Day Brook Village Senior Living
DAY BROOK VILLAGE SENIOR LIVING in HOLYOKE, MA — inspection on November 18, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 09/24/25 at 2:00 P.M., the Administrative Assistant said Resident #1's medical records were mailed to Family Member #1 on 09/23/25 and provided a copy of the postal receipt to the surveyor that indicated an expected delivery date of 09/29/25.
During an interview on 09/24/25 at 2:00 P.M., the Medical Records Coordinator said she was aware of Family Member #1's request for copies of Resident #1's medical records, and that she was notified by email by the Executive Director.The Medical Records Coordinator said she emailed a Medical Record Request Form to Family Member #1, which was completed by him and emailed back to the facility.After reviewing the completed Medical Records Request form with the surveyor, the Medical Records Coordinator said the Form was signed by Family Member #1 on 09/12/25, and scanned into Resident #1's Electronic Medical Record on 09/16/25 at 9:26 A.M.The Medical Records Coordinator said she believed the facility's policy was to release medical records within 30 days of receipt of the request, and that she was unaware of any regulation that stated otherwise.
During an interview on 09/24/25 at 2:50 P.M., the Executive Director said that Family Member #1 emailed the Business Office Manager on 09/03/25 at 8:50 P.M. requesting Resident #1's medical records.
The Executive Director said the Business Office Manager subsequently forwarded the email to both him and the Social Worker on 09/04/25 at 7:52 A.M., and at that time, he notified the Medical Records Coordinator to begin to print/copy Resident #1's medical records.The Executive Director said they require a Medical Record Release Form to be completed by whoever is requesting the medical records prior to releasing them, but the process can still begin prior to receiving the signed release form.The Executive Director said he offered to have Family Member #1 or his designee view Resident #1's medical records on or around 09/10/25, but Family Member #1 declined, and that the medical records were mailed to Family Member #1 on 09/23/25.
During an interview on 09/25/25 at 3:15 P.M., the Quality Improvement Manager (QIM) said the Facility did not release Resident #1's medical records to Family Member #1 in a timely manner.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/18/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Day Brook Village Senior Living
298 Jarvis Avenue Holyoke, MA 01040
SUMMARY STATEMENT OF DEFICIENCIES
During a telephone interview on 09/26/25 at 4:06 P.M., Unit Manager #2 said the resident's primary nurse is responsible for completing weekly skin assessments and if there is a new area of concern, or worsening of a wound, nurses are required to notify the resident's representative.
During an interview on 09/25/25 at 3:15 P.M., with the Director of Nurses (DON) and the Corporate Quality Improvement Manager (QIM), the DON, QIM and the surveyor reviewed Resident #1's Interdisciplinary Progress Notes and Ongoing Skin Condition Assessment Records.The DON said she did not see any Nursing Progress Notes that indicated Nursing notified Family Member #1 after discovering he/she developed a wound on 03/26/25, or after the wound was assessed to have deteriorated on 07/14/25, 07/29/25, and 08/05/25.
Both the DON and QIM said 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 08/05/25. On 09/24/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 09/17/25, which addressed the area of concern as evidenced by:A) On 08/26/25, an Interdisciplinary Progress note included a Skin/Wound Note, dated 08/26/26 that indicated Resident #1's Representative was contacted regarding his/her worsening wound.B) On 09/12/25, the Director of Nursing completed a Facility-wide audit to determine the notification process was followed for all Residents in the Facility that had developed wounds and/or had significant changes to wounds (including treatment changes). C) On 09/19/25, 09/26/25, the Unit Managers conducted Facility-wide audits to ensure that Resident Representatives have been notified for any Resident that have had any changes related to wound status or treatment of wounds. D) From 09/12/25 through 09/24/25, the Director of Nursing completed Nursing education, titled Notification Protocol for Residents with Change in Wound Status or Treatment, including review the Facility policies titled, Informing Residents of Health and Medical Condition, and Physician Notification.E) The Facility's Unit Managers will continue to perform weekly audits to ensure Physicians and Resident Representatives are notified of changes with wound status, as appropriate, and after 100% compliance has been attained weekly, random audits will continue until deemed otherwise.F) The deficient practice and audit results will be presented at the Monthly Quality Assurance Performance Improvement (QAPI) meeting on 10/08/25.G) The Director of Nursing and/or their Designee are responsible for overall compliance.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/18/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Day Brook Village Senior Living
298 Jarvis Avenue Holyoke, MA 01040
SUMMARY STATEMENT OF DEFICIENCIES
During a telephone interview on 10/07/25 at 9:30 A.M., the Director of Nursing (DON) reviewed the CNA Documentation she faxed to the surveyor and she said anywhere there are blank spaces, the CNA should have entered the appropriate code for the task.
The DON said if there are any blank spaces, that meant the CNA did not complete their documentation, as required.
Facility ID: