Amethyst Health Of Brown Deer
Amethyst Health of Brown Deer in MILWAUKEE, WI — inspection on February 26, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
and oriented and has never made any allegations of abuse since LPN-AA has worked in the facility.
went into R6's room to assist another CNA with emptying R6's bedside commode. CNA-BB stated R6
there trying to help R6. CNA-BB stated R6 tried to activate R6's call light while CNA-BB and the other CNA were in R6's room, so CNA-BB reached for the call light to cancel it and knocked over a cup of ice from R6's bedside table. CNA-BB stated CNA-BB cleaned up the ice and then left R6's room and did not return to R6's room the rest of CNA-BB's shift, and CNA-BB clocked out and left the facility at 6:00 pm. CNA-BB was unable to recall the name of the other CNA who was in R6's room at the time.
On 2/25/26 at 1:17 PM, Surveyor spoke with CNA-CC who confirmed CNA-CC works for an agency company but was working at the facility and cared for R6 on 2/9/26. CNA-CC stated CNA-CC went to assist R6 on the evening of 2/9/26 with emptying the bedside commode. CNA-CC stated CNA-CC had difficulty getting the top off the commode so requested help from CNA-BB. CNA-CC stated CNA-BB showed CNA-CC how to get the top off the commode when R6 made a noise and CNA-BB told R6 CNA-BB is trying to help, do not give me attitude. CNA-CC stated R6 stuck R6's middle finger up at CNA-BB and CNA-BB yelled at R6 not to do that. CNA-CC stated R6 was trying to grab R6's call light but CNA-BB tried to grab it first and everything fell off the bedside table. CNA-CC stated CNA-CC did not see CNA-BB touch R6. CNA-CC stated after everything was cleaned up, CNA-CC answered R6's call light the rest of the evening without issues and R6 was fine the rest of the shift. CNA-CC stated CNA-CC explained to the nurse on duty what happened but was unable to recall the name of the nurse CNA-CC talked to. In an interview on 2/25/26 at 3:30 PM, NHA-A stated NHA-A initially reported the incident to the state agency on 2/10/26 at 6:16 AM, but the reporting website was not working at the time, so NHA-A sent an email with the initial report. NHA-A provided Surveyor with a copy of the email, and Surveyor noted the email was sent on 2/10/26 at 6:16 AM.
Surveyor asked NHA-A why NHA-A did not report the allegation of abuse within 2 hours of initial knowledge of an alleged allegation of abuse. NHA-A replied LPN-AA first texted NHA-A around 11:00 PM on 2/9/26 asking what LPN-AA should do if a resident reports abuse. NHA-A told LPN-AA to get a statement and send it to the NHA-A. NHA-A stated NHA-A did not receive any information that there was potential physical contact until the morning of 2/10/26, and that is why the allegation was not reported to the state agency until the morning of 2/10/26.
Surveyor shared concern with NHA-A that an allegation of abuse involving R6 was not reported to the state agency within 2 hours of the allegation, and staff did not report the incident within 2 hours of the alleged abuse occurring. No further information was provided.
525498 02/26/2026
Amethyst Health of Brown Deer 7500 W Dean Rd Milwaukee, WI 53223
investigated for 1 of 2 Facility Reported Incidents (FRI) reviewed involving R6. On 2/9/26 at 11:00
abuse involving R6 and CNA-BB.
The investigation of the allegation of abuse did not include interviews with witnesses and staff the allegations were originally reported to.Findings include: The facility policy titled Abuse Prevention Program with effective date 1/23/26 and review date 1/23/26 documents: . As part of the resident abuse prevention, the facility's administration will: . protect our residents from abuse by anyone including, but not necessarily limited to facility staff .
The individual conducting the investigation will, as a minimum: . interview the person(s) reporting the incident; . interview any witnesses to the incident; . interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; . R6 was admitted to the facility 6/25/2015 with diagnoses including post-traumatic stress disorder (PTSD) (a mental health condition in people who have experienced or witnessed a traumatic event). R6 had a legal guardian appointed.R6's most recent minimum data set (MDS) assessment dated [DATE] documented R6 had a brief interview for mental status (BIMS) score of 15, indicating intact cognition.On 2/24/26 at 9:11 AM, Surveyor reviewed the FRI regarding an allegation of physical abuse involving R6 on 2/9/26, time unknown, who alleged certified nursing assistant (CNA)-BB grabbed R6's arm and R6 felt CNA-BB's nails on R6's skin.
The facility documented in the conclusion of the investigation: The facility was unable to conclusively determine that the scratch was from physical contact between the resident and CNA due to varying statements.
Through investigation, it is prudent to deduct the scratch occurring from the CNA making contact with the resident's arm.
Due to the facility's ability to substantiate inappropriate use of language, the facility terminated [CNA-BB] on 2/16/26. On 2/24/26 at 11:53 AM, Surveyor spoke with Licensed Practical Nurse (LPN)-AA via phone call, who reported R6's allegation of potential abuse to NHA-A on the evening of 2/9/26. LPN-AA stated R6 told LPN-AA that CNA-BB grabbed R6's arm around 7:30 pm on 2/9/26. LPN-AA stated LPN-AA reported the allegation to NHA-A and the Director of Nursing (DON)-B shortly after R6 told this information to LPN-AA and asked NHA-A what LPN-AA should do. LPN-AA stated NHA-A told LPN-AA to get a statement from the resident and do a skin check, so LPN-AA did that and gave that information to NHA-A. LPN-AA confirmed CNA-BB was no longer in the facility at the time.
