The Vardell Report.Amethyst Health of Brown Deer

Across 10 inspections from September 2023 to May 2026, state surveyors documented 86 findings at Amethyst Health of Brown Deer; 86 have a recorded correction; CMS lists 5 enforcement actions in the window.

Inspections

10

2023–2026, complaint and standard

Findings

86

Deficiencies cited by state inspectors

Corrected

86

Of 86 findings, with a recorded correction date

Penalties

5

3 fines; payment not published, 2 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. May 202026

   Complaint investigation

   4 findings

   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Jun 12, 2026
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Jun 12, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 12, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Apr 142026

   Complaint investigation

   4 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected May 1, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 1, 2026
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected May 1, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected May 1, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Feb 262026

   Standard health inspection

   26 findings

   The same visit included a complaint investigation.

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected May 1, 2026
   • F814Dispose of garbage and refuse properly.Level FNo actual harm, potential for moreCorrected Mar 19, 2026
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Mar 19, 2026
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Mar 19, 2026
   • F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level FNo actual harm, potential for moreCorrected Mar 19, 2026
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level ENo actual harm, potential for moreCorrected Mar 19, 2026
   • F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level ENo actual harm, potential for moreCorrected Mar 19, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Mar 19, 2026
   • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Mar 19, 2026
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Mar 19, 2026
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Mar 19, 2026
   • F578Honor 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.Level DNo actual harm, potential for moreCorrected Mar 19, 2026
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Mar 19, 2026
   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Mar 19, 2026
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Mar 19, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Mar 19, 2026
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Mar 19, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Mar 19, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 1, 2026
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Mar 19, 2026
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected May 1, 2026
   • F699Provide care or services that was trauma informed and/or culturally competent.Level DNo actual harm, potential for moreCorrected Mar 19, 2026
   • F742Provide 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.Level DNo actual harm, potential for moreCorrected Mar 19, 2026
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Mar 19, 2026
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Mar 19, 2026
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Mar 19, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Feb 172026

   Complaint investigation

   13 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level JImmediate jeopardyCorrected May 1, 2026
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level JImmediate jeopardyCorrected Mar 19, 2026
   • F727Have 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.Level FNo actual harm, potential for moreCorrected Mar 18, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Mar 18, 2026
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Mar 18, 2026
   • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level ENo actual harm, potential for moreCorrected Mar 18, 2026
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Mar 19, 2026
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Mar 18, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 1, 2026
   • F693Ensure 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.Level DNo actual harm, potential for moreCorrected Mar 18, 2026
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Mar 18, 2026
   • F825Provide or get specialized rehabilitative services as required for a resident.Level DNo actual harm, potential for moreCorrected Mar 18, 2026
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Mar 18, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Dec 52025

   Complaint investigation

   1 finding

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 16, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Apr 292025

   Complaint investigation

   1 finding

   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected May 2, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Mar 172025

   Complaint investigation

   13 findings

   • F692Provide enough food/fluids to maintain a resident's health.Level JImmediate jeopardyCorrected Mar 26, 2025
   • F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Level FNo actual harm, potential for moreCorrected Mar 26, 2025
   • F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level FNo actual harm, potential for moreCorrected Mar 26, 2025
   • F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level FNo actual harm, potential for moreCorrected Mar 26, 2025
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level FNo actual harm, potential for moreCorrected Mar 26, 2025
   • F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Level FNo actual harm, potential for moreCorrected Mar 26, 2025
   • F946Provide training in compliance and ethics.Level FNo actual harm, potential for moreCorrected Mar 26, 2025
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level FNo actual harm, potential for moreCorrected Mar 26, 2025
   • F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level ENo actual harm, potential for moreCorrected Mar 26, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Mar 26, 2025
   • F688Provide 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.Level DNo actual harm, potential for moreCorrected Mar 26, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Mar 26, 2025
   • F693Ensure 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.Level DNo actual harm, potential for moreCorrected Mar 26, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Oct 302024

   Standard health inspection

   10 findings

   The same visit included a complaint investigation.

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Dec 17, 2024
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Dec 17, 2024
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Dec 17, 2024
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Dec 17, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Dec 17, 2024
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Dec 17, 2024
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Dec 17, 2024
   • F758Implement 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.Level DNo actual harm, potential for moreCorrected Dec 17, 2024
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Dec 17, 2024
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Dec 17, 2024

   Enforcement Action

   Civil money penalty, $16,346 imposed October 30, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 30, 2024, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed October 30, 2024. Status: Closed, December 17, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 30, 2024, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $176,345 imposed March 17, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 30, 2024, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $138,450 imposed February 17, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 30, 2024, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed February 17, 2026. Status: Closed, May 28, 2026. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 30, 2024, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

9. May 302024

   Complaint investigation

   1 finding

   • F837Establish 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.Level FNo actual harm, potential for moreCorrected Jun 30, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

10. Sep 132023

    Standard health inspection

    13 findings

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Oct 12, 2023
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Oct 12, 2023
    • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Oct 12, 2023
    • F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Level DNo actual harm, potential for moreCorrected Oct 12, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Oct 12, 2023
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Oct 12, 2023
    • F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Oct 12, 2023
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Oct 12, 2023
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Oct 12, 2023
    • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Oct 12, 2023
    • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Oct 12, 2023
    • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Oct 12, 2023
    • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Oct 12, 2023

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Quality of Care, Cited in Five Inspections

