Marlborough Hills Rehabilitation & Hlth Care Ctr

F-F838

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Level of Harm - Minimal harm or 47646 potential for actual harm Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Residents Affected - Few Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Resident (#176), of two applicable residents, out of a total sample of 34 residents.

Specifically, for Resident #176, the facility failed to:

-measure and document the external catheter length to ensure the PICC line had not migrated (moved from

the heart to another area, which could have a significant impact on treatment, or cause serious harm).

-measure and document arm circumference.

-document ordered Normal Saline (NS) flushes.

Findings include:

Review of facility policy titled Central Venous Access Device (VAD) Catheter Dressing Change, dated January 2022, indicated but was not limited to the following:

- .The intravenous (IV) therapy order for care and maintenance is required.

- .With each assessment of the VAD, presence of the following, at a minimum, should include: External Catheter Length.

Review of facility policy titled Central Venous Access Device flushing, dated January 2022, indicated but was not limited to the following:

- .A prescriber order is required for VAD flushing. The order will be specific with regards to flush solution, volume and frequency.

- Document procedure in resident's medical records, including but not limited to: date and time, site assessment, flushing agent and volume flushed, any complication, resident's response to procedure, and any resident/caregiver education.

Resident #176 was admitted to the facility in February 2025 with diagnoses including Endocarditis, valve unspecified (infection of the heart's inner lining usually involving the heart valve).

Review of the most recent Minimum Data Set (MDS) assessment, dated 2/14/25, indicated that Resident #176:

-was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of a possible 15.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0694 -required IV medications.

Level of Harm - Minimal harm or Review of Resident #176's Physician's orders in the electronic health record, dated 3/7/25, indicated but was potential for actual harm not limited to:

Residents Affected - Few -Enhanced Barrier Precautions related to PICC, start date 2/11/25

-Cephazolin Sodium (antibiotic) Intravenous (IV) Solution Reconstituted 2 GM (gram) every 8 hours for 6 weeks, 2/11/25 - 3/25/25 for Endocarditis, valve unspecified, start date 2/11/25.

Review of Resident #176's Infusion Therapy Order (paper Physician orders) dated 2/10/25, indicated but was not limited to:

-PICC, single lumen - Document total catheter length and external catheter length.

-Document baseline arm circumference and PRN (as needed).

-Document external length weekly with dressing change and PRN.

-Pre-flush (Prior to IV medication infusion) 10 ml (milliliter) NS (Normal Saline).

-Post-flush (after IV medication infusion) 10 ml NS.

During an interview on 3/7/25 at 12:15 P.M., the Assistant Director of Nursing (ADON) said that Resident #176 had a PICC line used to administer the IV Cephazolin and orders for PICC line care that were not in the electronic health record. The ADON said the PICC line orders were on paper Infusion Therapy Flowsheets.

The ADON further said that's how she would know what orders were in place and PICC line care provided should be documented on the paper Infusion Therapy Flowsheet.

On 3/7/25 at 1:00 P.M., the surveyor observed the following during a medication administration by the ADON:

-an ordered dose of Cephazolin 2 GM administered to Resident #176 via the PICC line.

-The ADON scrubbed the connector with an alcohol pad, and flushed the line with 10 ml (milliliter) of NS.

-The ADON scrubbed the connector again with an alcohol swab, then connected the IV tubing to the connector and started the infusion with the pump.

-The PICC line dressing was labeled with the date 3/7/25.

-The ADON did not complete measurements of the external catheter length and arm circumference at this time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0694 During an interview on 3/7/25 at 1:50 P.M., the surveyor and the ADON reviewed Resident #176's Infusion Therapy Flowsheets for February 2025 and March 2025. The ADON said that the Nurse should measure the Level of Harm - Minimal harm or external length of the catheter and the left arm circumference on admission and document it in the potential for actual harm designated areas on the flowsheet. The ADON said the two measurements should be done at least weekly when the dressing was changed. The ADON said she changed the dressing today, and has never done any Residents Affected - Few measurements. The ADON said that NS flushes should be done before and after the administration of the IV medication and documented on the flowsheet as well.

