Amethyst Health Of Algoma

Penalties

• Nov 3, 2025 — Fine ($143,202)
• Jun 11, 2024 — Fine ($8,152)

Inspection findings

1. Mar 25, 2026 Fire Safety · 16 findings
   • Not serious Scope/severity F

     E0013 Emergency Preparedness Deficiencies

     Develop Emergency Preparedness policies and procedures.

     Corrected Apr 25, 2026 · CMS fire safety

   • Not serious Scope/severity F

     E0020 Emergency Preparedness Deficiencies

     Establish policies and procedures including evacuation.

     Corrected May 27, 2026 · CMS fire safety

   • Not serious Scope/severity D

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected Apr 25, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Apr 25, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Apr 25, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Apr 25, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Apr 25, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 25, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0882 Infection Control Deficiencies

     Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

     Corrected Apr 25, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0883 Infection Control Deficiencies

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

     Corrected Apr 25, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0887 Infection Control Deficiencies

     Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

     Corrected Apr 25, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

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

     Corrected Apr 25, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 25, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Apr 25, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected Jun 5, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0925 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure that sources of ignition are removed from patients receiving respiratory therapy.

     Corrected Apr 25, 2026 · CMS fire safety

2. Nov 3, 2025 Health · 1 finding
   • Serious Scope/severity J Complaint

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Nov 4, 2025 · CMS health inspection

3. Jan 8, 2025 Health · 11 findings
   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     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 Feb 7, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

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

     Corrected Feb 7, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Feb 7, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Feb 7, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

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

     Corrected Feb 7, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

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

     Corrected Feb 7, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Feb 7, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0354 Smoke Deficiencies

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

     Corrected Feb 7, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected Feb 7, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Feb 7, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Mar 1, 2025 · CMS fire safety

4. Jun 11, 2024 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Apr 27, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0837 Administration Deficiencies

     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 Jul 1, 2024 · CMS health inspection

5. Nov 8, 2023 Fire Safety · 25 findings
   • Not serious Scope/severity E

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Dec 22, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0031 Emergency Preparedness Deficiencies

     Provide emergency officials' contact information.

     Corrected Dec 22, 2023 · CMS fire safety

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Dec 22, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Dec 22, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Dec 22, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0803 Nutrition and Dietary Deficiencies

     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 Dec 22, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Dec 22, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0883 Infection Control Deficiencies

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

     Corrected Dec 22, 2023 · CMS health inspection

   • Not serious Scope/severity C

     F0922 Environmental Deficiencies

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

     Corrected Dec 22, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     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 Dec 22, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0255 Egress Deficiencies

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

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0291 Egress Deficiencies

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

     Corrected Dec 22, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Dec 22, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

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

     Corrected Aug 26, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected May 2, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

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

     Corrected Jan 12, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Dec 22, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Dec 22, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0354 Smoke Deficiencies

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

     Corrected Dec 22, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0362 Smoke Deficiencies

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

     Corrected Aug 26, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

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

     Corrected Aug 29, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

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

     Corrected Sep 3, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Dec 22, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Dec 22, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

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

     CMS fire safety

6. Oct 13, 2023 Fire Safety · 3 findings
   • Not serious Scope/severity F Complaint

     E0013 Emergency Preparedness Deficiencies

     Develop Emergency Preparedness policies and procedures.

     Corrected Nov 13, 2023 · CMS fire safety

   • Not serious Scope/severity F Complaint

     K0500 Services Deficiencies

     Meet other general requirements that are deficient.

     Corrected Nov 13, 2023 · CMS fire safety

   • Not serious Scope/severity E Complaint

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected Nov 13, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• ALEKSANDROWICZ, MICHAEL — operational/managerial control, NOT APPLICABLE, since 07/01/2025
• ALEKSANDROWICZ, MICHAEL — adp of the snf, NOT APPLICABLE, since 07/01/2015
• BERNATH, HERSHEY — managing control - governing body, NOT APPLICABLE, since 07/01/2025
• BERNATH, HERSHEY — operational/managerial control, NOT APPLICABLE, since 07/01/2025
• BERNATH, HERSHEY — adp of the snf, NOT APPLICABLE, since 07/01/2025
• ROSADOWALL, RACHELLE — operational/managerial control, NOT APPLICABLE, since 07/01/2025
• ROSADOWALL, RACHELLE — adp of the snf, NOT APPLICABLE, since 07/01/2025
• AMETHYST HEALTH OF ALGOMA LLC — 5% or greater direct ownership interest, 100%, since 07/01/2025
• VELORAH HEALTH MANAGEMENT LLC — adp of the snf, NOT APPLICABLE, since 07/01/2025