Brewster Village
Inspection Findings
F-Tag F0585
F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Resident R4 and Resident R5's interviews that indicated concerns with rough care and asked if grievances were filed for Resident R4 and Resident R5's concerns. GO-C was aware of the interviews with Resident R4 and Resident R5 and verified the facility did not have documented follow-up regarding the concerns. GO-C indicated if residents express a concern, the concern should be addressed.On 8/15/25, Surveyor reviewed Resident R4's medical record. Resident R4 was admitted to the facility on [DATE REDACTED] and had diagnoses including morbid obesity, type 2 diabetes, and generalized anxiety disorder. Resident R4's Minimum Data Set (MDS) assessment, dated 6/13/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated Resident R4 had severe cognitive impairment. The MDS assessment also indicated Resident R4 was dependent on staff for cares and mobility. Resident R4 made Resident R4's own healthcare decisions.A progress note, dated 6/11/25, indicated Resident R4 had a Power of Attorney for Healthcare (POAHC) that was not activated.On 8/15/25 at 2:08 PM, Surveyor interviewed Resident R4 regarding Resident R4's report of rough care from RN-I. Resident R4 indicated RN-I is still rough and pulls/grabs Resident R4's arm and fingers during blood sugar checks. Resident R4 confirmed Resident R4 informed SW-D about the concern and also informed RN-I that Resident R4 did not like the treatment. Resident R4 indicated SW-D did not follow-up on the concern. Resident R4 denied pain or bruising, but stated Resident R4 does not like to be grabbed and it is rude the way RN-I talks and grabs Resident R4's fingers. Resident R4 indicated Resident R4 feels safe at the facility.On 8/15/25, Surveyor reviewed Resident R5's medical record. Resident R5 was admitted to the facility on [DATE REDACTED] and had diagnoses including chronic pain syndrome, anxiety disorder, and spinal stenosis. Resident R5's MDS assessment, dated 6/23/25, indicated Resident R5 had a BIMS score of 00 out of 15 which indicated Resident R5 had severe cognitive impairment. The MDS assessment also indicated Resident R5 required substantial assistance with mobility such as rolling left and right. Resident R5 had an activated POAHC for healthcare.Surveyor noted Resident R5's plan care did not contain an intervention to handle Resident R5's legs carefully.On 8/15/25 at 2:13 PM, Surveyor interviewed Resident R5 who indicated staff are rough and pull Resident R5's legs which causes pain. Resident R5 indicated Resident R5's legs did not currently hurt and Resident R5 feels safe at the facility.On 8/15/25 at 2:20 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-G and CNA-H who were not aware of Resident R5's concern.On 8/15/25 at 2:25 PM, Surveyor interviewed SW-D who confirmed SW-D completed resident interviews for the facility-reported incident on 7/23/25 but did not recall Resident R4 and Resident R5's concerns and indicated the interviews were given to GO-C. SW-D indicated either SW-D or GO-C should have followed-up and asked if Resident R4 and Resident R5 wanted to file a grievance.
SW-D did not know which staff Resident R5 referrred to in the interview. SW-D stated SW-D immediately followed-up with staff after learning of Resident R5's concern so staff would be more careful with Resident R5's legs. SW-D could not recall who SW-D followed-up with but indicated SW-D did not follow-up with RN-I. SW-D was unsure if the staff education was documented and indicated SW-D would check for documentation and follow-up with Surveyor. (The documentation was not provided.)On 8/15/25 at 2:35 PM, Surveyor interviewed RN-F who was aware Resident R5 had concerns about the way staff handled Resident R5's legs which caused pain.On 8/15/25 at 2:38 PM, Surveyor interviewed RN-E who was not aware of rough cares reported by Resident R4 or Resident R5.On 8/15/25 at 4:28 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff should have followed-up on Resident R4 and Resident R5's concerns and should have filed grievances.
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BREWSTER VILLAGE in APPLETON, WI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in APPLETON, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BREWSTER VILLAGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.