HOLYOKE, MA - State health inspectors identified numerous violations at Day Brook Village Senior Living during an April 2025 inspection, documenting failures in hospice care coordination, nutritional management for diabetic residents, and infection control practices that placed vulnerable residents at risk for serious health complications.
Critical Delay in Hospice Comfort Medications
One of the most concerning findings involved a 55-day delay in implementing physician-ordered comfort medications for a resident receiving hospice services. The resident, who had dementia and exhibited physical behaviors, rejection of care, and wandering, began hospice services on January 17, 2025. Despite the hospice team submitting three separate recommendations for comfort medications between January and March, facility staff failed to implement these orders until March 13, 2025.
The delayed medications included morphine for pain and shortness of breath, lorazepam for anxiety, and acetaminophen for mild pain or fever. When residents enter hospice care, timely administration of comfort medications becomes essential for managing end-of-life symptoms. These medications help control pain, reduce anxiety, and address terminal secretions that can cause significant distress. The 55-day delay meant this cognitively impaired resident potentially experienced unnecessary discomfort during a critical period when quality of life should be the primary focus.
Hospice coordination requires immediate action on comfort care recommendations. Standard practice dictates that hospice medication orders should be implemented within 24 hours to ensure residents receive appropriate palliative care. The facility's own policy required coordinated care planning between the facility and hospice agency, specifically including directives for managing pain and comfort measures. The repeated recommendations from the hospice team, including one marked "ACTION NEEDED" and another documented "WITH URGENCY," demonstrate the severity of this lapse in care coordination.
Dangerous Nutritional Mismanagement for Diabetic Resident
Inspectors discovered staff were providing incorrect nutritional supplements to a diabetic resident, creating significant risks for blood sugar management. The resident had been prescribed Boost Glucose Control supplements specifically formulated for people with diabetes, containing 16 grams of carbohydrates. Instead, staff repeatedly gave the resident Boost Original supplements containing 37 grams of carbohydrates - more than double the carbohydrate content.
This error occurred daily at breakfast, with one aide stating she "always provided the Boost Original" and never gave glucose control supplements to any resident. The aide admitted she didn't check with nursing staff and simply gave residents what she thought they preferred. On one occasion, the resident consumed two regular supplements at breakfast instead of the prescribed glucose control formula.
For diabetic residents, carbohydrate control is fundamental to managing blood sugar levels. The difference between 16 and 37 grams of carbohydrates per supplement represents a significant variance that can destabilize blood glucose, potentially leading to hyperglycemia, increased A1C levels, and long-term complications including nerve damage, kidney problems, and cardiovascular issues. The facility's dietitian confirmed that providing incorrect supplements could impact her ability to accurately assess nutritional status and make appropriate interventions.
Documentation showed staff were recording in medical records that the resident was receiving the glucose control supplement when they were actually providing the wrong product. This false documentation masked the error and prevented proper monitoring of the resident's diabetic management plan.
Failure to Monitor Critical Fluid Restrictions
A resident with End Stage Renal Disease requiring dialysis three times weekly had a physician-ordered fluid restriction of 1200 milliliters daily. However, the facility's documentation system incorrectly allotted 1800 milliliters - 50% more than ordered - for three consecutive months. Additionally, staff failed to total daily fluid intake for the majority of days, with 20 out of 31 days in March showing no calculated totals.
Fluid restriction compliance is vital for dialysis patients. Excess fluid intake between dialysis sessions can cause fluid overload, leading to pulmonary edema, congestive heart failure, hypertension, and potentially life-threatening cardiovascular complications. The additional 600 milliliters daily represented a dangerous deviation from medical orders. Proper fluid monitoring requires accurate documentation and daily totaling to ensure patients stay within prescribed limits. The facility's failure to maintain accurate fluid restriction records for months demonstrates systemic problems with their monitoring systems.
Weight Loss and Nutritional Interventions Ignored
Another resident experienced a significant weight loss of nearly 7% in one month, dropping from 169.6 pounds to 156.9 pounds between February and March 2025. Despite the dietitian documenting this concerning weight loss on March 13 and again on March 27, no nutritional interventions were implemented. The resident, who had dysphagia and required staff assistance with eating, remained without supplementation or other interventions to address the weight loss.
A weight loss exceeding 5% in one month is clinically significant and requires immediate intervention. Unintended weight loss in elderly residents can lead to muscle wasting, weakened immune function, increased fall risk, delayed wound healing, and overall decline in functional status. Standard practice requires implementing interventions such as nutritional supplements, increased meal frequency, or calorie-dense foods immediately upon identifying significant weight loss.
Additional Issues Identified
Inspectors documented numerous other violations affecting resident care and safety:
Infection Control Failures: Staff failed to wear required gowns during wound care for a resident on Enhanced Barrier Precautions, despite signage clearly indicating this requirement. Enhanced Barrier Precautions help prevent transmission of resistant organisms during high-contact care activities. A medication cart on Unit Two was found contaminated with dried spilled liquid, old medication particles, and dark stains in drawer corners.
Controlled Substance Mismanagement: The facility stored controlled substances including opioids, narcotics, and sedatives in the administrator's office for over a year without proper destruction. Some medications had been removed from medication carts as far back as January 2024. Staff also failed to obtain required dual-nurse verification when transferring controlled substances between documentation pages.
Meal Service Problems: Staff routinely ignored resident meal tickets and dietary preferences. Residents prescribed fortified foods for weight management didn't receive them. Staff served only orange or cranberry juice regardless of documented preferences or restrictions. One resident with "no orange juice" on their meal ticket received orange juice, while others requiring special milk products or specific breakfast items received standard alternatives instead.
Pest Control Issues: Fruit flies were observed in multiple resident rooms, hallways, and the Unit Two pantry. A hole in the pantry cabinet wall, first identified by pest control in 2019, remained unrepaired through April 2025. The maintenance director claimed ignorance of the issue despite it appearing on every pest control report for years.
Documentation Errors: The facility failed to complete admission assessments for a resident with substance use disorder history who subsequently left without staff knowledge. Staff didn't assess elopement risk or complete required documentation upon admission. The facility also incorrectly coded medication information on assessment forms and failed to provide required pneumococcal vaccinations for eligible residents who had consented to immunization.
These violations demonstrate systemic failures in multiple areas of resident care, from basic nutrition and medication management to infection control and facility maintenance. The pattern of delayed interventions, ignored recommendations, and inadequate monitoring systems placed vulnerable elderly residents at risk for serious health complications and diminished quality of life.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Day Brook Village Senior Living from 2025-04-03 including all violations, facility responses, and corrective action plans.
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