Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brewster Convalescent Center during CMS and state inspections, most recent first.
A facility failed to maintain comfortable air temperatures on the 500 hall. Two residents were observed cold and bundled in multiple blankets and extra clothing, and one stated the room stayed cold until afternoon and again at night. An LPN reported residents complain about cold nights, the Administrator and Maintenance Director confirmed thermostat readings of 68 degrees, and room temperatures measured by the Maintenance Director ranged from 67 to 71 degrees; the Maintenance Director also stated staff had been messing with the thermostats.
A resident with chronic respiratory issues had their oxygen increased from two to four liters without physician notification, contrary to facility policy. The resident showed signs of lethargy and decreased oxygen saturation, but the physician was not informed of these changes, as confirmed by the DON and a nurse.
A facility failed to implement and monitor interventions for a resident's weight loss. Despite the resident's family providing a nutritional supplement, there were no physician orders or documentation for its use. Interviews with the RD and DON confirmed the lack of specific orders and documentation. The facility's policy indicated providing a supplement if meals were less than 50% consumed, but this was not documented as an intervention for the resident's weight loss.
A facility failed to monitor a dialysis resident's condition before and after treatments, as required by policy. The resident, with a history of chronic kidney disease and diabetes, received dialysis three times a week. Interviews with an LPN and the DON confirmed that only blood pressure and weight were taken at the dialysis center, with no assessments conducted by the facility. The facility's policy mandated assessments of vitals, dialysis site, and fluid retention before and after dialysis, which were not performed.
An LPN failed to follow proper hand hygiene protocols during wound care for two residents with severe cognitive impairment. The LPN did not change gloves or sanitize hands after removing soiled dressings, contrary to the facility's infection control guidelines. The LPN acknowledged the oversight, attributing it to nervousness.
The facility failed to document education on the risks and benefits of influenza and pneumococcal vaccines for two residents who refused these immunizations. Despite policies requiring such documentation, the medical records lacked evidence of education, as confirmed by an RN.
Uncomfortable Room Temperatures on 500 Hall
Penalty
Summary
The facility failed to maintain a comfortable air temperature in the resident living environment on the 500 unit. Resident #32, admitted with quadriplegia, anxiety disorder, and major depressive disorder, was cognitively intact and dependent with ADLs. During interview, the resident stated he was always cold and that the room was cold until the afternoon and then cold again at night. Observation showed the resident wearing a winter skull cap and covered with four blankets. Resident #28, admitted with emphysema, anxiety disorder, trigeminal neuralgia, and hypertension, was also cognitively intact and was observed with three blankets and a fuzzy robe on; the resident stated they were cold and that staff covered the registers because cold air was blowing out. At the time of observation, LPN #202 reported the thermostat temperatures were reading 70 degrees and 68 degrees and stated that nights get cold and residents complain. The Administrator confirmed thermostat #3 on the 500 hall read 68 degrees, and the Maintenance Director confirmed the same reading and stated staff mess with the thermostats, noting there had been a meeting the prior month with the DON telling staff not to touch them. The Maintenance Director digitally measured multiple resident rooms on the unit and found temperatures ranging from 67 degrees to 71 degrees. Review of the Daily Thermostat Log for thermostat #3 in May 2026 showed readings of 69 degrees and 70 degrees.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to update the physician on a change of condition for a resident diagnosed with chronic respiratory failure, chronic obstructive pulmonary disease, and emphysema. The resident's care plan included monitoring for signs of respiratory distress and reporting any changes to the physician. However, on a specific date, the resident appeared slightly lethargic, and her oxygen saturation was recorded at 90-92% while on two liters of oxygen via nasal cannula. The nursing staff increased the oxygen to four liters without notifying the physician, which was against the facility's policy that required oxygen therapy to be prescribed by the physician. An observation conducted with a registered nurse confirmed that the resident's oxygen concentrator was set to four liters, despite the physician's order for two liters continuously. The Director of Nursing verified that the physician was not informed about the resident's lethargy, decreased oxygen saturation, and the increased need for oxygen. The facility's policy clearly stated that the physician was responsible for prescribing the type and rate of oxygen therapy, which was not adhered to in this instance.
