Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Day Brook Village Senior Living during CMS and state inspections, most recent first.
Delayed Release of Medical Records to Resident’s Legal Representative: A resident with DM and CKD had an invoked HCP naming the son as HCA. After the HCA made a written request for copies of the resident’s medical records, the facility required completion of its own release form and did not provide the records in a timely manner. Staff stated they believed records could be released within 30 days, while the HCA reported repeated emails and calls without receiving the requested wound care and clinical documentation.
Failure to notify a resident’s HCP of a new and worsening wound. A resident with an activated HCP and diagnoses including DM and CKD developed MASD that was first identified by nursing, but the record did not show the HCA was informed. The wound later deteriorated multiple times, with treatment changes, undermining, wound culture, and antibiotics, yet staff interviews and documentation showed no timely notification to the resident’s representative.
Incomplete wound and CNA documentation: A resident with DM and CKD had wound treatment records that used an unexplained code on the TAR, and the DON determined the ordered treatments were not documented as completed on several dates. In addition, CNA skin care and bathing/shampooing records had multiple blank entries across several shifts and months, despite staff stating all care must be documented by the end of the shift.
The facility did not ensure timely destruction of discontinued controlled substances, instead storing them in the Administrator's office for over a year. Required dual nurse verification for transferring controlled substances in medication log books was not consistently performed, and multiple types of controlled medications for several residents remained unsecured for extended periods.
Staff did not follow residents' documented meal and beverage preferences as indicated on meal tickets, instead relying on personal knowledge of preferences and providing only limited beverage options. As a result, residents did not receive specific foods and fluids ordered for their clinical needs, despite these items being available and documented by the RD and FSD.
Surveyors found that the facility did not follow safe food handling practices, with multiple unlabeled and undated food and beverage items observed in the kitchen's refrigerator, freezer, and dry storage. Staff interviews confirmed that proper labeling and dating procedures were not followed, especially among new dietary staff, in violation of facility policy.
The facility did not maintain an effective pest control program, leading to a persistent fruit fly infestation in a resident unit's pantry, hallways, and two residents' rooms. Despite repeated pest control company recommendations to repair a large hole under the pantry sink, the issue remained unresolved, and unsanitary conditions such as food residue and rodent droppings were also observed. Staff and visitors reported frequent sightings of fruit flies, but communication and corrective action were lacking.
Staff did not consistently place the call light within reach for a resident with left-sided hemiplegia and Parkinson's Disease, despite care plan and policy requirements. Observations and staff interviews confirmed that the call light was left out of reach on multiple occasions, preventing the resident from calling for assistance when needed.
A resident with severe cognitive impairment and multiple diagnoses was admitted without a complete nursing admission assessment or proper documentation of cognitive and mood status. The MDS assessment was inaccurately completed by a social worker who had not seen the resident. The resident subsequently eloped from the facility, with staff only discovering the absence after the fact.
A resident with moderate cognitive impairment and a need for assistance with personal hygiene was not provided with necessary grooming support, specifically facial hair removal, despite facility policy and a care plan indicating this need. Staff interviews confirmed the resident's preference and the expectation to offer grooming assistance, but observations showed the resident remained with unwanted facial hair, and this aspect of care was not documented or addressed.
A resident with severe cognitive impairment and on Hospice care did not receive timely comfort medications due to the facility's failure to implement multiple documented Hospice recommendations. Despite repeated urgent requests and physician approval, the necessary medications were not ordered for 55 days, contrary to facility policy and professional standards.
A resident with a history of substance use disorder, Wernicke Encephalopathy, anxiety, and depression was not assessed for wandering or elopement risk upon admission, and no individualized interventions were implemented. The resident left the facility without staff awareness, and the required elopement prevention protocols were not followed.
Two residents at risk for nutritional decline did not receive appropriate nutritional care: one experienced significant weight loss without timely intervention from the dietician, and another with diabetes was given unapproved nutritional supplements with higher carbohydrate content than ordered, leading to inaccurate documentation and potential mismanagement of blood sugar. Staff provided supplements based on preference rather than physician orders, and there was a lack of oversight and communication among staff regarding proper supplement administration.
