than minimal harm 2022-10-12

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-11-03

D · Potential for more than minimal harm 2022-10-12

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2022-11-10

D · Potential for more than minimal harm 2022-10-12