Day Brook Village: Records Access Violations - MA
The resident developed moisture-associated skin damage in March. The wound deteriorated in July and August. Nobody called the family.
The facility's wound nurse told inspectors she should have notified the family member when the resident first developed the condition on March 26 and again when the wound was assessed to have deteriorated on July 14, July 29, and August 5.
"Family Member #1 should have been notified," the wound nurse said during interviews in September. She admitted she couldn't recall if she called the family when the wound worsened in July, despite documenting "HCP Aware" in medical records.
The wound nurse said she needed to work on improving her documentation.
When the resident's wound deteriorated further on August 5, the wound nurse acknowledged that if there wasn't a progress note documenting family notification, "Family Member #1 was not notified, but that he should have been."
Federal regulations require nursing homes to immediately inform residents or their representatives of changes in health status. The facility's own policies mandate notification when wounds develop or worsen significantly.
Two unit managers confirmed nursing staff responsibilities during inspector interviews. Unit Manager #1 said staff nurses must complete weekly skin assessments and notify residents' representatives of new skin issues. Unit Manager #2 said nurses are required to notify representatives when wounds worsen.
The Director of Nurses reviewed the resident's medical records with inspectors and the facility's Corporate Quality Improvement Manager. She found no nursing progress notes indicating staff had notified the family after the wound developed in March or after it deteriorated three times over the summer.
"There was no evidence on the Ongoing Skin Condition Assessment that the Wound Nurse notified Family Member #1 of Resident #1's worsening wound on August 5," both the Director of Nurses and Quality Improvement Manager told inspectors.
The pattern of non-notification stretched across months of documented wound deterioration. Medical records showed the moisture-associated skin damage first appeared March 26. Assessments on July 14, July 29, and August 5 all documented worsening conditions.
Each time, nursing staff failed to follow notification protocols.
The facility didn't contact the family member until August 26, five months after the wound first developed and three weeks after the August 5 assessment showed further deterioration. A progress note from that date finally documented that the resident's representative was contacted about the worsening wound.
By September 24, inspectors found the facility in "Past Non-Compliance" and required a correction plan. The facility's response revealed the scope of potential notification failures beyond this single resident.
The Director of Nursing completed a facility-wide audit on September 12 to determine if notification protocols were followed for all residents who had developed wounds or experienced significant wound changes. Unit managers conducted additional facility-wide audits on September 19 and September 26.
Between September 12 and September 24, nursing staff received mandatory education on notification protocols for residents with changing wound status. The training included review of facility policies on informing residents of health and medical conditions.
The facility committed to weekly audits by unit managers to ensure physicians and resident representatives receive proper notification of wound status changes. After achieving 100 percent compliance weekly, random audits will continue indefinitely.
The deficient practice and audit results were scheduled for presentation at the October 8 Quality Assurance Performance Improvement meeting.
The case illustrates how communication breakdowns can leave families uninformed about their loved ones' deteriorating health conditions for months. The resident's representative remained unaware of the developing skin wound and its progression through multiple documented assessments showing worsening damage.
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 20, 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 in March.
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.