Amethyst Health of Brown Deer
7500 W Dean Rd, Milwaukee, WI 53223
Amethyst Health of Brown Deer is a nursing home in Milwaukee, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionFebruary 26, 2026 (8 months ago)
- Health citations since September 13, 202386 (Wisconsin average 28)
- Fines in the past three years3, $331,141 in total
- CMS flagsSpecial Focus Facility candidate
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CMS flags
Special Focus Facility candidate
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Name
CMS lists a new legal business name for this home.
Fine
CMS changed the fine from October 30, 2024 from $16,065 to $16,346.
CMS update of June 24, 2026
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS update of May 27, 2026
Fine
CMS changed the fine from October 30, 2024 from $24,715 to $16,065.
Fine
CMS changed the fine from March 17, 2025 from $173,310 to $176,345.
Health inspection on May 20, 2026
4 citationsCMS lists this as a complaint inspection.
Show the 4 citations
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on June 12, 2026.
CMS has cited this home for F0755 2 times since 2026.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on June 12, 2026.
CMS has cited this home for F0757 2 times since 2023.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on June 12, 2026.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 12, 2026.
CMS has cited this home for F0880 5 times since 2023.
Health inspection on April 14, 2026
4 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
63 of 323 Wisconsin homes (20%) got a citation at the actual harm level in 2026.
Show the 4 citations
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on May 1, 2026.
CMS has cited this home for F0686 5 times since 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 1, 2026.
CMS has cited this home for F0684 5 times since 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on May 1, 2026.
CMS has cited this home for F0692 3 times since 2025.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on May 1, 2026.
CMS has cited this home for F0695 2 times since 2025.
CMS update of March 25, 2026
Name
CMS lists a new legal business name for this home.
March 18, 2026
Payment stoppedCMS stopped payment for new admissions from March 18, 2026, for 71 days.
Health inspection on February 26, 2026
26 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
63 of 323 Wisconsin homes (20%) got a citation at the actual harm level in 2026.
Show the 26 citations
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on May 1, 2026.
Citation F0814. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on March 19, 2026.
Citation F0868. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS lists it as corrected on March 19, 2026.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 19, 2026.
Citation F0882. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on March 19, 2026.
Citation F0628. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on March 19, 2026.
Citation F0640. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
CMS lists it as corrected on March 19, 2026.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on March 19, 2026.
CMS has cited this home for F0689 4 times since 2023.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 19, 2026.
CMS has cited this home for F0761 2 times since 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on March 19, 2026.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on March 19, 2026.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS lists it as corrected on March 19, 2026.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on March 19, 2026.
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on March 19, 2026.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on March 19, 2026.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on March 19, 2026.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on March 19, 2026.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on March 19, 2026.
CMS has cited this home for F0677 2 times since 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 1, 2026.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on March 19, 2026.
CMS has cited this home for F0690 2 times since 2026.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on May 1, 2026.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on March 19, 2026.
Citation F0742. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
CMS lists it as corrected on March 19, 2026.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on March 19, 2026.
CMS has cited this home for F0756 2 times since 2024.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on March 19, 2026.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on March 19, 2026.
Fire safety inspection on February 26, 2026
10 citationsCMS lists this as a standard inspection.
Show the 10 citations
Citation E0006. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on March 18, 2026.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on April 3, 2026.
CMS has cited this home for K0345 2 times since 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on March 18, 2026.
CMS has cited this home for K0712 3 times since 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on March 18, 2026.
CMS has cited this home for K0918 3 times since 2023.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 18, 2026.
Citation K0281. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install proper backup exit lighting.
CMS lists it as corrected on May 28, 2026.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on March 18, 2026.
CMS has cited this home for K0321 2 times since 2023.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on March 18, 2026.
CMS has cited this home for K0324 2 times since 2023.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on March 18, 2026.
CMS has cited this home for K0511 2 times since 2024.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on March 18, 2026.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Fine
CMS changed the fine from March 17, 2025 from $266,630 to $173,310.
Health inspection on February 17, 2026
13 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
39 of 323 Wisconsin homes (12%) got a citation at the immediate jeopardy level in 2026.
CMS fine of $138,450 on February 17, 2026.
Show the 13 citations
Citation F0686. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on May 1, 2026.
Citation F0690. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on March 19, 2026.
Citation F0727. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on March 18, 2026.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on March 18, 2026.
CMS has cited this home for F0656 2 times since 2024.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on March 18, 2026.
Citation F0726. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 18, 2026.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 19, 2026.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on March 18, 2026.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 1, 2026.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 18, 2026.
CMS has cited this home for F0693 2 times since 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on March 18, 2026.
Citation F0825. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or get specialized rehabilitative services as required for a resident.
CMS lists it as corrected on March 18, 2026.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on March 18, 2026.
CMS has cited this home for F0732 2 times since 2024.
Health inspection on December 5, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 16, 2025.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of July 30, 2025
Name
CMS lists a new name for this home. It was WATERFALL HEALTH OF BROWN DEER.