A resident with ESRD on hemodialysis was not accurately monitored for fluid intake, as the facility set the daily fluid allotment at 1800 ml instead of the physician-ordered 1200 ml, and failed to consistently total daily intake. Staff interviews and record reviews confirmed that the electronic medical record system contained incorrect preset values and that required documentation and monitoring were not performed as per facility policy.
The facility did not ensure that all required QAPI Committee members, including the Infection Preventionist (IP), attended each quarterly meeting. For one meeting, the IP was absent because the facility did not have an IP at that time, as confirmed by the Administrator.
Staff did not follow Enhanced Barrier Precautions during wound care for a resident with a pressure ulcer, failing to wear required gowns despite clear policy and signage. Additionally, a medication administration cart was found unclean, with dried spills, pill particles, and rusted scissors, and the DON was unable to confirm when it was last cleaned.
Two residents who were eligible and had consented to receive Pneumococcal vaccinations did not receive them as required by facility policy and CDC guidelines. Both individuals had medical conditions and no contraindications, yet their clinical records showed no evidence of vaccine administration, a lapse confirmed by the Regional Infection Preventionist.
A resident who was not their own responsible party did not receive the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) through their Health Care Proxy after their Medicare Part A skilled services coverage ended. The Clinical Reimbursement Coordinator confirmed the notice was not issued, and the resident remained in the facility without discharge.
A resident with cardiac-related diagnoses was prescribed an antiplatelet medication, but staff did not accurately code this medication on the MDS assessment. The MDS nurse confirmed the omission and stated that the assessment should have included the antiplatelet medication, as required by the RAI Manual.
A resident with dementia and depressive disorder developed influenza symptoms and was tested for a respiratory panel. Although the test returned positive for influenza the next day, nursing staff did not obtain or communicate the results to the provider for six days. This delay prevented timely initiation of antiviral treatment, as staff failed to check the lab printer or follow up with the lab, and the NP and infection preventionist were not informed until it was too late for effective intervention.
A resident exhibiting fever and respiratory symptoms was tested for Influenza, with a positive result reported by the lab the next day. Nursing staff did not notify the ordering provider of the result until six days later, as they failed to follow up on the laboratory report and did not check or act on the lab printer output, leaving the provider and staff unaware of the resident's positive status.
Three residents who tested positive for Influenza did not have physician's orders or documentation for Droplet Precautions, and one resident's CNA ADL Flow Sheets were incomplete over multiple shifts, despite requiring staff assistance. Staff interviews revealed confusion about responsibility for obtaining necessary orders and completing documentation.
Delayed Release of Medical Records to Resident’s Legal Representative
Penalty
Summary
The facility failed to ensure that a resident’s legal representative received copies of the resident’s medical records in a timely manner after making a written request. Resident #1 was admitted in January 2023 with diagnoses including Diabetes and Chronic Kidney Disease. The resident had a Health Care Proxy dated 01/09/23 naming the resident’s son as the Health Care Agent, and the proxy had been activated, making the son the invoked representative for the resident. The resident’s son requested copies of the resident’s medical records by email to the facility late in the day on 09/04/25. In response, the Executive Director acknowledged receipt of the request and stated the team would work with the Medical Records Coordinator, but also indicated the request would need to be completed through the facility’s Medical Record Request Form. The son replied that, as the resident’s legal representative, he was entitled to access the records within 24 hours of the written request excluding weekends and holidays, and stated he had not received the records or a response despite repeated emails and calls. He specifically requested wound care records, physician and nursing notes, treatment documentation, wound care team assessments, photographs, staging reports, progress notes, and any incident reports or internal communications related to the resident’s pressure ulcer. The Medical Records Coordinator later stated she believed the facility released medical records within 30 days of receipt of the request and was unaware of any regulation stating otherwise. The Administrative Assistant stated the records were mailed on 09/23/25, and the postal receipt showed an expected delivery date of 09/29/25. The Executive Director stated the request was forwarded internally on 09/04/25 and that the records process began then, but the records were not mailed until 09/23/25. The Long-Term Care Ombudsman also reported being told by facility staff that the facility had 30 days to provide the records, while she informed them the records should have been provided within 24-48 hours as written in the regulations.