Review of Resident 176's Infusion Therapy Flowsheet, dated February 2025, failed to indicate:

-the measurement of the external length of the catheter and the left arm circumference were done or documented on admission

-the measurements were done weekly with dressing changes or PRN as ordered.

-NS IV flushes were documented with the administration of the IV Cephazolin 36 times.

Review of Resident 176's Infusion Therapy Flowsheet, dated March 2025, failed to indicate:

-the measurements were done weekly with dressing changes or PRN as ordered.

-NS IV flushes were documented with the administration of the IV Cephazolin 9 times.

During an interview on 3/7/25 1:58 P.M., the Director of Clinical Operations said IV orders were not in the electronic health record, the Nurses use the Infusion Therapy flow sheets as orders. The Director of Clinical Operations said the orders on the flowsheets were from the Physician and should be documented and signed off by the Nurse. The Director of Clinical Operations said that the expectation was that the measurements of the external catheter length and arm circumference for Resident #176 should have been done and documented as ordered. The surveyor and the Director of Clinical Operations reviewed the Infusion Therapy Flowsheets for external catheter and arm circumference measurements and found no evidence that the external catheter and arm circumference measurements were done or documented, and

the ordered flushes were not signed off consistently. The Director of Clinical Operations said that the measurements and flushes should have been documented but had not been.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or 44222 potential for actual harm Based on record review, and interview, the facility failed to provide care and services consistent with Residents Affected - Few professional standards of practice for one Resident (#109), of one applicable resident, out of a total sample of 34 residents, who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop functioning properly).

Specifically, the facility failed to communicate and maintain ongoing documentation with the dialysis center to ensure that the dialysis center and the facility received the most current information pertaining to Resident #109.

Findings include:

Review of the facility policy titled Hemodialysis, dated April 2015, included but was not limited to:

-Communication between the facility and the hemodialysis center will occur using a communication book/sheet that consists of:

>vital signs,

>Copy of MAR (Medication Administration Record)

>any change of condition from last hemodialysis treatment

-Documentation will be completed prior to dialysis treatment

-The communication book/sheet will be reviewed upon return from dialysis.

Resident #109 was admitted to the facility in April 2021 with diagnoses including End Stage Renal Disease (ESRD), Dependence on Renal Dialysis, and Major Depressive Disorder, recurrent, unspecified.

Review of Resident #109's comprehensive person-centered care plan for hemodialysis, initiated 4/16/21, indicated:

-goal to tolerate dialysis without complications, revised 2/10/25,

-an intervention of: Dialysis Communication book in use, initiated 5/10/21.

Review of Resident #109's most recent Minimum Data Set (MDS) Assessment, dated 2/14/25, indicated:

-the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points.

-Resident #109 received Dialysis treatment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0698 During an interview on 3/4/25 at 11:31 A.M., Resident #109 said that he/she went to the dialysis center three times a week on Monday, Wednesday, and Friday, and has been doing so for many years. Resident #109 Level of Harm - Minimal harm or said that the dialysis treatments were going well. potential for actual harm

Review of Resident #109's March 2025 Physician's orders included an order for: Residents Affected - Few -Dialysis Days: Monday, Wednesday, and Fridays, Times: p/u (pick up) at 10 am (Dialysis Center)

Review of Resident #109's Dialysis Communication Book did not provide evidence of any communication sent to, or received back from the Dialysis Center for any dialysis days in January 2025, February 2025, or March 2025.

Review of the Resident #109's clinical record did not provide any evidence of ongoing communication between the facility and the dialysis center.

