Day Brook Village Senior Living

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had an invoked Health Care Proxy (HCP), and whose Health Care Agent (HCA) had submitted a written request for copies of his/her medical record, the facility failed to ensure the records were provided timely as required, when the HCA waited three weeks to get the requested copies.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP) and had developed a pressure injury that was new, the Facility failed to ensure nursing notified his/her Health Care Agent (HCA) when he/she was first assessed to have an alteration in his/her skin integrity, and when the pressure injury deteriorated.

Inspectors wroteBased on records reviewed and interviews for one of three sampled Residents (Resident #1), the facility failed to ensure they maintained a complete and accurate medical record when Nursing documentation related to wound treatments and Certified Nurse Aide (CNA) documentation related to skin integrity and bathing were incomplete.

Inspectors wroteBased on observation, record review, and interview, the facility failed to establish a system of records of receipt and disposition of controlled medications consistent with applicable state and federal requirements for two out of four medication carts on one unit (Unit One) out of two units observed to prevent loss, diversion and/or accidental exposure. Specifically, the facility failed to: -destroy controlled substance medications (including opioids, narcotics, and sedatives) that were removed from two locked medication carts on unit one and were being stored in the Administrator's office for a documented duration of greater than one year. -ensure the transfer of controlled substance medications from one page of the facility-controlled substance medication log book to another page of the log book was reconciled by the appropriate and required licensed nursing staff.

Inspectors wroteBased on observation, and interview, the facility failed to provide resident choices for beverage and meal preferences, on one unit (Unit Two) out of two units observed. Specifically, the facility failed to ensure that fluids and meal preferences were honored when the meals tickets identified residents' choices of fluids and meals.

Inspectors wroteBased on observation, and interview, the facility failed to adhere to safe food practices to prevent contamination of food and beverage items intended for resident consumption in the facility's main kitchen. Specifically, the facility failed to implement safe food practices in the main kitchen relative to labeling, dating and storage guidelines.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to maintain an effective pest control program to ensure that the facility was free of pests on one Resident Unit (Unit Two) of two Resident Units. Specifically, the facility staff failed to implement measures to eradicate and contain fruit flies located in the Unit Two Pantry, Unit Two hallways, and two Resident's rooms (#35 and #24), increasing the risk for rapid multiplicity of fruit flies and contamination.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide appropriate access to the call light for one Resident (#24) out of a total sample size of 18 residents. Specifically for Resident #24, the facility staff failed to place the Residents' call light within his/her reach placing Resident #24 at risk for unmet needs.

Inspectors wroteBased on interview, and record review, the facility failed to conduct an admission assessment and document participation in the assessment to determine the necessary care and services required for one Resident (#88) out of three closed records reviewed. Specifically, for Resident #88, the facility failed to conduct direct observation and communication and complete an accurate Resident assessment upon admission, resulting in the Resident eloping from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming assistance for one Resident (#55), out of a total sample of 18 residents. Specifically, the facility failed to ensure that Resident #55 was assisted with facial hair removal when he/she required assistance from staff with personal hygiene.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide treatment and services adhering to professional standards of practice related to Hospice services for one Resident (#62) out of a total sample of 18 residents. Specifically, for Resident #62, the facility failed to ensure that Hospice recommendations for comfort medication orders were implemented in a timely manner leading to a delay in medication administration for the Resident. Findings Include: Review of the facility policy titled Hospice Program, last revised 3/28/22, indicated: -when a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other comfort measures. [...]

Inspectors wroteBased on record review, and interview, the facility failed to ensure the safety of one Resident (88) out of a total sample of 18 residents, who was at risk for elopement. Specifically, for Resident #88, the facility failed to assess on admission the Resident with a history of substance use disorder (SUD) for risk of elopement and initiate the elopement response when the Resident left the facility without staff being aware.

Inspectors wroteBased on record review, and interview, the facility failed to provide adequate nutritional care and services for two Residents (#54 and #35) out of a total sample of 18 residents, identified as being at risk for nutritional decline. Specifically: 1. For Resident #54, the facility failed to address significant weight loss and implement effective nutritional interventions when the Resident was identified as having greater than a 5 percent (%) weight loss in one month. 2. [...]