Failure to Notify Resident Representative of New and Worsening Wound
Penalty
Summary
The facility failed to notify the resident’s health care agent when a new skin alteration was first identified and when the wound later worsened. The resident had an activated Health Care Proxy and diagnoses including diabetes and chronic kidney disease. Facility policy required the resident, resident representative, and physician to be informed of significant changes in health status, medication, or treatment orders, and staff interviews confirmed that the resident’s representative should be notified when a new wound is found or when a wound deteriorates. On 03/26/25, nursing staff assessed the resident to have an open area identified as moisture associated skin damage (MASD) and obtained provider notification and treatment orders. The medical record did not contain documentation that the resident’s family member or health care agent was notified of this new wound. The resident’s ongoing skin condition assessments later documented deterioration of the wound on 07/14/25, 07/29/25, 08/05/25, and 08/11/25, including worsening findings such as undermining, treatment changes, wound culture, and antibiotics. The family member reported learning of the wound only after the resident returned from the hospital and stated that the wound worsened over time, with no notification from the facility until late August when the wound nurse called to request consent for debridement. The wound nurse, unit managers, and DON all acknowledged that there was no documentation showing the family member was notified when the wound was first identified or when it deteriorated on the earlier assessment dates, and there was also no evidence of notification on 08/05/25 when the wound worsened further.
Incomplete wound and CNA documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one sampled resident when nursing documentation related to wound treatments was incomplete and CNA documentation related to skin integrity and bathing contained multiple blank entries. The resident was admitted in January 2023 with diagnoses including diabetes and chronic kidney disease. In July 2025, the resident had new wound treatment orders for a sacrum wound, including collagen powder with calcium alginate/silver and foam dressing daily, followed by Santyl with Aquacel after the first order ended. Review of the July 2025 TAR showed a code of M entered for the sacrum wound treatment on 07/11/25, 07/12/25, 07/16/25, and 07/18/25. The TAR code legend did not include M as a documented option or explain its use. During interview, the DON reviewed the TAR and stated she was not sure what M represented because it was not listed on the legend. After interviewing the nursing staff responsible for the treatments on those dates, the DON determined the treatments were not documented as completed as required. The resident’s CNA documentation also contained numerous blank entries on the Skin Care by Day Reports and Bathing and Hygiene by Day Reports across June, July, August, and September 2025. Blank spaces were recorded for skin care and for bathing/shampooing on multiple shifts, including day, evening, and night shifts. Staff interviews stated that all care provided must be documented in the computer by the end of the shift, and that blank spaces meant the CNA did not enter documentation. The DON also reviewed the CNA documentation and stated that blank spaces should have been coded appropriately and that blank spaces meant the CNA did not complete documentation as required.
Failure to Properly Document and Destroy Controlled Substances
Penalty
Summary
The facility failed to maintain proper records and procedures for the receipt, disposition, and destruction of controlled substances on one unit. Controlled medications, including opioids, narcotics, and sedatives, were removed from two locked medication carts and stored in the Administrator's office for over a year without being destroyed as required by facility policy. Documentation showed that these medications were removed from the medication carts on multiple occasions, but there was no evidence that destruction had occurred, despite being documented for disposal. Additionally, the controlled substance medication log books revealed that transfers of controlled substances from one page to another were not consistently verified and documented by two licensed nurses, as required by policy. Observations confirmed that multiple controlled substances for several residents, such as Tramadol, Lorazepam, Oxycodone, Morphine Sulfate, Hydromorphone, Lyrica, Clonazepam, Ambien, Dilaudid, Vimpat, and Nayzilam, were stored under lock and key in the Administrator's office. Interviews with nursing staff and the DON confirmed that the required dual verification for medication transfers and timely destruction of discontinued controlled substances did not occur. The facility's failure to follow its own policies and regulatory requirements for controlled substance management was directly observed and acknowledged by staff.
