Copley at Stoughton Nursing Care Center

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), whose family initiated a transfer to the Hospital Emergency Department (ED) for an evaluation after concerns he/she may have fallen, the Facility failed to ensure Resident #1 was able to return to the Facility following his/her evaluation and considered Resident #1 discharged at the time of transfer.

Inspectors wroteBased on observations and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that food was labeled and dated in the main kitchen and in three of three unit kitchenette refrigerators.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one Resident (#41) was free from unnecessary psychotropic medication, out of a total sample of 24 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain a safe environment for one Resident (#91) out of 24 total sampled residents. Specifically, the facility failed to implement socks with grips to prevent falls as indicated in plan of care for Resident #91.

Inspectors wroteBased on record review and interviews, the facility failed to implement pharmacy recommendations for one Resident (#41) out of a total sample of 24 residents.

Inspectors wroteBased on observations and interviews the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically, the facility failed to ensure expired medications were removed from medication room on 1 out 3 medication units and failed to ensure medications were dated once opened according to manufacturer's guidelines in one of three medication carts observed.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two Residents (#39 and #72) out of 24 total sampled residents. Specifically, the facility failed to ensure healthcare personnel appropriately don (put on) a precaution gown while providing incontinence care for Resident #39 and Resident #72, who required enhanced barrier precautions (EBP).

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately code in the Minimum Data Set (MDS) for one Resident (#1) out of 24 total sampled residents. Specifically, the use of antipsychotic medications was inaccurately coded in three MDS assessments for Resident #1.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure: 1. For Resident #31, who has an indwelling urinary catheter, that staff implemented Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities); and 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one Resident (#93), out of a total sample of 22 residents. Specifically, the facility failed to act on the consultant pharmacist's recommendation to add a stop date to the Resident's as needed Ativan (an antianxiety medication) order.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident's (#93) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 22 residents. Specifically, the facility failed to ensure as needed antianxiety medications were limited to 14 days or extended beyond 14 days with a documented clinical rationale and duration.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident's (#93) representative, as designated by the Resident, was able to make medical decisions for the Resident, in a sample of 22 records reviewed. Specifically, the facility failed to ensure that the Resident's representative was able to formulate the Resident's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for two Residents (#93 and #37), out of a total sample of 22 residents. Specifically, the facility failed: 1. For Resident #93, to develop and implement interventions to address the Resident's risk for falls; and 2. For Resident #37, to ensure the care plan was updated when a Foley catheter (small flexible tube inserted into the urethra to drain urine from the bladder) used to manage the Resident's urinary retention was ineffective and changed to a larger size catheter in response following two episodes of urinary incontinence.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for two Residents (#77 and #37), out of a total sample of 22 residents. Specifically, the facility failed: 1. For Resident #77, to identify and provide care for an implanted central line catheter (port, type of central line that allows for long-term access to a patient's bloodstream); and 2. For Resident #37, to ensure physician's orders for insertion of indwelling Foley catheters, including the size of the device, was obtained/documented in the medical record on three occasions.

Inspectors wroteBased on record review and interview, the facility failed to complete a discharge assessment to ensure timely coding and transmitting of a Minimum Data Set (MDS) assessment for two Residents (#25 and #42), out of two resident assessments reviewed, resulting in a delay in the encoding and transmission of an MDS post-discharge from the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments were completed for three Residents (#80, #93, and #76), out of a total sample of 22 residents. Specifically, the facility failed to: 1. For Resident #80, accurately code the Resident's prognosis of less than six months on the 9/4/24 MDS; 2. For Resident #93, a. Accurately code hospice care on the 3/1/24 MDS, b. Accurately code a fall with injury on the 5/29/24 MDS, and c. Accurately code the Resident's prognosis of less than six months on the 8/28/24 MDS; and 3. For Resident #76, accurately code the Resident's use of antipsychotic medication on the 8/21/24 MDS.

Inspectors wroteBased on observation, record review and interview, the facility failed to 1.) develop and implement care plan interventions related to falls for one Resident (#76) resulting in a fall with injury and 2.) failed to implement a fall care plan for wearing the appropriate footwear for one Resident (#4), out of a total of 21 sampled Residents. Review of the facility's Managing Falls and Fall Risk policy, dated December 2007 indicated: *Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure professional standards of practice were followed for the changing of oxygen and nebulizer tubing for 5 Residents (#68, #16, #9, #22 and #67) in a total sample of 21.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to assess a scoop mattress as a potential restraint for one Resident (#80) out of a total sample of 21 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement the plan of care for 3 Residents (#22, #5 and #80) out of a total sample of 21 residents. Findings Include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated revised March 2022, indicated that the comprehensive, person-centered care plan describes the services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Resident #22 was admitted to the facility in March 2014 with diagnoses including dysphagia (difficulty eating), dementia with psychosis and blindness secondary to macular degeneration and glaucoma. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #22 scored a 4 out of 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to provide the prescribed, therapeutic diet for one Resident (#67) out of a total sample of 21 Residents. Specifically, Resident #67 was prescribed a therapeutic ground textured diet and did not receive ground textures during meals.

Inspectors wroteBased on observations, record reviewed and interviews, the facility failed to maintain accurate medical records for 2 Residents (#22 and #80) out of a total sample of 21 Residents. Specifically, 1.) For Resident #22 the facility failed to ensure they maintained an accurate medical record for a) the application of foam booties, b) the application of a bed cradle, c) the setting of an air mattress. 2.) For Resident #80 the facility failed to ensure they maintained an accurate medical record for Prevlon boot application