Brewster Village: Rough Care Complaints Ignored - WI
That resident, identified in inspection records as R4, has morbid obesity, type 2 diabetes, and generalized anxiety disorder. A cognitive assessment from June placed her score at 6 out of 15, indicating severe impairment. She depends on staff for all her care and movement. When a federal surveyor sat down with her on August 15, she said the nurse, identified as RN-I, was still doing it.
"R4 does not like to be grabbed and it is rude the way RN-I talks and grabs R4's fingers," the inspection report states, paraphrasing her account. She said she had told the social worker, SW-D, about the problem. She said she had told RN-I directly that she did not like the treatment. She denied bruising or pain. She said she felt safe at the facility. But the grabbing had not stopped, and no one had followed up.
Down the hall, a second resident, R5, described something similar. She has chronic pain syndrome, anxiety disorder, and spinal stenosis. Her cognitive score was zero out of 15. She requires substantial help to roll left or right in bed. She told the surveyor that staff pull her legs and that it causes pain. Her legs did not hurt at that moment, she said, and she also felt safe. But her care plan contained no instruction to handle her legs carefully. The two certified nursing assistants assigned to her care that day told the surveyor they had never heard about her concern.
The social worker, SW-D, told the surveyor that she had conducted resident interviews as part of a facility-reported incident on July 23 and had passed those interviews along to the director of operations. She did not remember R4 and R5's specific complaints. She acknowledged that either she or the director should have followed up and should have asked both residents whether they wanted to file a grievance. Neither had been asked.
SW-D said she had spoken with staff after learning of R5's leg pain, telling them to be more careful. She could not remember which staff members she had spoken with. She confirmed she had not spoken with RN-I, the nurse R4 had named. She was not sure whether she had documented any of the education she described providing. She told the surveyor she would check and follow up. The documentation was never provided.
The director of operations, identified as GO-C, confirmed the facility had no documented follow-up on either resident's concern. "If residents express a concern," GO-C told the surveyor, "the concern should be addressed." The nursing home administrator said the same thing in a separate interview that afternoon: staff should have followed up, and grievances should have been filed.
One nurse, RN-F, knew that R5 had complained about how staff handled her legs. Another nurse, RN-E, had heard nothing about either resident's complaints.
The violation was cited under the federal standard requiring facilities to establish and operate a grievance process that ensures residents can voice concerns without fear of retaliation and receive a written response. Inspectors classified it as causing minimal harm or potential for actual harm, one of the lower severity levels in the federal rating system. A small number of residents were affected.
What the classification does not capture is the specific situation of these two residents. Both had severe cognitive impairment. Both depended entirely on staff for their physical care. Both had already tried to report what was happening to them, through the channels the facility was supposed to maintain for exactly that purpose. R4 had gone to the social worker. She had told the nurse herself. R5's complaint had traveled far enough that at least one nurse on the floor knew about it.
The complaints reached the right people. They were noted, passed along, and then set aside. When the surveyor arrived weeks later, R4 said the nurse was still grabbing her fingers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brewster Village from 2025-08-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
Brewster Village in Appleton, WI was cited for violations during a health inspection on August 15, 2025.
That resident, identified in inspection records as R4, has morbid obesity, type 2 diabetes, and generalized anxiety disorder.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.