Failure to Honor Resident Meal and Beverage Preferences
Penalty
Summary
The facility failed to honor residents' meal and beverage preferences as indicated on their meal tickets, despite these tickets being based on resident needs and preferences and reviewed by the Registered Dietitian (RD). During multiple meal observations, staff were seen distributing meals and beverages that did not match the choices listed on the residents' meal tickets. For example, residents were only offered orange juice or cranberry juice, regardless of their documented preferences, and one resident received orange juice despite their ticket specifying only Lactaid milk. Additionally, specific food items such as fortified cream of wheat, fruited yogurt, and fresh melon fruit cup, which were indicated on meal tickets, were not provided to residents, even though these items were available in the facility. Interviews with Certified Nurses Aides (CNAs), nursing staff, and dietary staff revealed that staff relied on their personal knowledge of residents' likes and dislikes rather than following the documented meal tickets. CNAs and other staff members stated that they did not follow the meal tickets, believing their familiarity with residents' preferences was sufficient. The RD and Food Service Director (FSD) confirmed that the meal tickets should have been followed and that the failure to do so resulted in residents not receiving their chosen or clinically indicated meals and beverages. The deficiency was further evidenced by the RD's review of specific cases where residents did not receive the prescribed fortified foods necessary for their clinical conditions, such as weight loss. The FSD acknowledged that meal tickets were not reviewed or honored as required, and staff substituted items based on their own judgment rather than the documented preferences and dietary needs. The facility's policy required that residents' nutritional needs and preferences be met, but this was not consistently implemented on the observed unit.
Failure to Label, Date, and Properly Store Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to safe food practices in the main kitchen, specifically regarding the labeling, dating, and storage of food and beverage items intended for resident consumption. During an initial walk-through of the main kitchen, the surveyor observed multiple unlabeled and undated food items in the walk-in refrigerator, walk-in freezer, and dry storage area. These included large pitchers of juice, boxes and bags of various frozen foods such as donuts, waffles, onion rings, French fries, cookie dough, spring rolls, lemon bars, as well as dry goods like spaghetti, pudding mix, muffin mix, lasagna, and oatmeal. Some items were also found open to air, further increasing the risk of contamination. Interviews with dietary staff and the Food Service Director confirmed that the observed food items should have been labeled and dated after opening, in accordance with facility policy. Staff acknowledged that many employees in the main kitchen were new and that proper procedures for labeling and dating were not followed. The facility's policy requires all foods stored in refrigerators, freezers, and dry storage to be covered, labeled, and dated to ensure safety and prevent foodborne illness, but these practices were not consistently implemented.
Failure to Maintain Effective Pest Control Program Resulting in Fruit Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program on one of its resident units, specifically Unit Two, resulting in the presence of fruit flies in multiple areas including the pantry, hallways, and two residents' rooms. Observations by surveyors and reports from staff and visitors confirmed ongoing sightings of fruit flies in these locations, particularly during meal times. The facility's own pest control policy required ongoing efforts to keep the building free of insects and rodents, but these measures were not effectively implemented. Review of pest control service inspection reports revealed that a large hole in the wall around pipes under the Unit Two Pantry sink had been repeatedly identified as a potential entry point for pests since at least 2019. Despite ongoing pest control visits and repeated recommendations from the contracted pest control company to repair the hole, the issue remained unaddressed. The hole was observed by both the surveyor and the Maintenance Director, who initially denied its existence and later downplayed its significance, even though pest control reports consistently highlighted it as a concern. Interviews with staff indicated that sightings of fruit flies were common, but not always communicated to facility leadership. The Maintenance Director acknowledged the ongoing issue and confirmed that pest control recommendations were his responsibility, yet the necessary repairs had not been completed. The Administrator was under the impression that the fruit fly problem was recent, despite evidence to the contrary. Additionally, unsanitary conditions such as food residue and rodent droppings were observed in the pantry, further contributing to the pest issue.