Failure to Implement and Monitor Nutritional Interventions for Weight Loss
Penalty
Summary
The facility failed to implement and monitor interventions for a resident's trending weight loss. The resident, who was readmitted with diagnoses including anxiety disorder, dementia, and hypertension, experienced a weight decrease from 196.6 pounds to 179.2 pounds over several months. Despite the resident's family bringing in a nutritional supplement, there were no physician orders for its use, and the facility did not have specific orders or documentation for the supplement as an intervention for the resident's weight loss. Interviews with the Registered Dietitian and the Director of Nursing confirmed the lack of specific orders and documentation regarding the nutritional supplement. The facility's policy indicated that if the resident consumed less than 50% of a meal, staff would provide a supplement, but this was not documented as an intervention for the resident's weight loss. The facility's Significant Weight Loss policy aimed to stabilize weight and identify underlying causes, but these steps were not evident in the resident's case.
Failure to Monitor Dialysis Resident Pre- and Post-Treatment
Penalty
Summary
The facility failed to ensure proper pre-treatment and post-treatment monitoring for a resident requiring dialysis services. Resident #24, who has a medical history including type two diabetes mellitus, diabetic chronic kidney disease, diabetic polyneuropathy, dependence on renal dialysis, acquired absence of left leg below knee, and stage four chronic kidney disease, was affected by this deficiency. The resident received dialysis treatments on Tuesdays, Thursdays, and Saturdays through a right-sided tunneled internal jugular catheter. The medical record lacked evidence of monitoring the resident's condition before and after dialysis treatments. Interviews with an LPN and the Director of Nursing (DON) revealed that the resident's blood pressure and weight were only obtained at the dialysis center, and no assessments were conducted by the facility before or after the treatments. The facility's policy required that residents' vitals, dialysis site, and fluid retention be assessed prior to departure for dialysis, and upon return, vitals, dialysis site, and symptoms of complications should be assessed, along with weighing the resident to compare pre- and post-dialysis weights.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for two residents with severe cognitive impairment. Resident #1, diagnosed with Parkinson's disease, Alzheimer's disease, and anxiety disorder, had a left buttock wound that required specific care. During an observation, an LPN sanitized her hands and donned gloves but did not change gloves or wash her hands after removing the soiled dressing, which is a breach of infection control protocols. The LPN confirmed this oversight during an interview, acknowledging the failure to change gloves and sanitize hands before completing the wound care. Similarly, Resident #33, with diagnoses including anxiety disorder, dementia, and hypertension, had moisture-associated skin damage on the buttocks. During the dressing change, the LPN did not wash or sanitize her hands before putting on gloves. The LPN admitted to forgetting to disinfect her hands due to nervousness. The facility's Wound Cleansing policy requires adherence to standard infection control guidelines, including hand hygiene and glove changes, which were not followed in these instances.
Lack of Documentation for Vaccine Education
Penalty
Summary
The facility failed to ensure that the medical records of two residents, identified as Residents #24 and #42, contained appropriate documentation of education provided regarding the risks and benefits of influenza and pneumococcal vaccines. Resident #24's Consent/Declination form dated 11/14/23 indicated a refusal of the pneumococcal, influenza, and COVID-19 vaccines. However, the medical record lacked evidence of education on the risks and benefits of these vaccines. An interview with RN #538 confirmed the absence of such documentation in Resident #24's medical record. Similarly, Resident #42's Consent/Declination form dated 10/05/21 showed a refusal of the pneumococcal, influenza, and COVID-19 vaccines. The medical record for Resident #42 also did not contain evidence of education on the risks and benefits of the vaccines. RN #538 confirmed this lack of documentation during an interview. The facility's policies required that residents or their legal representatives receive education on the benefits and potential side effects of these immunizations, with documentation in the medical record, but this was not adhered to in these cases.
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What surveyors actually found near you
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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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brewster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Country Lawn Ctr For Rehab | 1.9 mi | ★★★★★ | 0 | 0 |
| Altercare Of Navarre Ctr For Rehab & Nrsg Care | 3.5 mi | ★★★★★ | 19 | 0 |
| Legends Care Rehabilitation And Nursing Center | 5.3 mi | ★★★★★ | 12 | 0 |
| Shady Lawn Nursing Home | 7.3 mi | ★★★★★ | 0 | 0 |
| Amherst Meadows Skilled Nursing And Rehab | 7.7 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.