Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
Based on record review, staff interview, review of facility policy, and observation, the facility failed to update
the physician on a change of condition for Resident #38. This affected one (Resident #38) of one resident
reviewed for changes in conditions. The facility census was 55.
Findings include:
Review of the medical record for Resident #38 revealed an admission date of 03/22/23 with diagnoses
including chronic respiratory failure, chronic obstructive pulmonary disease and emphysema (a condition of
the lungs that causes shortness of breath).
Review of the care plan dated 04/03/23 for Resident #38 revealed she was at risk for altered respiratory
status and difficulty breathing related to anxiety, chronic obstructive pulmonary disease, congestive heart
failure and chronic respiratory failure. Interventions included to monitor for signs and symptoms of
respiratory distress and report to the physician increased respirations, decreased pulse oximetry,
restlessness, lethargy and confusion.
Review of the physician's order for Resident #38 revealed an order for oxygen at two liters via nasal
cannula continuously dated 07/15/24.
Review of the treatment administration record for December 2024 for Resident #38 revealed nursing staff
had been administering oxygen at two liters continuously and documenting her oxygen saturation at
morning and bedtime.
Review of the nursing progress notes for Resident #38 from 12/24/24 through 12/27/24, revealed on
12/24/24 at 4:56 A.M. Resident #38 appeared slightly lethargic when the nurse woke her for her morning
medications. Resident #38 stated she was tired and oxygen saturation was checked which revealed it was
90-92 percent (%) on two liters nasal cannula. The nursing progress note dated 12/24/24 at 5:21 A.M.
revealed oxygen had been increased to four liters nasal cannula. There was no indication the physician was
updated related to increased need for oxygen.
Observation with Registered Nurse (RN) #551 on 12/26/24 at 3:27 P.M. revealed Resident #38's oxygen
concentrator was set to four liters. She verified Resident's #38's physician's orders were for two liters of
oxygen continuously. RN #551 verified there was no written or verbal order for four liters of oxygen.
Interview on 12/26/24 at 3:53 P.M. with the Director of Nursing (DON) verified the physician was not
updated on Resident #38's change of condition of lethargy, decreased oxygen saturation and need
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
366264
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366264
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brewster Convalescent Center
264 Mohican Street NE
Brewster, OH 44613
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
for increased oxygen.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility policy titled, Use of Oxygen, dated 05/01/16, revealed oxygen therapy must be
prescribed by the resident's physician. The physician was responsible for identifying the type of therapy and
the rate of oxygen based on oxygen saturation and respiratory assessment.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366264
If continuation sheet
Page 2 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366264
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brewster Convalescent Center
264 Mohican Street NE
Brewster, OH 44613
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to ensure interventions were implemented and monitored for
Resident #33's trending weight loss. This finding affected one (Resident #33) of two residents reviewed for
nutrition.
Residents Affected - Few
Findings include:
Review of Resident #33's medical record revealed the resident was readmitted on [DATE] with diagnoses
including anxiety disorder, dementia in other diseases classified elsewhere and essential hypertension.
Review of Resident #33's initial weight dated 07/29/24 revealed the resident weighed 187.2 pounds.
Resident #33's weights revealed the resident weighed 196.6 pounds on 08/20/24, 183.9 pounds on
11/07/24 and 179.2 pounds on 12/04/24.
Review of Resident #33's physician orders revealed an order dated 08/16/24 revealed a reduced
carbohydrate diet, no added sodium with a regular texture, regular/thin consistency. There were no
physician orders for nutritional supplements including the boost brought in by the resident's family
members.
Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 exhibited
severe cognitive impairment.
Review of the quarterly Medical Nutrition Therapy form dated 11/05/24 revealed Resident #33 was on a
reduced carbohydrate controlled diet with no added sodium, regular texture with thin liquids. The form
indicated the resident received metformin as ordered and the oral intakes were greater than fifty-one
percent at most per meals. The residents feeds himself after setup assistance. The weight was 183.9
pounds and has had a 3.3 pound weight loss since his initial admission weight of 187.2 pounds. No edema
was noted.
Review of Resident #33's nurse aide tracking from 11/28/24 to 12/26/24 revealed documentation the
resident was offered the boost for weight loss on 11/29/24, 12/07/24, 12/08/24, 12/21/24, 12/22/24, and
12/25/24. The resident refused the boost supplement on 12/16/24, 12/18/24, 12/20/24 and 12/25/24. All
other dates were blank or documented as not applicable.
Review of Resident #33's medical record did not reveal evidence the resident's physician was notified of the
resident's trending weight loss.