Failure to Ensure Call Light Accessibility for Resident with Hemiplegia
Penalty
Summary
Facility staff failed to provide appropriate access to the call light for a resident with left-sided hemiplegia and Parkinson's Disease, who was also receiving hospice care. The resident's care plan specifically required that the call light be placed within reach on the unaffected side, and facility policies mandated that call lights be accessible to residents at all times. Despite these requirements, observations revealed that the call light was repeatedly left out of the resident's reach—once on top of the nightstand on the left side of the bed and another time clipped to the left side of the bed below the lowest bar of the siderail, both inaccessible to the resident. Interviews with staff confirmed that the call light had been moved during care activities and not returned to an accessible position. The resident reported being unable to find the call light when needing to request medication. Staff acknowledged the importance of keeping the call light within reach and admitted to forgetting to reposition it after providing care. The Director of Nursing also confirmed that call lights should always be within reach to allow residents to alert staff as needed.
Failure to Complete Admission Assessment Resulting in Resident Elopement
Penalty
Summary
The facility failed to conduct a complete and timely admission assessment for a resident with diagnoses including alcohol withdrawal, Wernicke Encephalopathy, anxiety, and depression. Upon admission, there was no nursing admission assessment, no nursing admission note documenting the resident's arrival, cognitive patterns, mood and behavior, psychological well-being, or discharge planning. The required direct observation and communication to complete an accurate assessment were not performed. As a result, the resident eloped from the facility shortly after admission. Record review showed that the Minimum Data Set (MDS) assessment was inaccurately completed, with a BIMS score of 0 documented by a social worker who had not seen or assessed the resident. Interviews confirmed that the social worker did not assess the resident and that the MDS assessment was not based on direct observation. Nursing staff reported that the resident expressed a desire to leave, and later, the resident was found to have left the facility without proper documentation or understanding of the discharge process.
Failure to Provide Grooming Assistance for Resident Requiring ADL Support
Penalty
Summary
The facility failed to provide necessary grooming assistance to a resident who required help with personal hygiene, specifically facial hair removal. According to the facility's Activities of Daily Living (ADLs) policy, residents are to receive care and services for hygiene, including grooming, based on their assessed abilities and care plan. The resident in question was moderately cognitively impaired, required assistance with personal hygiene, and had a care plan indicating a need for help with grooming. Despite this, the resident was observed on two consecutive days with long, thick facial hair on the chin, which the resident stated was undesirable and that staff would help remove it only when reminded. Interviews with staff revealed that the resident needed assistance with all ADLs and had previously expressed a preference for not having facial hair. The CNA familiar with the resident acknowledged that if the resident did not request facial hair removal, she would offer to assist, but also stated that documentation of this care was not required. The DON confirmed that CNAs are expected to ask residents with facial hair if they would like it removed and that this aspect of daily ADL care was not addressed for the resident. The deficiency was identified through observation, interview, and record review, showing a failure to provide grooming assistance as required by the resident's care plan.
Delay in Implementation of Hospice Comfort Medication Orders
Penalty
Summary
The facility failed to provide timely treatment and services in accordance with professional standards of practice for a resident receiving Hospice care. Despite multiple documented recommendations from Hospice, comfort medication orders for the resident were not implemented promptly. The initial Hospice recommendation for comfort medications was made and signed by the resident's physician, but these orders were not added to the resident's medication profile for 55 days. During this period, repeated recommendations and urgent requests from Hospice staff were documented, highlighting the ongoing lack of action to ensure the resident had access to necessary comfort medications. The resident involved had severe cognitive impairment, was receiving Hospice services, and exhibited behaviors such as rejecting care and wandering. The facility's own policy required a coordinated plan of care with directives for managing pain and comfort measures, and designated staff from both the facility and Hospice were responsible for ensuring care coordination. Interviews with the Director of Nursing confirmed that Hospice recommendations should have been implemented within 24 hours, but this did not occur, resulting in a significant delay in the administration of comfort medications for the resident.