During an interview on 3/11/25 at 12:07 P.M., Nurse #2 said he was providing care for Resident #109 today and has cared for the Resident many times in the past. Nurse #2 said that the Resident has gone to dialysis treatments regularly on Mondays, Wednesdays, and Fridays. Nurse #2 said he never sent the Resident out to dialysis because the Resident goes to dialysis during the early morning when the night shift staff was still

on duty. Nurse #2 said he had never seen any communication sheet return with the Resident when the Resident returned from dialysis.

During an interview on 3/11/25 at 2:07 P.M., the Director of Nursing (DON) said that the Resident went to dialysis treatment every Monday, Wednesday, and Friday. The surveyor and the DON reviewed the dialysis communication book and were unable to find any evidence of ongoing communication between the facility and the dialysis center for any days in January 2025, February 2025, or March 2025. The DON said that facility staff were expected to complete a communication form before sending the Resident to dialysis and then send the form with the Resident in the dialysis book that accompanies the Resident to the dialysis center. The DON further said that the expectation was that the dialysis center would communicate on the bottom half of the form, and the facility staff would review the communication from the dialysis center upon

the Resident's return back to the facility. The DON said the staff should have been communicating with the dialysis center every time the Resident went for dialysis treatment but she could not provide any evidence that the staff had done so.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47646

Residents Affected - Few Based on observation, interview, and document review, the facility failed to ensure that nursing staff possessed the appropriate competencies and skills to assure resident safety when providing nursing and related services for one Resident (#14), out of a total of 51 residents who smoke as identified through smoking assessments.

Specifically, for Resident #14, Certified Nurses Aide (CNA) #5 failed to demonstrate competency in skills and techniques necessary to provide safe smoking care and services during assigned smoking sessions when CNA #5 lit a cigarette in the Resident's mouth while he/she was using oxygen.

Findings include:

Resident #14 was admitted to the facility in January 2025 with diagnoses including Respiratory Failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and Nicotine Dependence.

Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated Resident #14:

-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of total possible 15

-utilized a walker to aid with ambulation

-received oxygen therapy

Review of the Facility Assessment, dated 8/14/24, failed to indicate that the facility thoroughly evaluated and documented the needs of the resident population who smoke and identified the required resources needed to provide safe care and services.

Further review of the Facility Assessment failed to identify staff competencies necessary to provide the skill sets and safety training needed for the resident population who smoke.

On 3/6/25 at 1:13 P.M., during an assigned smoking session, two surveyors observed Resident #14 enter

the designated smoking area wearing a nasal cannula and carrying a portable oxygen tank. The surveyors observed that there were 8 residents in addition to Resident #14 in the smoking area. The surveyors further observed CNA #5 light a cigarette in Resident #14's mouth while the nasal cannula remained present in his/her nostrils. Resident #14 removed the lit cigarette from his/her mouth when he/she saw the surveyors, dropped the lit cigarette to the ground, went back into the facility and returned to resume smoking without the oxygen equipment.

During an interview on 3/6/25 at 1:16 P.M., Resident #14 said that CNA #5 lighted the cigarette in his/her mouth while his/her oxygen was being used via nasal cannula.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0726 During an interview on 3/6/25 at 2:17 P.M., Resident #14 said that not all staff members reminded him/her to remove the oxygen equipment before going outside to the smoking area. Resident #14 said his/her oxygen Level of Harm - Minimal harm or was being used when CNA #5 lit the cigarette in his/her mouth. potential for actual harm

Review of CNA #5's educational file failed to indicate that the CNA demonstrated competency with smoking Residents Affected - Few and oxygen safety.

Review of the Facility Orientation Packet for new staff failed to indicate any training or competencies to demonstrate smoking safety for residents who smoke.

During an interview on 3/6/25 at 1:16 P.M., CNA #5 said that he did not see Resident #14 wearing oxygen when he lit the cigarette in the Resident's mouth. CNA #5 said he knew that residents were not allowed to smoke while wearing oxygen.

