Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brewster Health Center during CMS and state inspections, most recent first.
Surveyors found that insulin pens for several residents were not labeled with the date opened or expiration date as required by facility policy and professional standards. Nursing staff confirmed that insulin pens should be labeled with both the date opened and expiration date, and that the pens generally expire 28 days after being put into use. The facility's policy and regulations require clear labeling and timely disposal of expired medications, but these requirements were not followed in the observed cases.
Three residents were given antipsychotic medications without CMS-approved indications, with records lacking documentation of unsuccessful nonpharmacological interventions and clear risk versus benefit statements. Despite facility policies requiring regular medication reviews and attempts at dose reduction, clinical documentation did not consistently support the use of these medications for dementia-related behaviors.
Staff did not report or investigate a physical altercation between two residents, one with severe cognitive impairment and behavioral issues, despite facility policy and recent staff training on abuse and neglect reporting. The incident involved one resident attempting to push and making physical contact with another, but administration was not informed and no investigation was initiated.
A resident with severe cognitive impairment and multiple medical conditions was transferred to the hospital following a change in mental status and physician order. The facility did not notify the State LTCO of this facility-initiated discharge, as required by policy, and administrative staff confirmed that such notifications were not being made for LTC residents.
A resident with multiple diagnoses, including a hip fracture, jaw cancer, and spinal stenosis, did not have a comprehensive care plan addressing all triggered care areas such as cognitive loss, psychosocial well-being, nutrition, and dental care. Despite identified needs and staff awareness, confusion over care planning responsibilities and lack of a care plan policy led to omissions in the resident's care plan, placing the resident at risk for unmet needs.
Two residents with significant fall risks experienced multiple falls and near-miss incidents, but the facility did not promptly update their care plans with new fall prevention interventions identified during investigations. Staff were unclear about who was responsible for care plan updates, and required interventions such as scheduled toileting, supervision during bathroom use, and monitoring orthostatic blood pressure were not consistently documented or communicated. This failure to revise care plans led to unaddressed care needs and increased risk of injury.
The facility did not consistently identify or implement effective fall prevention interventions for several residents with histories of falls and mobility or cognitive impairments. Despite care plans and policies requiring specific actions, staff failed to keep mobility aids within reach, update care plans after falls, and ensure supervision during high-risk activities, resulting in repeated falls and injuries.
A nurse provided wound care to a resident with a pressure ulcer without following Enhanced Barrier Precautions, using only gloves and not a gown, and without PPE or EBP signage available in the room. Administrative staff confirmed that PPE and signage were not in place as required by facility policy for residents with wounds.
Failure to Properly Label Insulin Pens with Open and Expiration Dates
Penalty
Summary
Surveyors observed that insulin flex pens for multiple residents were not properly labeled with the date opened or expiration date as required by facility policy and professional standards. Specifically, one resident's Basaglar flex pen lacked both an opened date and an expiration date, while another resident's Novolog flex pen was only labeled with an expiration date. Additionally, two other insulin pens (Humalog and Lantus) for a different resident were found in a medication room tote drawer without open or expiration dates. These observations were confirmed by nursing staff, who acknowledged that insulin pens should be labeled with both the date opened and the expiration date, and that the pens generally expire 28 days after being put into use. The facility's own policy, as well as federal and state regulations, require that all medications, including insulin pens, be clearly labeled with the date opened and the resident's name, and that expired medications be discarded. The failure to label these insulin pens as required was verified by administrative and licensed nursing staff during the survey. The facility's policy also specifies that any medication containers with incorrect or illegible labels should be returned to the pharmacy for relabeling or destroyed according to the medication destruction policy.
