Day Brook Village: Notification Failures Cited - MA
The resident developed moisture-associated skin damage on March 26, 2025. The facility's wound nurse said the family should have been notified immediately. They weren't.
The wound worsened on July 14. No call to the family.
It deteriorated again on July 29. Still no notification.
By August 5, the condition had declined a fourth time. The wound nurse documented "N/A" on assessment records where family notification should have been recorded, meaning no contact was made.
During a September interview, the wound nurse told inspectors she "should have" called the family member when the resident first developed the skin damage in March. She also acknowledged the family should have been notified each time the wound assessment showed deterioration in July and August.
The wound nurse said when she calls families about declining conditions, she typically documents the conversation in progress notes. She told inspectors she couldn't recall if she had called the family member about the July deteriorations, despite documenting "HCP Aware" in medical records. She admitted she needed to improve her documentation practices.
For the August 5 worsening, inspection records show no progress notes indicating family contact. The wound nurse confirmed that if there wasn't a note documenting the call, then the family member wasn't notified. "But he should have been," she told inspectors.
Unit Manager #1 explained that staff nurses complete weekly skin assessments on every resident. If they discover new skin problems, they're responsible for notifying the resident's representative.
Unit Manager #2 reinforced this policy during a telephone interview, stating that primary nurses must notify families about new areas of concern or worsening wounds.
Director of Nurses and the Corporate Quality Improvement Manager reviewed the resident's medical records with inspectors on September 25. Neither could find any nursing progress notes indicating the family had been notified when the wound first appeared in March or during any of the subsequent deteriorations in July and August.
Both managers confirmed there was no evidence in assessment records that the wound nurse had contacted the family member about the August 5 worsening.
The facility was found to be in "Past Non-Compliance" on September 24, meaning they had already begun addressing the problem before inspectors arrived. Their correction plan included several immediate actions.
On August 26, a progress note finally documented that the resident's representative had been contacted about the worsening wound. The facility completed a facility-wide audit on September 12 to review notification procedures for all residents with wounds or significant wound changes.
Unit managers conducted additional audits on September 19 and 26 to ensure families were being notified about wound status changes. Between September 12 and 24, the Director of Nursing provided education to staff on notification protocols, including review of policies for informing residents and families about health conditions.
The facility committed to weekly audits by unit managers to ensure proper notification of both physicians and families about wound changes. After achieving 100 percent compliance, they plan to continue random audits indefinitely.
Results will be presented at the October 8 Quality Assurance Performance Improvement meeting, with the Director of Nursing responsible for overall compliance.
The inspection classified this as causing "minimal harm or potential for actual harm" affecting "few" residents. Federal regulations require nursing homes to immediately inform residents and their representatives about changes in health status, accidents, or significant changes in condition.
For one family at Day Brook Village, four months passed without knowing their loved one was developing and suffering from a progressively worsening wound that staff were monitoring, treating, and documenting throughout the spring and summer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Day Brook Village Senior Living from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
DAY BROOK VILLAGE SENIOR LIVING in HOLYOKE, MA was cited for violations during a health inspection on November 18, 2025.
The resident developed moisture-associated skin damage on March 26, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.