Inspectors wroteBased on record reviews, and interviews, the facility failed to accurately monitor the fluid intake for one Resident (#36) out of a total sample of 18 residents. Specifically, for Resident #36, the facility staff failed to accurately allot the daily fluid intake as ordered by the Physician and monitor the total daily fluid intake for the Resident dependent on renal dialysis, placing him/her at risk for complications related to fluid overload.

Inspectors wroteBased on interview, and records reviewed, the facility failed to ensure all required members of the QAPI Committee participated in quarterly QAPI meetings. Specifically, the facility failed to ensure the Infection Preventionist (IP) attended and participated in one of four consecutive quarterly QAPI meetings reviewed.

Inspectors wroteBased on record review, observation, and interview the facility failed to adhere to infection control standards of practice for one Resident (#44) out of a total sample of 18 residents, and maintain sanitary medication storage for a medication administration cart on one unit (Unit Two) out of two units. Specifically, 1. For Resident #44, the facility staff failed to follow Physician orders for Enhanced Barrier Precautions (EBP's-the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), while providing high contact wound care for the Resident. 2. the facility failed to maintain a clean medication administration cart during a medication administration observation on Unit Two putting the unit residents at risk for medication contamination.

Inspectors wroteBased on interviews, and records reviewed, the facility failed to administer Pneumococcal Vaccinations for two Residents (#36 and #81) of five applicable residents, out of a total sample of 18 residents, increasing the Residents' risk for acquiring Pneumococcal illnesses. Specifically, the facility failed to administer Pneumococcal Vaccines for Residents #36 and #81, when the Residents were eligible to receive, and consented to, the Pneumococcal immunization.

Inspectors wroteBased on interview, and record review, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) for one Resident (#389) out of a total sample of 18 residents. Specifically, for Resident #389, the facility failed to issue a SNF ABN to the Resident and/ or Resident Representative when effective date of coverage for skilled services ended.

Inspectors wroteBased on record review, and interview, the facility failed to accurately code a Minimum Data Set (MDS) Assessment for one Resident (#36) out of a total sample size of 18 residents. Specifically, for Resident #36, the facility staff failed to code the MDS accurately relative to antiplatelet (medication which prevents blood platelets from clumping together to form a clot) medication use.

Inspectors wroteBased on record review and interviews, for one of three sampled residents (Resident #1) who was exhibiting signs and symptoms of Influenza, the facility failed to ensure he/she was provided with quality care and services that meet professional standards of practice, when after an Influenza test had been conducted on 03/06/25, with positive test results on 03/07/25, the test results were not obtained by nursing until 03/12/25, six days after the test was obtained, as a result Resident #1 was unable to receive antiviral medication used to treat Influenza putting him/her at risk for complications from influenza.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was exhibiting signs and symtoms of Influenza, and for whom nursing received a new order on 3/06/25 for an Influenza test, the Facility failed to ensure Nursing promptly notified the ordering physician, physician assistant, or nurse practitioner of the laboratory results, when he/she tested positive for Influenza on 03/07/25, but the provider was not made aware until 03/12/25, six days later. Findings Include: Review of the policy titled Laboratory and Radiology Services, dated as revised 11/17/16, indicated laboratory and testing will be performed as per medical provider orders and be communicated to the provider and recorded in the patient record in a timely and effective manner. [...]

Inspectors wroteBased on records reviewed and interviews, for three of three sampled residents, (Resident #1, Resident #2 and Resident #3), the Facility failed to ensure they maintained complete and accurate medical records, when 1) for Residents #1, #2 and #3, who all tested positive for Influenza, there were no Physician's orders obtained and therefore no documentation related to the need for Droplet precautions to be initiated and 2) for Resident #1, his/her Certified Nurse Aide (CNA) Activities of Daily Living (ADL) Flow Sheets were incomplete.

Inspectors wroteBased on interview and record review, the facility failed to ensure treatment and assistive devices for hearing were provided to ensure one Resident (#35) out of a total sample of 18 residents, maintained his/her highest level of hearing abilities. Specifically, for Resident #35 the facility failed to ensure the Audiologist's (health care professional who diagnose, manage, and treat hearing, balance, or ear problems) recommendations to facilitate further medical follow-up related to the Resident's hearing loss was provided timely, so the Resident's request for hearing aids could be addressed.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one Resident (#37) out of a total sample of 18 residents, received dialysis (a procedure to remove waste products and fluid from the body when the kidneys stop working) care consistent with professional standards of practice. Specifically, the facility failed to: 1. demonstrate ongoing communication and collaboration with the contracted dialysis facility, as required on dialysis treatment days. 2. failed to ensure Resident #37's prescribed medication was scheduled in such a way to be administered prior to dialysis treatment.

