Cycle 1
Health 2025-01-08 · Fire 2025-01-08
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Appleton, WI
Brewster Village
5-star overall rating with 4-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
3300 W Brewster St, Appleton, WI
(920) 832-5400
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
204
Certified beds
Average residents
114
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.45
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.29
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.22
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.96
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.52
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.15
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.38
CMS adjusted RN staffing hours
Adjusted total hours
4.73
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,876
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9952
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.01% · Performance 23.79% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.66
Baseline 6.04% · Performance 6.44% · Measure score 4.66 · Achievement 4.66 · Improvement 0
Total nurse turnover
7.67
Baseline 41.49% · Performance 32.32% · Measure score 7.67 · Achievement 7.67 · Improvement 5.01
Adjusted total nurse staffing
4.59
Baseline 4.54 hours · Performance 4.38 hours · Measure score 4.59 · Achievement 4.59 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.17% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 7.27% · Lower 95% interval 6.03% |
| Discharge to community | 52.41% |
50.57%
1.8 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 52.27% · Lower 95% interval 40.91% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 95.12% |
95.27%
0.1 pts worse
|
Numerator 39 · Denominator 41 |
| Falls with major injury | 2.44% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 41 |
| Discharge self-care score | 11.76% |
53.69%
41.9 pts worse
|
Numerator 4 · Denominator 34 |
| Discharge mobility score | 26.47% |
50.94%
24.5 pts worse
|
Numerator 9 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 41 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.44% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 2.56% · Lower 95% interval 3.69% |
| Staff COVID-19 vaccination coverage | 3.4% |
8.2%
4.8 pts worse
|
Numerator 10 · Denominator 294 |
| Staff flu vaccination coverage | 92.22% |
42%
50.2 pts better
|
Numerator 320 · Denominator 347 |
| Discharge function score | 23.53% |
56.45%
32.9 pts worse
|
Numerator 8 · Denominator 34 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.6
0.6 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.5 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
2.2
1.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
95.7%
3.1 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 97.2% · Q3 100.0% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
95.0%
1.6 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.2%
0.8 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.7% · Q3 3.8% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.9% |
5.0%
1.1 pts better
|
11.4%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.1% · Q3 4.2% · Q4 6.1% · 4Q avg 3.9% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
4.9%
1.8 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.1% · Q3 3.3% · Q4 4.8% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.5% |
16.6%
1.9 pts worse
|
19.6%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 17.9% · Q3 17.8% · Q4 19.0% · 4Q avg 18.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.1% |
16.7%
10.4 pts worse
|
16.7%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 27.1% · Q3 29.4% · Q4 27.3% · 4Q avg 27.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.2% |
21.1%
3.9 pts better
|
16.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 22.0% · Q3 17.0% · Q4 19.3% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.8% |
17.3%
3.5 pts better
|
14.9%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 20.5% · Q3 11.8% · Q4 12.5% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
2.3%
0.2 pts better
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.6% · Q3 2.5% · Q4 2.4% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.0% |
3.0%
1 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 6.5% · Q3 3.8% · Q4 2.9% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.1% |
25.5%
1.6 pts worse
|
19.8%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 35.5% · Q3 21.6% · Q4 23.4% · 4Q avg 27.1% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.5%
1 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 5.6% · Q3 4.5% · Q4 6.4% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
86.8%
10.2 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 95.9% · Q3 98.0% · Q4 96.7% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.5% |
15.0%
12.5 pts better
|
12.0%
9.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.5% · Observed 2.4% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.5% |
82.2%
6.3 pts better
|
79.7%
8.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.4% |
22.7%
2.3 pts better
|
23.9%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.4% · Observed 19.0% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-29 · Fire 2023-11-29
1 health deficiencies
Top issue: Administration (1 deficiency)
20 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2022-10-19 · Fire 2022-10-19
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-08
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-02-03
F · Potential for more than minimal harm
2025-01-08
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-01-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-01-08
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-01-08
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-03
F · Potential for more than minimal harm
2023-11-29
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-12-20
F · Potential for more than minimal harm
2023-11-29
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-12-20
F · Potential for more than minimal harm
2023-11-29
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-12-20
F · Potential for more than minimal harm
2023-11-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-12-20
F · Potential for more than minimal harm
2023-11-29
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-12-20
F · Potential for more than minimal harm
2023-11-29
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-12-20
F · Potential for more than minimal harm
2023-11-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-26
F · Potential for more than minimal harm
2023-11-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-11-29
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-12-26
E · Potential for more than minimal harm
2023-11-29
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-12-26
E · Potential for more than minimal harm
2023-11-29
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-12-26
E · Potential for more than minimal harm
2023-11-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-11-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-26
E · Potential for more than minimal harm
2023-11-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-26
D · Potential for more than minimal harm
2023-11-29
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-12-26
D · Potential for more than minimal harm
2023-11-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-12-26
D · Potential for more than minimal harm
2023-11-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-26
D · Potential for more than minimal harm
2023-11-29
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-29
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-12-26
D · Potential for more than minimal harm
2023-11-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-26
F · Potential for more than minimal harm
2022-10-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-07
E · Potential for more than minimal harm
2022-10-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-11-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-15
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-01-08
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-08
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-08
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-02-07
D · Potential for more than minimal harm
2023-11-29
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-12-26
E · Potential for more than minimal harm
2022-10-19
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2022-11-30
D · Potential for more than minimal harm
2022-10-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-11-30
Penalties and ownership
What sits behind the stars
Ownership
County Of Outagamie
5% Or Greater Direct Ownership Interest · Organization
Gruper, Ann
W-2 Managing Employee · Individual
Nelson, Tamra
Operational/Managerial Control · Individual
Neuman, Timothy
W-2 Managing Employee · Individual
Walk, Taya
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Rennes Health And Rehab Center- Appleton
Appleton, WI
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Meadowbrook At Appleton
Appleton, WI
1-star overall rating with 1-star inspections with $15,642 in total fines with 24 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Edenbrook Of Appleton North
Appleton, WI
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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