CMS update of June 25, 2025
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Health citation
CMS removed citation F0758 from the health inspection on October 30, 2024.
CMS update of May 28, 2025
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Health inspection on April 29, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on May 2, 2025.
Health inspection on March 17, 2025
13 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $176,345 on March 17, 2025.
Show the 13 citations
Citation F0692. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on March 26, 2025.
Citation F0940. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
CMS lists it as corrected on March 26, 2025.
Citation F0941. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
CMS lists it as corrected on March 26, 2025.
Citation F0943. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS lists it as corrected on March 26, 2025.
Citation F0944. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on March 26, 2025.
Citation F0945. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
CMS lists it as corrected on March 26, 2025.
Citation F0946. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide training in compliance and ethics.
CMS lists it as corrected on March 26, 2025.
Citation F0947. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on March 26, 2025.
Citation F0949. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on March 26, 2025.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on March 26, 2025.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 26, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on March 26, 2025.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 26, 2025.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
December 7, 2024
Payment stoppedCMS stopped payment for new admissions from December 7, 2024, for 10 days.
Health inspection on October 30, 2024
10 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
67 of 323 Wisconsin homes (21%) got a citation at the actual harm level in 2024.
CMS fine of $16,346 on October 30, 2024.
Show the 10 citations
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 17, 2024.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 17, 2024.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on December 17, 2024.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on December 17, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on December 17, 2024.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on December 17, 2024.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on December 17, 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 17, 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on December 17, 2024.
CMS has cited this home for F0759 2 times since 2023.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on December 17, 2024.
Fire safety inspection on October 30, 2024
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on November 12, 2024.
Citation K0341. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on October 1, 2025.
CMS has cited this home for K0341 2 times since 2023.
Citation K0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on November 12, 2024.
Citation K0161. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on November 12, 2024.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on November 12, 2024.
Citation K0918. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on November 12, 2024.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.1 to 3.7 hours per resident per day.
CMS update of August 29, 2024
Fine
CMS changed the fine from September 13, 2023 from $82,290 to $84,065.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.8 to 4.1 hours per resident per day.
Health inspection on May 30, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0837. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on June 30, 2024.
CMS update of May 29, 2024
Fine
CMS changed the fine from September 13, 2023 from $126,600 to $82,290.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
CMS update of February 29, 2024
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 4 of 5.
CMS update of December 21, 2023
Name
CMS lists a new legal business name for this home.
Health inspection on September 13, 2023
13 citationsCMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
42 of 323 Wisconsin homes (13%) got a citation at the actual harm level in 2023.
Show the 13 citations
Citation F0684. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on October 12, 2023.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 12, 2023.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on October 12, 2023.
Citation F0661. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
CMS lists it as corrected on October 12, 2023.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on October 12, 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on October 12, 2023.
Citation F0687. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate foot care.
CMS lists it as corrected on October 12, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on October 12, 2023.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on October 12, 2023.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on October 12, 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on October 12, 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 12, 2023.
Citation F0791. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain dental services for each resident.
CMS lists it as corrected on October 12, 2023.
Fire safety inspection on September 13, 2023
14 citationsCMS lists this as a standard inspection.
Show the 14 citations
Citation K0341. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on May 1, 2024.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on October 7, 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on October 7, 2023.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on October 9, 2023.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on October 9, 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on October 7, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on October 12, 2023.
Citation K0271. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on November 9, 2023.
Citation K0291. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on October 7, 2023.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on October 7, 2023.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on October 9, 2023.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on October 7, 2023.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on October 7, 2023.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on October 7, 2023.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (414) 371-7500
- Last standard health inspection
- February 26, 2026 (8 months ago)
- Certified beds
- 87
- Residents per day, on average
- 56.8
- Ownership type
- For profit - Corporation
- Legal business name
- Brown Deer Health Opco LLC
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
More health citations than the Wisconsin average (86 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- AMETHYST HEALTH OF BROWN DEER LLCDirect ownership interest · not applicable · since 07/01/2025
- BERNATH, HERSHEYIndirect ownership interest · not applicable · since 07/01/2025
- BERNATH, HERSHEYOperational/managerial control · not applicable · since 07/01/2025
- PATRICK, JENSENOperational/managerial control · not applicable · since 07/01/2025
- SIDHU, SARFRAZOperational/managerial control · not applicable · since 07/01/2025
Questions
When was Amethyst Health of Brown Deer last inspected?
CMS lists February 26, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Amethyst Health of Brown Deer have?
CMS lists 86 health citations since September 13, 2023. CMS also calls these deficiencies.
Has Amethyst Health of Brown Deer been fined?
CMS lists 3 fines in the past three years, $331,141 in total.
What is the CMS star rating of Amethyst Health of Brown Deer?
Its CMS overall star rating is 1 of 5.
Is Amethyst Health of Brown Deer a Special Focus Facility?
Yes. CMS lists it as a Special Focus Facility candidate.