Interview on 12/27/24 at 8:39 A.M. with Registered Dietitian (RD) #600 stated Resident #33's family
brought in boost nutritional supplement from home for the resident's decreasing weight loss. RD #600
stated the resident's family supplied the boost and the facility offered and monitored the resident's boost
intake. RD #600 confirmed Resident #33's medical record did not have specific orders for the
implementation of the boost supplement for weight loss to determine how often or how much the resident
should receive the boost supplement.
Interview on 12/27/24 at 9:02 A.M. with the Director of Nursing (DON) confirmed Resident #33's medical
record did not have evidence the resident's boost was offered for a specific duration and stated
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366264
If continuation sheet
Page 3 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366264
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brewster Convalescent Center
264 Mohican Street NE
Brewster, OH 44613
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the facility offered the boost when the resident requested the boost supplement. The DON confirmed the
medical record did not have specific orders for the resident's boost as an intervention for the resident's
trending weight loss.
An additional interview on 12/27/24 at 2:58 P.M. with RD #600 revealed it was her understanding if
Resident #33 consumed less than 50% of the meal offered, staff would grab a magic shake or boost and
nurses would administer. She stated that was the facility policy and she confirmed the boost supplement
was not a documented intervention for the resident's trending weight loss including physician notification
and specific orders to implement the boost supplement.
Review of the Significant Weight Loss policy dated 01/01/17 revealed the facility has the goal of medical
nutrition therapy (MNT) to stabilize the weight, identify underlying causes or factors contributing to the
significant unplanned weight loss, and intervene as appropriate to resolve the problem.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366264
If continuation sheet
Page 4 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366264
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brewster Convalescent Center
264 Mohican Street NE
Brewster, OH 44613
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview, medical record review, and facility policy review, the facility failed to ensure
pre-treatment and post-treatment monitoring was completed for a dialysis resident. This affected one
(Resident #24) of two residents reviewed for dialysis. The facility census was 55.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #24 revealed an admission date of 11/13/23 and diagnoses
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.
Review of physician's order dated 09/26/24 revealed Resident #24 received dialysis treatments on
Tuesdays, Thursdays, and Saturdays. Resident #24 has right sided tunneled internal jugular catheter
dialysis site.
The medical record revealed no evidence of monitoring of Resident #24's condition prior to or following
dialysis treatments.
Interview on 12/27/24 at 11:07 A.M. with Licensed Practical Nurse (LPN) #542 revealed Resident #24's
blood pressure and weight were obtained at dialysis.
Interview on 12/27/24 at 12:02 P.M. with Director of Nursing (DON) confirmed they do not assess Resident
#24 prior to or returning from dialysis treatments. DON indicated pre and post weights were obtained as
well as their blood pressure.
Review of the facility policy titled Managing and Monitoring Residents Receiving Outpatient Hemodialysis
dated 06/01/22 revealed residents' vitals, dialysis site, and fluid retention would be assessed prior to
departing for dialysis treatment. Upon return, residents' vitals, dialysis site, and symptoms of complications
would be assessed. Residents would also be weighed following dialysis treatment to compare to
pre-dialysis weight.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366264
If continuation sheet
Page 5 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366264
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brewster Convalescent Center
264 Mohican Street NE
Brewster, OH 44613
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview, the facility failed to ensure appropriate hand washing or hand
sanitization was completed prior to completing Residents #1 and #33's non-pressure wound care. This
affected two (Residents #1 and #33) of two residents reviewed for general skin conditions.
Residents Affected - Few
Findings include:
1. Review of Resident #1's medical record revealed the resident was admitted on [DATE] with diagnoses
including Parkinson's disease without dyskinesia, Alzheimer's disease and anxiety disorder. Review of the
quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 exhibited severe
cognitive impairment.
Review of Resident #1's Weekly Wound Report form dated 12/17/24 revealed the resident had left buttock
moisture associated skin damage (MASD)/shearing acquired 12/14/24.
Review of Resident #1's physician orders revealed an order dated 12/17/24 to cleanse the open area on
the left buttock with normal saline, pat dry, apply collagen moistened with normal saline to the wound bed
and apply a dry dressing in the morning for wound care and as needed.
Observation on 12/26/24 at 11:29 A.M. with Licensed Practical Nurse (LPN) #545 of Resident #1's left
buttock wound care revealed the nurse sanitized her hands and put on gloves. Then the nurse removed the
soiled dressing on the resident's left buttock, cleansed the wound with normal saline, applied the collagen
and normal saline to the left buttock and placed a dry dressing on the left buttock wound. LPN #545 did not
change her gloves during the treatment change.
Interview on 12/26/24 at 12:47 P.M. with LPN #545 verified she did not change her gloves, wash her hands
and putting on new gloves prior to completing the resident's wound care after she removed the soiled
dressing.
