AMETHYST HEALTH OF BROWN DEER

7500 W DEAN RD, MILWAUKEE, WI 53223

Facility Assessment 17 federal violations at this facility remain unresolved. Inspectors recorded 7 citations at the actual-harm level or worse in the last three survey cycles. This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.

Below the repealed 0.55 hr RN benchmark — review inspection history before visiting.

Quality Breakdown

RN Staffing Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.	0.48 — Below the repealed 0.55 hr benchmark
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why
Health Deficiencies (last 3 survey cycles) Violations found during federal inspections, with how many remain open and how many involved actual harm.	Total 83 Outstanding 17 Actual harm or worse (G–L) 7
CMS Ratings Overall and Staffing quality ratings from CMS (1-5 stars).	Quality: ★★★★☆ (4/5) Staffing: ★☆☆☆☆ (1/5)
NursingHomeGrade Score	0/100

Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

3 immediate jeopardy, 4 actual harm issues found among 83 total deficiencies. 66 corrected. — 17 still outstanding

Most recent inspection (February 26, 2026)

D Potential harm — isolated F0609 Status: Outstanding — No Plan

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0610 Status: Outstanding — No Plan

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has no plan of correction

E Potential harm — pattern F0880 Status: Outstanding — No Plan

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has no plan of correction

E Potential harm — pattern F0725 Status: Outstanding — No Plan

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies — Deficient, Provider has no plan of correction

E Potential harm — pattern F0726 Status: Outstanding — No Plan

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Nursing and Physician Services Deficiencies — Deficient, Provider has no plan of correction

F Potential harm — widespread F0727 Status: Outstanding — No Plan

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Nursing and Physician Services Deficiencies — Deficient, Provider has no plan of correction

C No harm — widespread F0732 Status: Outstanding — No Plan

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0755 Status: Outstanding — No Plan

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0677 Status: Outstanding — No Plan

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction

E Potential harm — pattern F0689 Status: Outstanding — No Plan

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

Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0684 Status: Outstanding — No Plan

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction

J Immediate jeopardy — isolated F0686 Status: Outstanding — No Plan

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

Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction

J Immediate jeopardy — isolated F0690 Status: Outstanding — No Plan

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

Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0693 Status: Outstanding — No Plan

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0825 Status: Outstanding — No Plan

Provide or get specialized rehabilitative services as required for a resident.

Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0655 Status: Outstanding — No Plan

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has no plan of correction

E Potential harm — pattern F0656 Status: Outstanding — No Plan

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has no plan of correction

F Potential harm — widespread F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2024

C No harm — widespread F0732 Status: Corrected

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2024

D Potential harm — isolated F0756 Status: Corrected

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2024

D Potential harm — isolated F0758 Status: Corrected

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2024

D Potential harm — isolated F0759 Status: Corrected

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2024

D Potential harm — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 16, 2025

D Potential harm — isolated F0695 Status: Corrected

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 2, 2025

G Actual harm — isolated F0689 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2024

D Potential harm — isolated F0697 Status: Corrected

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2024

D Potential harm — isolated F0644 Status: Corrected

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2024

D Potential harm — isolated F0645 Status: Corrected

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2024

D Potential harm — isolated F0656 Status: Corrected

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 17, 2024

Inspection cycle 2 (March 17, 2025)

F Potential harm — widespread F0940 Status: Corrected

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Administration Deficiencies — Deficient, Provider has date of correction, corrected March 26, 2025

F Potential harm — widespread F0941 Status: Corrected

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Administration Deficiencies — Deficient, Provider has date of correction, corrected March 26, 2025

F Potential harm — widespread F0944 Status: Corrected

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Administration Deficiencies — Deficient, Provider has date of correction, corrected March 26, 2025

F Potential harm — widespread F0946 Status: Corrected

Provide training in compliance and ethics.

Administration Deficiencies — Deficient, Provider has date of correction, corrected March 26, 2025

E Potential harm — pattern F0949 Status: Corrected

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Administration Deficiencies — Deficient, Provider has date of correction, corrected March 26, 2025

F Potential harm — widespread F0837 Status: Corrected

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.

Administration Deficiencies — Deficient, Provider has date of correction, corrected June 30, 2024

F Potential harm — widespread F0943 Status: Corrected

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected March 26, 2025

F Potential harm — widespread F0945 Status: Corrected

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected March 26, 2025

F Potential harm — widespread F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2023

F Potential harm — widespread F0947 Status: Corrected

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected March 26, 2025

D Potential harm — isolated F0757 Status: Corrected

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2023

D Potential harm — isolated F0761 Status: Corrected

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2023

D Potential harm — isolated F0759 Status: Corrected

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2023

D Potential harm — isolated F0686 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 26, 2025

D Potential harm — isolated F0688 Status: Corrected

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 26, 2025

D Potential harm — isolated F0689 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 26, 2025

J Immediate jeopardy — isolated F0692 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 26, 2025

D Potential harm — isolated F0693 Status: Corrected

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 26, 2025

D Potential harm — isolated F0677 Status: Corrected

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2023

G Actual harm — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2023

D Potential harm — isolated F0686 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2023

D Potential harm — isolated F0698 Status: Corrected

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2023

D Potential harm — isolated F0791 Status: Corrected

Provide or obtain dental services for each resident.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2023

D Potential harm — isolated F0687 Status: Corrected

Provide appropriate foot care.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2023

D Potential harm — isolated F0689 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2023

D Potential harm — isolated F0661 Status: Corrected

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2023

D Potential harm — isolated F0580 Status: Corrected

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2023

Inspection cycle 3 (June 20, 2022)

D Potential harm — isolated F0770 Status: Corrected

Provide timely, quality laboratory services/tests to meet the needs of residents.

Administration Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2022

F Potential harm — widespread F0839 Status: Corrected

Employ staff that are licensed, certified, or registered in accordance with state laws.

Administration Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2022

D Potential harm — isolated F0609 Status: Corrected

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected July 6, 2023

D Potential harm — isolated F0610 Status: Corrected

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected July 6, 2023

E Potential harm — pattern F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2022

F Potential harm — widespread F0881 Status: Corrected

Implement a program that monitors antibiotic use.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2022

D Potential harm — isolated F0887 Status: Corrected

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.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2022

E Potential harm — pattern F0812 Status: Corrected

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2022

D Potential harm — isolated F0756 Status: Corrected

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2022

D Potential harm — isolated F0758 Status: Corrected

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2022

D Potential harm — isolated F0759 Status: Corrected

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2022

E Potential harm — pattern F0761 Status: Corrected

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2022

D Potential harm — isolated F0676 Status: Corrected

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.