During an interview on 3/10/24 at 3:30 P.M., the Regional Nurse said that the Facility Orientation Packet contained all of the training materials and competencies used to orient new employees. The Regional Nurse said there was no content in staff orientation regarding safe smoking for residents. The Regional Nurse further said there was no evidence that safe smoking and oxygen competency was demonstrated by CNA #5 prior to the incident on 3/6/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0732 Post nurse staffing information every day.

Level of Harm - Potential for 50138 minimal harm Based on observation, and interview, the facility failed to post nursing staff data daily, at the beginning of Residents Affected - Some each shift, relative to licensed and unlicensed nursing staff directly responsible for resident care per shift as required.

Specifically, the facility failed to post nursing staff data that included the actual hours worked for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nurses Aides (CNAs).

Findings include:

On 3/5/25 at 11:18 A.M., the surveyor observed the daily staffing posted on a dry erase board at the reception desk. The staffing information posted at that time included the facility name, current date, current census and number of Registered Nurses (RN's), Licensed Practical Nurses (LPN's), and Certified Nurses Aides (CNA's) by shift worked. The dry erase board information did not indicate the actual hours worked for

the RN's, LPN's and CNA's. Further review of the daily staffing information posted did not indicate the actual hours worked for licensed and unlicensed staff.

On 3/6/25 at 11:23 A.M., the surveyor observed the daily staffing information posted on a dry erase board at

the reception desk. The staffing information posted at that time included the facility name, current date, current census and number of Registered Nurses (RN's), Licensed Practical Nurses (LPN's), and Certified Nurse Aides (CNA's) by shift worked.

Further review of the daily staffing information posted did not indicate the actual hours worked for licensed and unlicensed staff.

During an interview on 3/6/25 at 11:26 A.M., the Receptionist said that she updates the staffing dry erase board every morning and the evening shift if adjustments occur based on the daily staffing schedule provided to her by the Scheduler.

During an interview on 3/6/25 at 11:49 A.M., the Scheduler said that she provides staffing information from

the printed facility staffing list to the Receptionist on the total number of RNs, LPNs, and CNAs that are scheduled.

During an interview on 3/6/25 at 11:53 A.M., the Scheduler said that she kept track of the total hours worked by each of the RN's, LPN's and CNA's but was unaware of the requirement to post nursing staff data that included the actual hours worked by the RNs, LPNs, and CNAs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50320 potential for actual harm Based on interview, and record review, the facility failed to ensure that two Residents (#379 and #42) out of Residents Affected - Some a total sample of 34 residents, were free from significant medication errors.

Specifically, the facility failed to:

1. For Resident #379, ensure the appropriate medication administration syringe was available to administer Physician ordered medications through the Resident's Percutaneous Gastronomy (PEG) tube (a tube that provides a direct route to the stomach for delivering nutrition, fluids and medication to a person who is unable to eat or drink through their mouth) resulting in missed doses of the ordered medications.

2. For Resident #42, the facility failed to ensure that Permethrin (medication used to treat scabies [a contagious skin infestation caused by tiny mites]) cream was accurately transcribed on the Medication Administration Record (MAR), resulting in the Resident receiving five doses instead of one prescribed dose, and increasing the risk for adverse reaction to the medication.

Findings include:

Review of the facility policy, Medication Error Reporting, dated April 2015, indicated:

-A medication error is any preventable event that may cause or lead to inappropriate medication use, which

the medication is in control of the health care professional.

-A licensed nurse makes an immediate evaluation of the resident in relation to the nature of the error.

-The person finding the error is responsible for completing the medication error report and forwarding it to the Director of Nursing immediately.

Resident #379 was admitted to the facility in February 2025 with diagnoses including, Dysphagia Oropharyngeal Phase, Personal History of Pulmonary Embolism, Mood Disorder due to known physiological condition with depressive features, and Essential (primary) Hypertension.

Review of the Resident's clinical record indicated that no Minimum Data Set (MDS) Assessment had not been submitted due to Resident #379's recent admission to the facility.