Deficient Use of Antipsychotic Medications Without CMS-Approved Indications
Penalty
Summary
Surveyors identified that three residents were administered antipsychotic medications without a Centers for Medicare and Medicaid Services (CMS) appropriate indication for use. The records for these residents showed diagnoses such as dementia, anxiety, and psychosis, but lacked sufficient documentation of unsuccessful nonpharmacological interventions and clear risk versus benefit statements for the continued use of antipsychotic medications. For example, one resident received Seroquel for anxiety and senile degeneration of the brain, but the electronic medical record did not include a physician's rationale or documentation of attempted nonpharmacological symptom management prior to medication use. Another resident with dementia and psychosis was prescribed Zyprexa for hallucinations and anxiety. Although the care plan and pharmacy consultant recommended gradual dose reduction and required clinical rationale for continued use, the orders and documentation did not consistently provide FDA-approved indications for antipsychotic use in dementia patients. The facility's own policies required regular medication reviews, documentation of side effects, and attempts at dose reduction, but these were not always supported by the clinical documentation in the residents' records. A third resident with dementia, psychosis, and congestive heart failure was also administered Seroquel for anxiety-related behaviors. Despite multiple attempts at gradual dose reduction, the medication was restarted after behavioral symptoms re-emerged, but the documentation did not always reflect clear nonpharmacological interventions or a CMS-appropriate indication for antipsychotic use. The facility's policies emphasized the need for proper diagnosis, documentation, and regular review of psychotropic medications, but the survey found that these requirements were not consistently met, resulting in the administration of unnecessary antipsychotic medications.
Failure to Report and Investigate Resident-to-Resident Physical Incident
Penalty
Summary
The facility failed to ensure that staff reported and investigated a physical incident between two residents, one of whom had severe cognitive impairment and multiple behavioral health diagnoses, including dementia, major depressive disorder, and anxiety. The resident's care plan indicated a need for staff assistance with activities of daily living and highlighted behaviors such as restlessness, aggression, and a dislike of others in close proximity. On the evening in question, the resident exhibited increased anxiety and physical aggression, refused to use his walker, and attempted to sit in seats occupied by other residents. At one point, he tried to push another severely cognitively impaired resident and made physical contact with her chest. Staff intervened and redirected the resident, but the incident was not reported to administration or investigated as required by facility policy. Administrative staff confirmed they were unaware of the incident and stated that such events should be reported to the unit supervisor and administration for investigation and possible reporting to state authorities. The facility's policy mandates immediate reporting of abuse, neglect, or mistreatment, including resident-to-resident altercations, to the administrator and appropriate authorities. Despite recent staff training on abuse and neglect reporting, the nurse involved did not report the incident, resulting in a failure to follow established procedures for investigating and documenting potential abuse or mistreatment.
Failure to Notify Ombudsman of Facility-Initiated Discharge
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman (LTCO) of a facility-initiated discharge of a resident to the hospital. The resident in question had a history of chronic kidney disease with behavioral disturbance, osteoporosis, and encephalopathy, and was documented as having severe cognitive impairment, requiring extensive staff assistance with activities of daily living, and being frequently incontinent. On the day of the incident, the resident experienced a change in mental status, was unable to assist with transfers, and was observed by a speech therapist to be leaning to the left and drooling. The physician was notified and ordered the resident to be sent to the hospital for evaluation, with the resident's DPOA agreeing to the transfer. The resident was subsequently admitted to the hospital and later readmitted to the facility. Despite the facility's policy requiring notification of the LTCO for all facility-initiated discharges, there was no documentation in the clinical record that such notification was made for this resident's discharge. Administrative staff confirmed that they did not send notifications of discharge to the Ombudsman for long-term care residents, only for assisted living residents. The facility's policy also outlined specific documentation requirements for discharges, including the basis for transfer and communication with the Ombudsman, which were not followed in this case.
Failure to Develop Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive care plan for a resident with multiple complex medical conditions. The resident had diagnoses including a displaced fracture of the right femur, malignant neoplasm of the mouth and mandible, a laceration on the right forearm, and spinal stenosis. The Minimum Data Set (MDS) and Care Area Assessments (CAAs) triggered several areas requiring care planning, such as cognitive loss/dementia, functional abilities, urinary incontinence, psychosocial well-being, falls, nutritional status, pain, and dental care. Despite these identified needs, the comprehensive care plan did not address cognitive loss/dementia, psychosocial well-being, nutritional status, or dental care within the required timeframe after admission. Observations and record reviews showed that the resident required significant assistance with activities of daily living, had impaired mobility, was at risk for falls, experienced pain, and had a history of recent falls with injury. The resident also had a mechanically altered diet due to jaw cancer, experienced pain with swallowing, and was at risk for social isolation and depression. Staff interviews revealed confusion regarding responsibility for the care plan process, especially following recent staff changes. The MDS coordinator and administrative nurse acknowledged that the comprehensive MDS with triggered CAAs should have been incorporated into the care plan, but this was not completed as required. Additionally, the facility was unable to provide a comprehensive care plan policy when requested. Documentation indicated that while some aspects of the resident's care were addressed, key areas identified by the CAAs were omitted from the care plan. This failure to develop and implement a complete care plan placed the resident at risk for unmet care needs.
