Brewster Village

In the surveyor’s words

From the most serious findings on record at Brewster Village, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 13, 2026

  Based on interview, record review, and policy review, the facility did not ensure the resident environment was free from accident hazards for 1 resident (R) (R3) of 1 sampled resident from a total sample of 12 residents. During cares, staff raised the height of R3's bed but did not lower it prior to leaving the room. R3 fell out of bed and sustained a laceration above the left eye that required sutures. Findings include: Review of R3's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed they were admitted to the facility on [DATE] with diagnoses including weakness and Alzheimer's disease. […]

• Actual harm, isolatedF689Mar 19, 2026

  Based on staff interview and record review, the facility did not ensure adequate supervision and assistance to prevent accidents was provided for 1 resident (R) (R1) of 3 sampled residents.On 2/11/26 at approximately 6:00 AM, R1 had an unwitnessed fall in R1's room and was sent to the emergency room (ER) at approximately 7:00 AM. X-ray results revealed a worsened left humerus fracture, an L1 spinal compression fracture, and a scalp hematoma. On 2/27/26, R1 had surgery to repair the left humerus fracture. The facility's investigation indicated the fall occurred because R1's call light was not in reach and R1 self-transferred to the bathroom. […]

• No harm, potential for more than minimal, widespreadF880Apr 15, 2026

  Based on staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect all 122 residents residing in the facility. The facility's Legionella water management program did not include a building assessment to identify potential areas of concern where Legionella could develop. R4 was on enhanced barrier precautions (EBP). […]

• No harm, potential for more than minimal, patternF887Oct 19, 2022

  Based on interview and record review, the facility did not develop a policy for Covid-19 vaccination of residents and ensure education regarding risks and benefits of Covid-19 vaccination was provided to residents/resident representatives. Facility did not have a policy to address Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus and at the time of this situation considered pandemic, meaning worldwide spread) vaccination for residents. Facility medical records did not contain documented proof R112's guardian was educated regarding Covid-19 vaccination for informed decision prior to declining vaccine for R112. Facility vaccination rate was 88%. […]

• No harm, potential for more than minimal, patternF812Sep 1, 2021

  Based on observation, staff interviews, and record review, the facility did not ensure food was served under sanitary conditions for three of twelve households where 40 residents of the facility's 152 residents resided. The facility did not have a practice of monitoring and documenting monitoring of hot holding temperatures. Registered Nurse (RN)-N did not wear a hair restraint in a household kitchenette where exposed food was set out for service. Findings include: 1. Food and Drug Administration (FDA) Food Code 2017 documents at 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. […]