Review of the Resident's Speech Therapy comprehensive care plan initiated on 2/21/25, and revised on 3/3/25, indicated:

>The Resident had swallowing difficulty related to an abnormal swallow study with interventions including:

-Provide Resident with nothing by mouth (NPO) consistency diet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0760 -Provide Resident with NPO consistency liquid.

Level of Harm - Minimal harm or Review of Resident #379's Physician's orders for March 2025 indicated: potential for actual harm -NPO diets, NPO texture, NPO consistency, effective 3/7/25 Residents Affected - Some -Amlodipine Besylate (antihypertensive) oral tablet 2.5 milligrams (mg), give 1 tablet via PEG - tube in the morning, effective 2/20/25

-Apixaban (anticoagulant) oral tablet 5 mg, give one table via PEG-tube two times a day, effective 2/20/25

-Folic Acid (used to treat folate deficient anemia) oral tablet 1 mg, give one tablet via PEG-tube in morning, effective 2/20/25

-Levetiracetam (antiseizure) oral solution 100 MG/ML, give 7.5 ml two times a day via PEG - tube, effective 2/20/25

-Melatonin (supplement) oral tablet 3 mg, give one tablet via PEG - tube at bedtime, effective 2/20/25

-Quetiapine Fumerate (antipsychotics) oral table 25 mg, give one tablet via PEG - tube in the morning, effective 2/20/25

-Quetiapine Fumerate oral tablet 25 mg, give two tablets via PEG - tube at bedtime, effective 2/20/25

-Thiamine HCL (Vitamin) oral tablet 100 mg, give 1 tablet via PEG - tube in the morning, effective 2/20/25

-Trazadone HCL (antidepressant) oral tablet 100 mg, give one tablet via PEG tube at bedtime, effective 2/20/25

Review of the Resident #379' Medical Record indicated the following:

-An orders administration note dated 3/5/25 at 23:42: syringe for administration not available, NP (Nurse Practitioner)/Supervisor notified.

-An orders administration note dated 3/6/25 at 06:00: hold medications and follow-up with DON (Director of Nursing) for proper syringes.

-An orders administration note dated 3/7/25 at 05:36: awaiting syringe delivery.

-An orders administration note dated 3/8/25 at 06:11: awaiting delivery of special syringe.

Review of the Resident's March 2025 Medication Administration Record (MAR) indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0760 -Amlodipine Besylate was not administered as ordered on: 3/6, 3/7, and 3/8.

Level of Harm - Minimal harm or -Folic Acid was not administered as ordered on: 3/6, 3/7, 3/8. potential for actual harm -Melatonin was not administered as ordered on: 3/5 and 3/6. Residents Affected - Some -Quetiapine Fumerate was not administered as ordered the morning of: 3/6, 3/7, 3/8 and the evening of: 3/5 and 3/6.

-Thiamine HCL was not administered as ordered on: 3/6, 3/7 and 3/8.

-Trazadone HCL was not administered as ordered on: 3/5 and 3/6.

-Apixaban was not administered as ordered the morning of: 3/6, 3/7, 3/8 and the evening of: 3/5 and 3/6.

-Levetiracetam was not administered as ordered the morning of 3/6, 3/7, 3/8 and the evening of 3/5 and 3/6.

During an interview on 3/11/25 at 8:31 A.M., the DON said she did not find out until 3/10/25 that the medication administration syringe was not available, and that Resident #379 had not received the correct doses of his/her medications as prescribed by the Provider from 3/5/25 through 3/8/25. The DON said the procedure for missed doses of medication is the Nurse on duty should call the Physician or NP immediately for further instructions and contact the DON immediately. The DON said the Nurse should fill out the Report

on Medication Incidents and forward it to the DON immediately. The DON said that she should have been contacted immediately so that a medication administration syringe could have been obtained. The DON said

the facility should have had the syringes available prior to the Resident's admission to ensure that he/she received the medications as ordered by the Prescriber.