Failure to Revise Care Plans with Fall Prevention Interventions
Penalty
Summary
The facility failed to revise and update care plans with appropriate fall prevention interventions for two residents, despite multiple documented falls and near-miss incidents. For one resident with severe cognitive impairment, Alzheimer's disease, and a history of falls, there were repeated unwitnessed falls, some resulting in injury, such as lacerations and hematomas. Despite these incidents, new interventions identified during fall investigations, such as scheduled toileting and not leaving the resident unattended in the bathroom, were not promptly added to the care plan. Additionally, the facility did not provide a fall investigation for at least one unwitnessed fall, and there was confusion among staff regarding responsibility for updating care plans, as reported by both licensed nurses and administrative staff. Another resident, who was dependent on staff for transfers and toileting and had multiple comorbidities including chronic ulcers, diabetes, and morbid obesity, also experienced falls and near-miss events. After a near-miss where the resident nearly slid off the bed and a subsequent fall from bed witnessed by family via camera, interventions such as not waking the resident early and checking on her safety were not immediately incorporated into the care plan. Furthermore, after a fall from a mechanical lift, the intervention to check orthostatic blood pressure was not documented in the care plan, and staff were unaware of any new interventions related to the incident. The facility's own Fall Management and Prevention policy required that individual fall prevention interventions be developed and included in each resident's care plan. However, the care plans for both residents were not updated in a timely manner to reflect new interventions following falls or near-miss events. This lack of timely care plan revision resulted in uncommunicated care needs and placed the residents at risk for further injury.
Failure to Implement and Update Fall Prevention Interventions
Penalty
Summary
The facility failed to identify and implement effective fall prevention interventions for multiple residents, resulting in repeated falls and injuries. For one resident with a history of falls and significant mobility impairments, the care plan directed staff to keep the walker within reach and encourage its use. However, on multiple occasions, the walker and wheelchair were found out of reach, and the resident attempted to ambulate independently, leading to falls. Fall investigations did not consistently result in new or effective interventions, and previously identified interventions were not reliably implemented. Another resident with severe cognitive impairment and a history of falls experienced several unwitnessed falls, some resulting in injury. The care plan required supervision and keeping frequently used items within reach, but falls occurred when the resident attempted to use the bathroom without assistance, often without activating the call light or using mobility aids. Fall investigations frequently failed to add new interventions to the care plan, and staff were unclear about who was responsible for updating care plans with fall prevention strategies. A third resident, dependent on staff for transfers and toileting, experienced a near-miss fall and a fall from a mechanical lift. The care plan included general fall risk interventions, but specific incidents, such as sliding out of bed after being awakened or falling from the lift, were not followed by timely updates to the care plan. Staff were not always aware of new interventions following these events, and fall investigations lacked thorough root cause analysis. The facility's own policy required assessment and intervention after each fall, but this was not consistently followed.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a licensed nurse provided wound care to a resident with a coccyx pressure ulcer without adhering to the facility's Enhanced Barrier Precautions (EBP) policy. The nurse donned gloves but did not wear a gown while cleansing and dressing the resident's wound, and there was no personal protective equipment (PPE) or EBP signage available in the resident's room. The nurse confirmed that she had not been instructed to use additional PPE for the resident's wound care and that no PPE or EBP guidelines were present in the room at the time of care. Further, administrative staff verified that staff should have been using PPE for EBP during care for the resident with a wound, but acknowledged that necessary PPE and signage were not in place. The facility's policy required EBP for residents with wounds, including the use of gowns and gloves during high-contact care, and mandated that signage and PPE be accessible. These requirements were not met during the observed care of the resident with a pressure ulcer.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Topeka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Grove Estates | 1.1 mi | ★★★★★ | 0 | 0 |
| Tanglewood Nursing & Rehabilitation | 2.6 mi | ★★★★★ | 0 | 0 |
| Providence Living Center | 2.8 mi | ★★★★★ | 52 | 1 |
| Legacy On 10th Avenue | 3 mi | ★★★★★ | 22 | 0 |
| Lexington Park Nursing & Post Acute Center | 3.1 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.