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Deficiency Records for Amethyst Health of Brown Deer
View the most recent health deficiencies and inspection results for Amethyst Health of Brown Deer. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Amethyst Health of Brown Deer. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2026-02-17 | 2026-03-19 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2026-02-17 | 2026-03-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-02-26 | 2026-03-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2026-02-26 | 2026-03-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2026-02-26 | 2026-03-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2026-02-26 | 2026-03-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2026-02-17 | 2026-03-18 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2026-02-17 | 2026-03-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2026-02-17 | 2026-03-18 | Y |
| Post nurse staffing information every day. | Health | 2026-02-17 | 2026-03-18 | Y |
| 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. | Health | 2026-02-17 | 2026-03-18 | Y |
| 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. | Health | 2026-02-17 | 2026-03-18 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2026-02-17 | 2026-03-18 | Y |
| 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. | Health | 2026-02-17 | 2026-03-18 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2026-02-17 | 2026-03-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2026-02-17 | 2026-03-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-12-05 | 2025-12-16 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-10-30 | 2025-10-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-04-29 | 2025-05-02 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2025-03-17 | 2025-03-26 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2025-03-17 | 2025-03-26 | Y |
| Provide training in compliance and ethics. | Health | 2025-03-17 | 2025-03-26 | Y |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2025-03-17 | 2025-03-26 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2025-03-17 | 2025-03-26 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2025-03-17 | 2025-03-26 | Y |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2025-03-17 | 2025-03-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-03-17 | 2025-03-26 | Y |
| 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. | Health | 2025-03-17 | 2025-03-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-03-17 | 2025-03-26 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-03-17 | 2025-03-26 | Y |
| 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. | Health | 2025-03-17 | 2025-03-26 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2025-03-17 | 2025-03-26 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-10-30 | 2024-12-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-10-30 | 2024-12-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-10-30 | 2024-12-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-10-30 | 2024-12-17 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-10-30 | 2024-12-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-10-30 | 2024-12-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-10-30 | 2024-12-17 | N |
| Post nurse staffing information every day. | Health | 2024-10-30 | 2024-12-17 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-10-30 | 2024-12-17 | N |
| 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. | Health | 2024-10-30 | 2024-12-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-10-30 | 2024-11-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-10-30 | 2024-11-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-10-30 | 2024-11-12 | N |
| Use approved construction type or materials. | Fire Safety | 2024-10-30 | 2024-11-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-10-30 | 2024-11-12 | N |
| 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. | Health | 2024-05-30 | 2024-06-30 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-09-13 | 2024-05-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-09-13 | 2023-11-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-13 | 2023-10-12 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-13 | 2023-10-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-13 | 2023-10-12 | N |
| Provide appropriate foot care. | Health | 2023-09-13 | 2023-10-12 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-13 | 2023-10-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-13 | 2023-10-12 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-09-13 | 2023-10-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-13 | 2023-10-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-13 | 2023-10-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-13 | 2023-10-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-13 | 2023-10-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-13 | 2023-10-12 | N |
| 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. | Health | 2023-09-13 | 2023-10-12 | N |
| Provide or obtain dental services for each resident. | Health | 2023-09-13 | 2023-10-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-09-13 | 2023-10-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-13 | 2023-10-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-09-13 | 2023-10-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-13 | 2023-10-07 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-09-13 | 2023-10-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-13 | 2023-10-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-13 | 2023-10-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-13 | 2023-10-07 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-09-13 | 2023-10-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-13 | 2023-10-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-13 | 2023-10-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-07 | 2023-07-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-07 | 2023-07-06 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-20 | 2022-07-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-20 | 2022-07-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-20 | 2022-07-18 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-06-20 | 2022-07-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-20 | 2022-07-18 | N |
| 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. | Health | 2022-06-20 | 2022-07-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-20 | 2022-07-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-20 | 2022-07-18 | N |
| 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. | Health | 2022-06-20 | 2022-07-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-20 | 2022-07-18 | N |
| 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. | Health | 2022-06-20 | 2022-07-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-20 | 2022-07-18 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-06-20 | 2022-07-18 | N |
| 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. | Health | 2022-06-20 | 2022-07-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-20 | 2022-07-18 | N |
| 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. | Health | 2022-06-20 | 2022-07-18 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-06-20 | 2022-07-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-20 | 2022-07-18 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-06-20 | 2022-07-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-20 | 2022-07-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-06-20 | 2022-07-18 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-20 | 2022-07-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-20 | 2022-07-18 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-06-20 | 2022-07-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-20 | 2022-07-18 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-06-20 | 2022-07-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-20 | 2022-07-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-20 | 2022-07-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-20 | 2022-07-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-20 | 2022-07-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-20 | 2022-07-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-20 | 2022-07-18 | N |
| 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. | Fire Safety | 2022-06-20 | 2022-07-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-06-20 | 2022-07-18 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-06-20 | 2022-07-18 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-06-20 | 2022-07-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-20 | 2022-07-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-20 | 2022-07-18 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-06-20 | 2022-07-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2026-02-17 | Not Fixed | Y |