During an interview on 3/11/25 at 10:48 A.M., Nurse #1 said she alerted the Assistant Director of Nurses (ADON) during her shift on 3/6/25, that the syringe to administer medications (via PEG tube) was unavailable. Nurse #1 said the Resident did not need to receive any medications during her shift on 3/6/25. Nurse #1 said if medications or equipment to administer medications is not available, the procedure is they should call the Physician and see how the Physician wants to proceed, and inform the DON right away.

During an interview on 3/11/25 at 10:56 A.M., the ADON said she was unaware Resident #379 did not receive his/her medications as prescribed by the Provider until 3/10/25.

During an interview on 3/11/25 at 12:49 P.M., Nurse #5 said she was the evening supervisor on 3/5/25, 3/6/25 and 3/7/25. Nurse #5 said the NP had been contacted but Nurse #5 could not recall what day or time. Nurse #5 said the NP said to call the DON so a syringe could be obtained. Nurse #5 said she did not call the DON. Nurse #5 said she ordered a syringe from Amazon on the evening of 3/7/25. Nurse #5 said the NP came in on Saturday 3/8/25 and showed the Nurses how to administer the medication without a syringe and how to assess the Resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0760 During an interview on 3/11/25 at 1:15 P.M., the Regional Nurse said someone from nursing should have called the Physician and the DON to notify them that Resident #379 was not receiving his/her medications. Level of Harm - Minimal harm or The Regional Nurse said the Nurse on duty should have entered the incident into the medical record in an 'at potential for actual harm risk note' for the facility to be alerted of the problem. The Regional Nurse said the Resident should have gotten his/her medications as prescribed by the Provider or a hold order for the medications should have Residents Affected - Some been obtained from the Physician.

51466

2. Review of the Mayo Clinic document, titled Drugs and Supplements - Permethrin, dated 2/1/25, indicated

the following:

-dosing for treatment of scabies is Permethrin 5% cream to be applied to the skin one time.

-Side effects from Permethrin recommended dosage can include itching, numbness, rash, redness, swelling of the skin, stinging or burning, and tingling sensation.

Resident #42 was admitted to the facility in September 2024 with diagnoses including an Open Wound of Abdominal Wall.

Review of Resident #42's Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated:

-The Resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview of Mental Status (BIMS).

-The Resident was able to make him/herself understood.

Review of the Resident's Physician order, dated 12/1/24 at 11:00 A.M., indicated:

-Permethrin 5% cream - Apply to whole body from the neck down and wash off after eight to 14 hours.

-Dermatology Consult.

Review of the December 2024 Treatment Administration Record (TAR), indicated Resident #42 received Permethrin Cream 5% daily on: 12/2/24, 12/3/24, 12/4/24, 12/5/24 and 12/6/24.

During an interview on 3/10/25 at 3:39 P.M., the DON said that Resident #42 received one dose of Permethrin cream every day for 5 days but should have received one dose only. The DON said the order for Permethrin cream written on 12/1/24 was transcribed incorrectly into the Resident #42's electronic medical

record (EMR) which caused the medication administration error to occur.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47646

Residents Affected - Many Based on observation, interview, and document review, the facility failed to conduct and implement a comprehensive facility wide assessment that was inclusive of resources necessary to provide both emergency and day-to-day care of the population the facility currently serves.

Specifically, the facility assessment failed to address the education and competencies for staff to provide a safe smoking environment for 51 residents identified as active smokers, out of a total census of 173.

Findings include:

On 3/6/25 at 1:13 P.M., two surveyors observed Resident #14 enter the designated smoking area for an assigned smoking session while wearing a nasal cannula and carrying a portable oxygen tank. The surveyors further observed Certified Nurses Aide (CNA) #5 light a cigarette in Resident #14's mouth while

the nasal cannula remained present in his/her nostrils. Resident #14 saw the surveyors, removed the lit cigarette from his/her mouth and dropped the lit cigarette to the ground. Resident #14 was observed to walk back inside the facility, leave his/her oxygen equipment in the building and return to the designated smoking area.