2. Review of Resident #33's medical record revealed the resident was readmitted on [DATE] with diagnoses
including anxiety disorder, dementia and essential hypertension.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33
exhibited severe cognitive impairment.
Review of the Weekly Wound Report dated 12/17/24 revealed Resident #33 acquired left buttock moisture
associated skin damage (MASD)/shearing on the left buttock which measured 1.5 centimeters (cm) length
by 1.2 cm width by 0.1 cm depth; right buttock MASD/shearing which measured 0.5 cm length by 0.5 cm
width by less than 0.1 cm depth; and right buttock MASD/shearing which measured 0.5 cm length by 0.5
cm width by less than 0.1 cm depth.
Observation on 12/26/24 at 12:40 P.M. with Licensed Practical Nurse (LPN) #545 of Resident #33's left
buttock dressing revealed the resident was rolled into the common bathroom on the unit. The resident was
assisted in a standing position, the nurse put on gloves and cleansed the resident's left and right buttocks
with normal saline, applied the collagen and normal saline on the left and right buttocks and applied a dry
dressing. LPN #545 did not wash her hands prior to putting on gloves.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366264
If continuation sheet
Page 6 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366264
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brewster Convalescent Center
264 Mohican Street NE
Brewster, OH 44613
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Interview on 12/26/24 at 12:47 P.M. with LPN #545 confirmed she did not wash or sanitize her hands prior
to completing Resident #33's left buttock dressing. She stated she was nervous and that was why she
forgot to disinfect her hands prior to completing the dressing.
Review of the Wound Cleansing policy dated 05/01/16 indicated the procedure indicated to adhere to
Standard Universal Infection Control Guidelines/Precautions, review physician orders, explain procedure to
the resident, establish a clean field with all the supplies and equipment, remove tape by pushing skin from
tape, remove soiled dressing, discard dressing and change gloves, decontaminate hands and don new
gloves, clean a linear wound from top to bottom working outward, dress wound with appropriate dressings
following the manufacturer's guidelines for use, and discard soiled supplies in the appropriate containers.
Event ID:
Facility ID:
366264
If continuation sheet
Page 7 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366264
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brewster Convalescent Center
264 Mohican Street NE
Brewster, OH 44613
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review and interview, the facility failed to ensure Residents #24 and #42's medical records
have the appropriate documentation of the education provided regarding the risks and benefits of the
influenza and pneumococcal vaccines. This affected two (Residents #24 and #42) of five residents reviewed
for immunizations.
Residents Affected - Few
Findings include:
1. Review of Resident #24's Consent/Declination of Pneumococcal, Influenza, and COVID-19 Vaccines
form dated 11/14/23 revealed the resident did not wish to receive the pneumococcal vaccine, the influenza
vaccine or the COVID-19 vaccine and/or booster.
Review of Resident #24's medical record revealed the resident refused the pneumovax and the influenza
immunization. The medical record did not reveal evidence the resident was educated on the risks and
benefits of the pneumovax and influenza immunizations.
Interview on 12/27/24 at 9:09 A.M. with Registered Nurse (RN) #538 confirmed Resident #42's medical
record did not have evidence the education was provided regarding the risks and benefits of the influenza
and pneumococcal vaccines.
2. Review of Resident #42's Consent/Declination of Pneumococcal, Influenza, and COVID-19 Vaccines
form dated 10/05/21 revealed the resident did not wish to receive the pneumococcal vaccine the influenza
vaccine or the COVID-19 vaccine and/or booster.
Review of Resident #42's medical record revealed the resident refused the influenza and pneumovax
vaccine. The medical record did not reveal evidence the resident was educated on the risks and benefits of
the influenza and pneumovax vaccines.
Interview on 12/27/24 at 9:09 A.M. with Registered Nurse (RN) #538 confirmed Resident #42's medical
record did not have evidence the education was provided regarding the risks and benefits of the influenza
and pneumococcal vaccines.
Review of the Resident Influenza Immunization policy dated 11/05/18 revealed before offering the influenza
immunization, each resident, or the resident's legal representative will receive education regarding the
benefits and potential side effects of the immunization. The resident's medical record includes
documentation that indicates, at a minimum, that the resident or resident's legal representative was
provided education regarding the benefits and potential side effects of the influenza immunization.
Review of the Pneumococcal of Residents Vaccine policy reviewed 01/01/17 revealed to provide the
resident or responsible party with literature on the Pneumococcal vaccine (from the Centers for Disease
Control or CDC).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366264
If continuation sheet
Page 8 of 8
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the December 28, 2024 survey of BREWSTER CONVALESCENT CENTER?
This was a inspection survey of BREWSTER CONVALESCENT CENTER on December 28, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BREWSTER CONVALESCENT CENTER on December 28, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement policies and procedures for flu and pneumonia vaccinations."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.