Day Brook Village Senior Living

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Electronic Medical Record indicated it included a scanned copy of a Massachusetts Medical Records Release Form, signed and dated by Family Member #1 on 09/12/25.During a telephone interview on 09/23/25 at 1:05 P.M., the Long-Term Care Ombudsman said Family Member #1 called her upset about Resident #1's care and told her that he requested copies of his/her medical records repeatedly from the Facility without results.The Long-Term Care Ombudsman said she left messages with the Facility to have somebody contact her about the lack of response to Family Member #1, and she was finally able to reach

the Social Worker on 09/23/25.The Long-Term Care Ombudsman said the Social Worker told her that the Facility had 30 days to provide Resident #1's medical records to Family Member #1. The Long-Term Care Ombudsman said she informed the Social Worker that the records should have been provided to Family Member #1 within 24-48 hours, as written in the regulations. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Day Brook Village Senior Living

298 Jarvis Avenue Holyoke, MA 01040

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

significantly, the resident's representative should be notified.The Wound Nurse said that Family Member #1 should have been notified on 03/26/25 when Resident #1 first developed MASD and should have been notified when the wound was assessed to have deteriorated on 07/14/25, 07/29/25, and 08/05/25.The Wound Nurse said when she calls residents' family members or representatives, she usually documents

the phone call in a Progress Note (Skin-Wound Note). The Wound Nurse she said she did not recall if she called Family Member #1 when she assessed there to be a deterioration in his/her wound on 07/14/25 and 07/29/25, when she documented HCP Aware and that she needed to work on improving her documentation.The Wound Nurse said when Resident #1's wound deteriorated further on 08/05/25, if there wasn't a Skin-Wound Note in the Interdisciplinary Progress Notes and N/A documented on the Ongoing Skin Condition Assessment Record, that Family Member #1 was not notified, but that he should have been.During an interview on 09/25/25 at 12:52 P.M., Unit Manager #1 said Staff Nurses are responsible to complete weekly skin assessments on every resident, and if there is a new skin issue, they are responsible for notifying the resident's representative. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Day Brook Village Senior Living

298 Jarvis Avenue Holyoke, MA 01040

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

an interview on 09/24/25 at 1:05 P.M., Nurse #1 said Nursing and CNAs must document all their treatments and tasks in the computer and the documentation must be done by the end of their shift.During an interview

on 09/24/25 at 10:30 A.M., CNA #1 said CNAs are required to document all the care they provide to the residents in the computer, and all the documentation needs to be entered by the end of their shift. CNA #1 said there are codes we can enter if a resident refuses or if they are out of the building, so there should be no blank spaces on our reports, and if there are, that means the CNA did not enter their documentation.During an interview on 09/24/25 at 4:45 P.M., CNA #2 said all CNA document the care they provide to the residents in the computer, and this documentation must be done by the end of the shift.During a telephone interview on 09/26/25 at 2:50 P.M., CNA #3 said CNAs document all care they provide to the residents in the computer, and the charting must be completed before they leave for the day.During a telephone interview on 10/01/25 at 1:20 P.M., CNA #4 said all CNA documentation is located

in the computer and should be completed by the end of the shift. CNA #4 said if there are any blank spaces

on the CNA reports, that meant that CNA documentation was not done. 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.

Event ID:

Facility ID:

If continuation sheet