Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 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.
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 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.
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.
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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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 0 | 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 | ★★★★★ | 0 | 0 |
| Edenbrook Of Green Bay | 24.5 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.