Brewster Village

Inspectors wroteBased on staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect all 122 residents residing in the facility. The facility's Legionella water management program did not include a building assessment to identify potential areas of concern where Legionella could develop. R4 was on enhanced barrier precautions (EBP). Staff did not wear appropriate personal protective equipment (PPE) during cares for R4.

Inspectors wroteBased on staff interview and record review, the facility did not report an allegation of neglect to the State Agency (SA) for 1 resident (R) (R24) of 1 sampled resident. R24 reported an allegation of neglect by Van Driver (VD)-E on 3/13/26. R24 stated VD-E did not use a seatbelt or tie-downs during transport to secure R24's wheelchair in the van. VD-E made an abrupt stop which caused R24 to slide in the wheelchair and suffer rib, back, and lower extremity pain and bruising. The facility did not report the allegation of neglect to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of neglect was investigated for 1 resident (R) (R24) of 1 sampled resident. R24 reported an allegation of neglect by Van Driver (VD)-E on 3/13/26. R24 stated VD-E did not use a seatbelt or tie-downs during transport to secure R24's wheelchair in the van. VD-E made an abrupt stop which caused R24 to slide in the wheelchair and suffer rib, back, and lower extremity pain and bruising. The facility did not thoroughly investigate the allegation of neglect.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R24) of 7 sampled residents. R24 reported that Van Driver (VD)-E did not use tie-downs or a seatbelt to secure R24's wheelchair in the van during transport on 3/13/26. VD-E made an abrupt stop which caused R24 to slide in the wheelchair and resulted in rib, back, and lower extremity pain and bruising to R24's knee.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to meet the needs of 2 residents (R) (R138 and R143) of 24 sampled residents. R138 had melatonin at the bedside. R138 did not have a self-administration of medication assessment or a physician order that indicated R138 could safely and accurately self-administer medication or keep medication at the bedside. R143 had four 21 milligram (mg) nicotine patches, an Incruse Ellipta 62.5 microgram (mcg) dry powder inhaler, and a Breo Ellipta 100 mcg/25 mcg dry powder inhaler at the bedside. R143 did not have a self-administration of medication assessment or a physician order that indicated R143 could safely and accurately self-administer medication or keep medication at the bedside. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure adequate supervision and assistance to prevent accidents was provided for 1 resident (R) (R1) of 3 sampled residents. On 2/11/26 at approximately 6:00 AM, R1 had an unwitnessed fall in R1's room and was sent to the emergency room (ER) at approximately 7:00 AM. X-ray results revealed a worsened left humerus fracture, an L1 spinal compression fracture, and a scalp hematoma. On 2/27/26, R1 had surgery to repair the left humerus fracture. The facility's investigation indicated the fall occurred because R1's call light was not in reach and R1 self-transferred to the bathroom. (This example is being cited at past non-compliance.)

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure grievances were documented, thoroughly investigated, and resolved for 2 residents (R) (R4 and R5) of 6 sampled residents. On 7/24/25, R4 and R5 reported rough care by staff during an investigation for a facility-reported incident that occurred on 7/23/25. The facility did not document the concerns a grievances, thoroughly investigate the concerns, or provide resolution for R4 and R5.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility did not ensure 1 resident (R) (R99) of 1 sampled resident was able to be informed of and participate in medical treatment/medical decisions in a language R99 could understand. R99's primary language was Spanish. R99 indicated a preference for staff to use interpreter services to ensure R99 could communicate medical treatment needs. Interpreter services were not consistently provided. In addition, R99's care plan did not address R99's language barrier.

Inspectors wroteBased on observation and staff interview, the facility did not ensure call lights were within reach for 3 residents (R) (R80, R83, and R93) of 4 sampled residents. During multiple observations between 1/6/25 and 1/8/25, R80 did not have a call light within reach. On 1/8/25, R83 was observed without a call light within reach. On 1/6/25, R93 was observed without a call light within reach.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a physician was notified of a change in condition for 1 resident (R) (R56) of 7 sampled residents. R56's physician was not notified of skin wounds until 7 days after the wounds were discovered.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R10) of 3 sampled residents received the necessary care and treatment for oxygen therapy. R10 had a physician order for 2-6 liters per minute (LPM) of oxygen and used oxygen continuously. R10 did not have a care plan for oxygen use. In addition, R10's oxygen tubing was not changed after R10 was diagnosed with pneumonia.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R99) of 1 resident received appropriate dialysis care and services. R99 received dialysis services. R99 did not have a dialysis care plan to ensure coordination of care and monitoring of R99's fistula (a surgically created connection between an artery and a vein in the arm).

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to meet the needs of 1 resident (R) (R99) of 29 sampled residents. On 1/7/24 at approximately 2:00 PM, Surveyor observed a tube of 1% hydrocortisone (anti-itch cream) cream on a shelf under R99's refrigerator.

Inspectors wroteBased on staff interview and record review, the facility did not ensure adequate monitoring for 1 resident (R) (R47) of 5 residents reviewed for psychotropic medications. R47 was prescribed diazepam (an antianxiety medication), quetiapine fumarate (an antipsychotic medication), and mirtazapine (an antidepressant medication). R47's medical record did not contain monitoring interventions for adverse reactions to the psychotropic medications.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 2 residents (R) (R78 and R22) of 5 sampled residents observed during the provision of care. In addition, the facility did not have the appropriate transmission-based precautions in place for 1 (R214) of 3 sampled residents. Certified Nursing Assistant (CNA)-C did not appropriately cleanse hands or change gloves during incontinence care for R78. R22 was on enhanced barrier precautions (EBP). CNA-M and CNA-N did not don the appropriate personal protective equipment (PPE) during care for R22. R214 had a diagnosis of pneumonia and was symptomatic. R214 was not on droplet precautions.

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccines were offered for 2 residents (R) (R80 and R36) of 5 sampled residents. R80 and R36 were not offered Prevnar 20 (PCV20) vaccines.

Inspectors wroteBased on staff interview and record review, the facility did not ensure coordination of Hospice services for 3 Residents (R) (R104, R20, and R54) of 3 residents reviewed for Hospice services. R104 received Hospice services. The facility did not have a Hospice care plan or visit notes and did not have a facility care plan regarding Hospice services. R20 received Hospice services. The facility did not have a Hospice care plan or visit notes. R54 received Hospice services. The facility did not have Hospice care plan or visit notes.