Failure to Assess and Prevent Elopement Risk for Resident with SUD
Penalty
Summary
The facility failed to ensure the safety of a resident with a history of substance use disorder, Wernicke Encephalopathy, anxiety, and depression by not assessing the resident for wandering or elopement risk upon admission. There was no nursing admission assessment, no documentation of the resident's mental or ambulation status, and no completion of the required wandering/elopement risk assessment as outlined in the facility's policy. The resident was not properly evaluated for elopement risk factors, including their medical and psychosocial history, and no individualized care interventions were implemented. The resident expressed a desire to leave the facility and was later found to have left without staff awareness. Staff interviews confirmed that the resident was not seen or assessed by nursing or social services upon admission, and the Director of Nursing acknowledged that the facility's elopement policy was not initiated when the resident was discovered missing. The lack of assessment and failure to follow established elopement prevention protocols resulted in the resident leaving the facility without appropriate supervision or response from staff.
Failure to Provide Adequate Nutritional Care and Adherence to Dietary Orders
Penalty
Summary
The facility failed to provide adequate nutritional care and services for two residents identified as being at risk for nutritional decline. For one resident with Marfan Syndrome, hemiplegia, and dysphagia, there was a significant weight loss of nearly 7% in one month. Despite this, the dietician did not implement any nutritional interventions after identifying the weight loss, citing a lack of time to consult with the Unit Manager. The resident's care plan indicated the need to notify the dietician if persistent weight loss occurred, but no action was taken until prompted by the surveyor. Another resident with a diagnosis of Diabetes Mellitus experienced a substantial weight loss and was ordered a glucose control nutritional supplement to be provided with lunch. However, staff provided the resident with a different supplement, Boost Original, which was not ordered and contained significantly more carbohydrates and sugar than the prescribed supplement. The medication administration record inaccurately documented that the resident was receiving the glucose control supplement, while observations and interviews confirmed the resident was regularly given the original supplement, sometimes in excess and without proper documentation. Staff interviews revealed a lack of understanding regarding which supplements to provide, with a CNA admitting to routinely giving the original supplement based on the resident's and visitor's preferences, without checking with nursing staff or following physician orders. The dietician was unaware that unapproved supplements were being given, which compromised the ability to accurately assess and manage the resident's nutritional and diabetic needs. The unit manager and regional nurse acknowledged that staff were not following proper procedures for supplement administration.
Failure to Accurately Monitor and Document Fluid Restriction for Dialysis Resident
Penalty
Summary
Facility staff failed to accurately monitor and document the fluid intake for a resident with End Stage Renal Disease (ESRD) who was dependent on hemodialysis. The resident was admitted with diagnoses including ESRD and required a strict fluid restriction of 1200 ml per day as ordered by the physician. Facility policies required comprehensive care planning, accurate monitoring, and documentation of fluid intake for residents on dialysis, including shift-based and daily totals, as well as coordination between nursing and dietary departments. Despite these requirements, review of the resident’s Medication Administration Records (MARs) for three consecutive months revealed that the daily fluid allotment was incorrectly set at 1800 ml instead of the physician-ordered 1200 ml. Additionally, the total daily fluid intake was not consistently calculated or documented, with numerous days missing totals each month. Interviews with nursing staff, the DON, and the Registered Dietitian (RD) confirmed that the fluid restriction order was not properly entered or monitored, and that the preset template in the facility’s electronic medical record system was incorrect and not updated to reflect the physician’s order. The lack of accurate monitoring and documentation of fluid intake, as well as the failure to follow the physician’s order for fluid restriction, placed the resident at risk for complications related to fluid overload. The facility’s own policies and staff interviews confirmed that the processes for determining, entering, and tracking fluid restrictions were not followed as required for residents receiving dialysis.
