Brewster Village

R4 and R5's interviews that indicated concerns with rough care and asked if grievances were filed for R4 and R5's concerns. GO-C was aware of the interviews with R4 and 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 R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including morbid obesity, type 2 diabetes, and generalized anxiety disorder. 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 R4 had severe cognitive impairment.

The MDS assessment also indicated R4 was dependent on staff for cares and mobility. R4 made R4's own healthcare decisions.A progress note, dated 6/11/25, indicated R4 had a Power of Attorney for Healthcare (POAHC) that was not activated.On 8/15/25 at 2:08 PM, Surveyor interviewed R4 regarding R4's report of rough care from RN-I. R4 indicated RN-I is still rough and pulls/grabs R4's arm and fingers during blood sugar checks. R4 confirmed R4 informed SW-D about the concern and also informed RN-I that R4 did not like the treatment. R4 indicated SW-D did not follow-up on the concern. R4 denied pain or bruising, but stated R4 does not like to be grabbed and it is rude the way RN-I talks and grabs R4's fingers. R4 indicated R4 feels safe at the facility.On 8/15/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including chronic pain syndrome, anxiety disorder, and spinal stenosis. R5's MDS assessment, dated 6/23/25, indicated R5 had a BIMS score of 00 out of 15 which indicated R5 had severe cognitive impairment.

The MDS assessment also indicated R5 required substantial assistance with mobility such as rolling left and right. R5 had an activated POAHC for healthcare.Surveyor noted R5's plan care did not contain an intervention to handle R5's legs carefully.On 8/15/25 at 2:13 PM, Surveyor interviewed R5 who indicated staff are rough and pull R5's legs which causes pain. R5 indicated R5's legs did not currently hurt and 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 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 R4 and 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 R4 and R5 wanted to file a grievance.

SW-D did not know which staff R5 referrred to in the interview. SW-D stated SW-D immediately followed-up with staff after learning of R5's concern so staff would be more careful with 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 R5 had concerns about the way staff handled 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 R4 or R5.On 8/15/25 at 4:28 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff should have followed-up on R4 and R5's concerns and should have filed grievances.

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