Surveyor notes the investigation of the allegation of abuse submitted by the facility did not include a statement or interview from LPN-AA, the individual who reported the incident. On 2/25/26 at 1:17 PM, Surveyor spoke with CNA-CC who confirmed CNA-CC works for an agency company but was working at the facility and cared for R6 on 2/9/26. CNA-CC stated CNA-CC explained to the nurse on duty what happened between CNA-BB and R6 but was unable to recall the name of the nurse CNA-CC talked to.
CNA-CC stated the facility did not contact CNA-CC to get a statement about the alleged incident between R6 and CNA-BB.
Surveyor notes the investigation of the allegation of abuse submitted by the facility did not include a statement or interview from CNA-CC, the individual who witnessed the incident. In an interview on 2/25/26 at 3:30 PM, Surveyor shared concerns with NHA-A that the allegation of abuse involving R6 and CNA-BB on 2/9/26 was not thoroughly investigated to include statements and interviews from LPN-AA who reported the incident or CNA-CC who witnessed the incident. NHA-A stated NHA-A tried to contact CNA-CC but did not obtain a statement from CNA-CC.
No additional information was provided as to why the allegation of abuse involving R6 was not thoroughly investigated to include statements and interviews with the person reporting the incident or the person who witnessed the incident.
525498 02/26/2026
Amethyst Health of Brown Deer 7500 W Dean Rd Milwaukee, WI 53223
checked and changed.Surveyor reviewed R55's CNA task of bowel and bladder documentation on 2/17
regarding R55's bowel and bladder continence on 2/17/26. On 2/18/26, CNAs documented urinary and
1:59 PM, almost 17 hours, CNAs did not document any bowel or bladder continence on R55 in the CNA task section of R55's EMR.On 2/25/26 at 9:58 AM, Surveyor interviewed CNA-P.
Surveyor asked about R55's every 2-hour check and change log.
Surveyor asked when staff started the paper log for check and changing. CNA-P stated CNA-P was not sure. CNA-P stated CNAs are supposed to document whether R55 is wet or dry every 2 hours. At the end of the shift that information is given to the nurse.On 2/25/26 at 10:00 AM, Surveyor interviewed CNA-KK about R55's every 2-hour check and change log.
Surveyor asked when staff started the paper log for check and changing. CNA-KK stated that it has been that way since CNA-KK has been employed at the facility for about a year and a half.
CNA-KK stated that staff have to document whether R55 is wet or dry every two hours.
The completed sheets then go to DON-B.Surveyor noted according to CNA-KK R55 needs to be checked and/or changed every 2 hours. On 2/25/26 at 10:03 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-FF.
Surveyor asked if LPN-FF had seen the check and change log for R55. LPN-FF stated yes.
Surveyor asked when the log was started. LPN-FF stated it was started on the date listed on the log. 2/16/26.
The log is kept in the binder at the nurse's station until it is completed and then the completed log will go to DON-B.
Surveyor asked if any other completed log sheets were in the binder. LPN-FF checked the binder and stated there was no other sheets. LPN-FF stated R55 is at the hospital so that is probably why there is none in the binder.On 2/25/26 at 10:10 AM, Surveyor interviewed ADON-C about the check and change log scanned into R55's EMR. ADON-C stated the log is only completed on specific people. ADON-C stated these logs are completed to establish a pattern and are completed for only that specific range of time documented on the log. ADON-C stated there is no policy for these logs.Surveyor noted discrepancy among staff regarding the check and change log.
Some staff stated it has been in place long term; some say it is short term.
Surveyor concluded that the completed log scanned into R55's EMR provided evidence that R55 was not checked and changed every 2 hours as care planned on 2/17 and 2/18/26. On 2/26/26 at 11:08 AM, Surveyor interviewed Director of Social Services (DSS)-L.
Surveyor asked about R55. DSS-L stated DSS-L had noticed a pattern that R55 was in the common area by the tv most of the day. DSS-L stated there was a day that DSS-L walked up to R55 and could smell R55. DSS-L stated DSS-L thought staff were putting R55 in the common area and leaving R55 there most of the day.
After DSS-L noticed this and told Nursing Home Administrator (NHA)-A, R55's family called and informed facility staff of the same concern.
This was on 1/21/2026. DSS-L stated DSS-L could not argue or dispute the concern because DSS-L saw it firsthand. On 2/26/26 at 1:17 PM, Surveyor informed NHA-A of the concerns R55 did not receive showers as care planned in January and February 2026. R55 was not checked and changed every 2 hours as care planned on 2/17 and 2/18/26.
525498 02/26/2026
Amethyst Health of Brown Deer 7500 W Dean Rd Milwaukee, WI 53223
was here for a fall for R73. DON- B stated she was surprised by this and went to R73's room.
Staff
DON- B immediately interviewed the Respiratory Therapist and the 2 Certified Nursing Assistants
providing cares. R73 does have an air mattress and regular staff know not to put R73 completely on her thigh when repositioning.
Sometimes the bed sheets can come off the air mattress and R73 has been coughing.
Surveyor notes it was DON- B's root cause analysis that R73 coughed and the way she was positioned on the air mattress and possible with the sheet un-done, R73 rolled from the bed.
DON- B stated she called R73's POA and spoke with them. DON- B stated they did have questions because R73 is not able to move about the bed on her own and is nonverbal. DON-B stated she explained she thought R73 must have coughed really hard and the fitted sheet may have not been attached to the air mattress and R73 could not have been positioned in a way to prevent her from rolling out of bed. DON- B stated R73 is now in bed with bolsters to each side, mats on each side of the bed and bed in lowest position.
As of the time of exit, the facility was not able to provide additional information as to how R73, who does not have any bed mobility on her own, was able to fall from the bed to the floor on 2/15/26.