Infection Preventionist Absent from QAPI Committee Meeting
Penalty
Summary
The facility failed to ensure that all required members of the Quality Assessment and Assurance (QAPI) Committee participated in each of the quarterly QAPI meetings. Specifically, review of attendance sheets for four consecutive quarterly meetings showed that the Infection Preventionist (IP) was not present for one of the meetings. During an interview, the Administrator confirmed that the facility did not have an IP at the time of that meeting, resulting in the absence of this required committee member.
Failure to Follow Enhanced Barrier Precautions and Maintain Medication Cart Cleanliness
Penalty
Summary
Facility staff failed to adhere to infection control standards in two key areas. First, staff did not follow physician orders and facility policy regarding Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer on the right heel. During observed wound care, two nurses entered the resident's room and performed high-contact wound care activities without donning gowns, despite clear signage and policy requiring both gloves and gowns for such procedures. Both staff acknowledged the requirement for gowns and recognized the EBP signage, but proceeded without the necessary protective equipment. The resident involved had a documented pressure ulcer and was under a care plan and physician orders that specified the use of EBP, including the posting of signage and the use of personal protective equipment during high-contact care. The infection preventionist confirmed that all residents with wounds should be on EBP and that staff had been educated on this requirement. Despite this, the observed wound care was conducted without gowns, contrary to both policy and physician orders. Additionally, the facility failed to maintain sanitary conditions for a medication administration cart on one unit. During a medication pass, the cart was found to contain dried spilled liquid, particles of medication pills, stained dried dark particles, and an old rusted scissors. The agency nurse using the cart acknowledged the potential for bacterial contamination, and the Director of Nursing confirmed the cart was dirty and in need of cleaning, but was unsure when it was last cleaned or disinfected, despite the existence of a cleaning schedule.
Failure to Administer Pneumococcal Vaccinations to Eligible Residents
Penalty
Summary
The facility failed to administer Pneumococcal vaccinations to two residents who were eligible and had provided consent for the immunization. According to the facility's own policy and CDC recommendations, residents should be offered and administered appropriate Pneumococcal vaccines unless medically contraindicated or previously immunized. In these cases, one resident had received a previous dose of PPSV23 but had not received any further recommended Pneumococcal vaccines, despite being eligible and having consented. The other resident had never received any Pneumococcal vaccine and had also provided consent, but there was no evidence of vaccine administration. Review of the residents' clinical records confirmed that both were over the age threshold for vaccination, had relevant medical conditions such as diabetes, end stage renal disease, hypertension, and chronic kidney disease, and had no medical contraindications to receiving the vaccine. The omission was acknowledged by the Regional Infection Preventionist, who confirmed that the facility missed providing the required immunizations to both residents.
Failure to Issue SNF ABN to Resident's Health Care Proxy After Skilled Coverage Ended
Penalty
Summary
The facility failed to issue the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to a resident's Health Care Proxy when the resident's Medicare Part A skilled services coverage ended. According to the clinical record, the resident was not their own responsible party, and the effective date of coverage for skilled services had expired. Despite the resident remaining in the facility and not being discharged, there was no evidence that the SNF ABN was provided to the designated Health Care Proxy. During an interview, the Clinical Reimbursement Coordinator acknowledged that the SNF ABN should have been issued to the resident's responsible party after the skilled benefit ended but confirmed that this was not done. The report also references the requirements for issuing the ABN, including the need for timely delivery, review with the beneficiary or representative, and proper documentation, none of which were met in this instance.
Failure to Accurately Code Antiplatelet Medication on MDS Assessment
Penalty
Summary
Facility staff failed to accurately code the Minimum Data Set (MDS) assessment for one resident who had a history of aortic valve stenosis, myocardial infarction, and hypertension. The resident was prescribed enteric coated aspirin, an antiplatelet medication, as part of their physician orders. However, review of the MDS assessment showed that while the resident was coded for antianxiety, antidepressant, hypoglycemic, and anticonvulsant medications, the use of an antiplatelet medication was not coded. During an interview, the MDS nurse confirmed that the resident was receiving an antiplatelet medication and acknowledged that the MDS assessment should have reflected this, in accordance with the Resident Assessment Instrument (RAI) Manual.
