Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Amethyst Health of Algoma
Algoma, WI · 50 certified beds · Last Life Safety survey March 25, 2026
CMS Certification Number 525533 · first certified June 1994
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
- New ownershipOwnership changed July 1, 2025 (change of ownership)from FREMONT SNF OPCO LLC
Position within WI
36 citations — more than 94% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 7 citations; the earlier surveys in the window averaged 9.7. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens May 2027 — about 7 months from now. This facility’s last Life Safety survey was March 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
5 of the 36 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 36 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 36 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 13, 2023 | 3 |
| November 8, 2023 | 18 |
| January 8, 2025 | 8 |
| March 25, 2026 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-03-25 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2026-03-25 |
| K-0711 | Provide a written emergency evacuation plan. | 2 | 2026-03-25 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-01-08 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 2 | 2026-03-25 |
| K-0293 | Have properly located and lighted "Exit" signs. | 2 | 2025-01-08 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2025-01-08 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-01-08 |
What the citations cover
- Smoke Deficiencies 14
- Miscellaneous Deficiencies 5
- Emergency Preparedness Deficiencies 5
- Egress Deficiencies 5
- Other 7
| Category | Citations |
|---|---|
| Smoke Deficiencies | 14 |
| Miscellaneous Deficiencies | 5 |
| Emergency Preparedness Deficiencies | 5 |
| Egress Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Services Deficiencies | 3 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 25, 2026 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (April 25, 2026) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (May 27, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 25, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 25, 2026) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (April 25, 2026) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (June 5, 2026) |
| K-0925 | Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Deficient, Provider has date of correction (April 25, 2026) |
January 8, 2025 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (February 7, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (February 7, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 7, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 7, 2025) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (February 7, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (February 7, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (February 7, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 1, 2025) |
November 8, 2023 — 18 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (December 22, 2023) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (December 22, 2023) |
| K-0222 | 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. | Deficient, Provider has date of correction (December 22, 2023) |
| K-0255 | Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction. | Waiver has been granted (August 23, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (December 22, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (December 22, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Waiver has been granted (August 26, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Waiver has been granted (May 2, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (January 12, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (December 22, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 22, 2023) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (December 22, 2023) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Waiver has been granted (August 26, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Waiver has been granted (August 29, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (September 3, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 22, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (December 22, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted |
October 13, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (November 13, 2023) |
| K-0500 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (November 13, 2023) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (November 13, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.