Inspectors wroteBased on record review and interview, the facility failed to ensure adequate psychotropic (drugs that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior) medication monitoring per Physician orders to promote and maintain the highest practicable mental, physical, and psychosocial well-being for two Residents (#56 and #1), out of a total sample of 18 residents. Specifically, the facility failed to: 1. obtain an EKG (Electrocardiogram - records the electrical signal from the heart to check for different heart conditions) per Physician orders for Resident #56. 2. obtain pertinent lab work per Physician's orders for Resident #1.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure the safe storage of medications. Specifically, the facility staff failed to ensure that one medication cart, out of five medication carts remained locked while unattended, allowing access to medications and risk of harm for other residents, visitors and staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that infection control protocols was followed during a medication administration pass procedure. Specifically, the facility staff failed to ensure: 1. medical equipment utilized by multiple residents was sanitized appropriately between use. 2. medications were administered in such a way to prevent contamination, and risk of infection.

Inspectors wroteBased on interview and record review, the facility failed to administer Influenza Vaccination (annual Flu vaccine) and Pneumococcal Vaccination for three Residents (#5, #22, #64) out of a sample of five residents, to minimize the risk of facility acquired infections. Specifically, the facility staff failed to: 1. For Resident #5 and #22, ensure the Residents received the requested Prevnar 20 vaccine (PCV20 - a type of Pneumococcal Vaccination) as consented to by the Resident and/or the Resident's Representative. 2. For Resident #64, ensure the Resident received the requested PCV20 and annual Flu vaccine as consented to by the Resident and/or the Resident's Representative.

Inspectors wroteBased on observation, record and policy review, and interview, the facility failed to accurately complete Minimum Data Set (MDS) Assessments for nine Resident's (#5, #19, #47, #56, #59, #64, #22, #7 and #73), out of a total sample of 18 residents. Specifically, 1. For Residents #5, #19, #47, #56, #59, and #64 the facility failed to accurately assess Sections C (cognitive patterns) and D (mood assessment). 2. Resident #22, the facility failed to ensure Sections C was accurately completed. 3. For Resident #7, the facility failed to accurately code the status of the Resident's fall. 4. For Resident #73, the facility failed to ensure the use of a catheter was accurately coded.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff provided written notice of transfer for three Residents (#13, #73, and #77) out of 19 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff provided the Bed Hold Policy before/upon transfer for five Residents (#13, #26, #73, #77, and #80) out of 19 sampled residents.

Inspectors wroteBased on observation, interview and policy review the facility failed to maintain appropriate kitchen sanitation methods, and failed to implement their policy, to prevent foodborne illness and food contamination related to hair restraints, food temperatures and hand hygiene.

Inspectors wroteBased on policy review and interview, the facility failed to maintain an Infection Prevention and Control Program (IPCP), specifically by not completing the SBAR (Situation, Background, Assessment and Recommendation form), or the McGeer criteria (criteria used to substantiate a true infection), per their own program. Also, the facility failed to conduct an annual review of the IPCP.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the facility was free of pests, specifically insects.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff notified a physician of a medication (narcotic) being unavailable for several days, to administer to one Resident (#74), out of 19 sampled residents.

Inspectors wroteBased on interview and record review the facility failed to follow the care plan and implement their policy relative to weights, for two Residents (#75 and #67), out of 19 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff responded to irregularities in the medication regimen review by the pharmacist timely, and to ensure the attending physician's documented their review, including actions taken, in the medical record of two Residents (#13, and #74) out of a total sample of 19 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident (#74) was free from a significant medication error, related to an omission of a narcotic, out of 19 sampled residents.

Inspectors wroteBased on record review and interview the facility staff failed to (1.) document the acceptance or refusal of immunizations for one Resident (#26) and (2.) offer the Pneumococcal Immunization for two Residents (#74 and #182) out of a total sample of five applicable residents.