Delayed Notification of Positive Influenza Result Led to Missed Antiviral Treatment
Penalty
Summary
A deficiency occurred when a resident exhibiting symptoms of influenza, including fever and cough, was not provided timely treatment due to a delay in obtaining and acting upon laboratory test results. The resident, who had a history of unspecified dementia and major depressive disorder, was tested for a respiratory panel as ordered by the nurse practitioner. The specimen was collected and resulted positive for influenza the following day, but the results were not obtained or communicated to the provider or nursing staff until six days later. Facility policy required that laboratory results be communicated to the provider and recorded in the patient record in a timely and effective manner, especially for results outside clinical reference ranges. However, the nursing staff did not check or follow up on the laboratory results promptly. The nurse who cared for the resident on the day of testing did not receive the results during her shift and did not follow up by calling the lab, assuming the results might take longer. The unit manager confirmed that results are typically received via a laboratory printer, but if unavailable, staff could call the lab. The nurse practitioner and infection preventionist were not made aware of the positive influenza result until several days later. As a result of the delay, the resident was not started on antiviral medication (Tamiflu) within the effective treatment window. The nurse practitioner stated that if she had been informed of the positive result in a timely manner, she would have initiated antiviral treatment, as the resident was symptomatic and at high risk for complications. The director of nursing acknowledged that the nurse should have checked for results the day after testing and communicated findings to the next shift if results were still pending.
Failure to Promptly Notify Provider of Positive Influenza Test Result
Penalty
Summary
Nursing staff failed to promptly notify the ordering practitioner of a positive Influenza laboratory result for a resident who was exhibiting fever, cough, and cold symptoms. The resident was swabbed for a respiratory panel, including Influenza, COVID, and RSV, as ordered by the Nurse Practitioner. The specimen was collected and the laboratory reported a positive Influenza result the following day. However, the result was not communicated to the provider until six days later, despite facility policy requiring timely notification of out-of-range laboratory results. Interviews revealed that the nurse assigned to the resident did not follow up on the test results and did not contact the laboratory when results were not received as expected. The Unit Manager and DON confirmed that nurses are responsible for checking the lab printer and following up with providers, and that the nurse should have ensured the results were obtained and communicated. The delay in notification was only discovered when the Nurse Practitioner independently obtained the results from the offsite laboratory, finding that staff were unaware of the resident's positive Influenza status and had not implemented appropriate precautions.
Failure to Maintain Complete and Accurate Medical Records and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents who tested positive for Influenza. For each of these residents, there was no documentation that a physician's order was obtained to implement Droplet Precautions, as required by facility policy. Additionally, there was no documentation in the Treatment Administration Records to support that Droplet Precautions had been implemented for these residents. Interviews with facility staff revealed confusion regarding responsibility for obtaining the necessary physician's orders, with both the Unit Manager and Infection Preventionist indicating it was the nurse or Unit Manager's responsibility, respectively. Furthermore, for one resident with dementia and major depressive disorder, Certified Nurse Aide (CNA) Activities of Daily Living (ADL) Flow Sheets were found to be incomplete over multiple shifts within a specified period. Documentation for several days and shifts was left blank in all ADL care areas, despite the resident's need for various levels of staff assistance with ADLs as indicated in their Minimum Data Set (MDS) assessment. The Director of Nursing confirmed that CNAs are responsible for completing this documentation by the end of their shift.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 244 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Holyoke
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Massachusetts Veterans Home At Holyoke | 0.7 mi | — | 0 | 0 |
| Care One At Holyoke | 1.2 mi | ★★★★★ | 2 | 0 |
| Regalcare At Holyoke | 1.2 mi | ★★★★★ | 0 | 0 |
| Renaissance Manor On Cabot | 1.3 mi | ★★★★★ | 3 | 0 |
| Mission Care At Holyoke | 2.3 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.