   Inspectors cited F684 in September 2023, December 2025, February 2026, February 2026 and April 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242425252526262626F684 across all 10 inspections, oldest to newest
2. 2

   Pressure Injury Care, Cited in Five Inspections

   Inspectors cited F686 in September 2023, March 2025, February 2026, February 2026 and April 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242425252526262626F686 across all 10 inspections, oldest to newest
3. 3

   Infection Control, Cited in Five Inspections

   Inspectors cited F880 in September 2023, October 2024, February 2026, February 2026 and May 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242425252526262626F880 across all 10 inspections, oldest to newest
4. 4

   Accident Hazards and Supervision, Cited in Four Inspections

   Inspectors cited F689 in September 2023, October 2024, March 2025 and February 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242425252526262626F689 across all 10 inspections, oldest to newest
5. 5

   Nutrition and Hydration, Cited in Three Inspections

   Inspectors cited F692 in March 2025, February 2026 and April 2026. This citation covers whether residents get enough food and fluids to stay healthy. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242425252526262626F692 across all 10 inspections, oldest to newest
6. 6

   Care Plans, Cited in Two Inspections

   Inspectors cited F656 in October 2024 and February 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242425252526262626F656 across all 10 inspections, oldest to newest
7. 7

   Help With Daily Living, Cited in Two Inspections

   Inspectors cited F677 in September 2023 and February 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242425252526262626F677 across all 10 inspections, oldest to newest
8. 8

   Continence and Catheter Care, Cited in Two Inspections

   Inspectors cited F690 in February 2026 and February 2026. This citation covers continence care, catheter care and preventing urinary tract infections. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242425252526262626F690 across all 10 inspections, oldest to newest
9. 9

   Citation F693, Cited in Two Inspections

   Inspectors cited F693 in March 2025 and February 2026. The agency describes it this way: 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. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242425252526262626F693 across all 10 inspections, oldest to newest
10. 10

    Respiratory Care, Cited in Two Inspections

    Inspectors cited F695 in April 2025 and April 2026. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242425252526262626F695 across all 10 inspections, oldest to newest
11. 11

    Post nurse staffing information every day, Cited in Two Inspections

    Inspectors cited F732 in October 2024 and February 2026. The agency describes it this way: Post nurse staffing information every day. None rose above level C (potential for minimal harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242425252526262626F732 across all 10 inspections, oldest to newest
12. 12

    Pharmacy Services, Cited in Two Inspections

    Inspectors cited F755 in February 2026 and May 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242425252526262626F755 across all 10 inspections, oldest to newest
13. 13

    Citation F756, Cited in Two Inspections

    Inspectors cited F756 in October 2024 and February 2026. The agency describes it this way: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242425252526262626F756 across all 10 inspections, oldest to newest
14. 14

    Citation F757, Cited in Two Inspections

    Inspectors cited F757 in September 2023 and May 2026. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242425252526262626F757 across all 10 inspections, oldest to newest
15. 15

    Medication Error Rate, Cited in Two Inspections

    Inspectors cited F759 in September 2023 and October 2024. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242425252526262626F759 across all 10 inspections, oldest to newest
16. 16

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in September 2023 and February 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242425252526262626F761 across all 10 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in five inspections, most seriously at level G.

2. 02

   How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

   Pressure Injury Care: cited in five inspections, most seriously at level J.

3. 03

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in five inspections, most seriously at level F.

4. 04

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in four inspections, most seriously at level G.

5. 05

   How are weight and fluid intake tracked, and what happens when a resident starts losing weight?

   Nutrition and Hydration: cited in three inspections, most seriously at level J.

6. 06

   How is a care plan written and reviewed here, and how do families take part in it?

   Care Plans: cited in two inspections, most seriously at level E.

7. 07

   How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

   Help With Daily Living: cited in two inspections, most seriously at level D.

8. 08

   How is continence care scheduled, and how do you prevent urinary infections?

   Continence and Catheter Care: cited in two inspections, most seriously at level J.

9. 09

   What changed after F693 was cited, and how do you check it now?

   Citation F693: cited in two inspections, most seriously at level D.

10. 10

    Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

    Respiratory Care: cited in two inspections, most seriously at level D.

11. 11

    What changed after F732 was cited, and how do you check it now?

    Post nurse staffing information every day: cited in two inspections, most seriously at level C.

12. 12

    How often does the consultant pharmacist review each resident’s medications?

    Pharmacy Services: cited in two inspections, most seriously at level E.

13. 13

    What changed after F756 was cited, and how do you check it now?

    Citation F756: cited in two inspections, most seriously at level D.

14. 14

    What changed after F757 was cited, and how do you check it now?

    Citation F757: cited in two inspections, most seriously at level D.

15. 15

    How are medication passes checked, and what happens when an error is found?

    Medication Error Rate: cited in two inspections, most seriously at level D.

16. 16

    How are medications stored and secured, and who checks the medication carts?

    Medication Labeling and Storage: cited in two inspections, most seriously at level E.

17. 17

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Insufficient nursing staff was cited in February 2026.

18. 18

    What led to the 2026 fine, and has it been paid?

    A $138,450 civil money penalty was imposed February 17, 2026. CMS publishes the fine, not whether it has been paid. The record holds five enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Wisconsin state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Sep 13, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection May 30, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Oct 30, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Mar 17, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Apr 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Dec 5, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Feb 17, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Feb 26, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Apr 14, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection May 20, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 525498

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.