Review of Resident Smoker - Oxygen Initial Audit, dated 3/6/25, indicated that 51 residents out of a facility census of 173 were identified as smokers.

Further review of the Initial Audit indicated that Resident #14's name was included on the audit and was listed as a smoker who utilized oxygen therapy.

Resident #14 was admitted to the facility in January 2025 with diagnoses including Respiratory Failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and Nicotine Dependence.

Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated Resident #14:

-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of total possible 15

-utilized a walker to aid with ambulation

-received oxygen therapy.

Review of Facility Assessment, dated 8/14/24, failed to indicate that the facility:

-thoroughly evaluated and documented the needs of its resident population who were smokers.

-identified the required resources to provide safe care and services for the resident population that smoked.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0838 -identified and implemented staff competencies necessary to provide safety and the skill sets needed for the resident population who smoke. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/6/25 at 1:16 P.M., Resident #14 said that CNA #5 had lit the cigarette in his/her mouth while his/her oxygen was being used via nasal cannula. Residents Affected - Many

During an interview on 3/6/25 at 2:17 P.M., Resident #14 said that not all staff members reminded him/her to remove the oxygen equipment before going outside to the smoking area. Resident #14 said his/her oxygen was being used when CNA #5 lit the cigarette in his/her mouth.

Review of CNA #5's educational file failed to indicate that the CNA demonstrated competency with smoking and oxygen safety.

During an interview on 3/6/25 at 1:16 P.M., CNA #5 said that he did not see Resident #14 wearing oxygen when he lit the cigarette in the Resident's mouth. CNA #5 said he knew that residents were not allowed to smoke while wearing oxygen.

During an interview on 3/10/24 at 3:30 P.M., the Regional Nurse said the Facility assessment dated [DATE REDACTED] was the most recent version. The surveyor and the Regional Nurse reviewed the Facility Assessment and

the Regional Nurse said the Facility Assessment did not address residents who smoke and it should have.

The Regional Nurse further said there was no evidence that safe smoking and oxygen competency was demonstrated by CNA #5 prior to the incident on 3/6/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50138 potential for actual harm Based on record review, and interview, the facility failed to maintain an infection prevention and control Residents Affected - Many 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 completion of annual water sampling for Legionella placing residents at risk for exposure to Legionella bacterium (a bacteria which lives in fresh water and can cause pneumonia like or flu like illnesses).

Findings include:

Review of the facility policy titled Legionella Policy, revised 10/24/22, included but was not limited to the following:

-It is the policy of this facility to have a water management program to reduce Legionella bacteria growth and spread in the facility, and staff to be educated annually on Legionella symptoms (Refer to the separate Water Management Program Policy).

-People can get sick when they breathe in mist or accidentally swallow water into the lungs containing Legionella bacteria.

-However, people [AGE] years or older .and people with a weakened immune system or chronic disease are at increased risk.

-Facility will conduct an annual water program assessment with a qualified contractor.

During an interview on 3/5/25 at 12:10 P.M., the Director of Physical Plant said that the facility water system was last tested for Legionella bacterium on 8/29/23, by an independent water management company. The surveyor and the Director of Physical Plant reviewed the laboratory results for Legionella testing that had been completed on 8/29/23. The Director of Physical Plant said he thought that testing should be done every year.

During an interview on 3/5/25 at 12:35 P.M., the Director of Clinical Operations said that although the facility's Legionella policy indicated that there should have been a separate water management program policy to review, in-fact there was not a separate water management program policy for the facility. The Director of Clinical Operations said that the facility followed the qualified contractors (FCS-Facility Compliance Services LLC) process for Legionella monitoring and mitigation, dated 4/3/18.

Review of the FCS Legionella sampling process for the facility dated 4/3/18, indicated but was not limited to

the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 35 225063 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225063 B. Wing 03/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marlborough Hills Rehabilitation & Hlth Care Ctr 121 Northboro Road Marlborough, MA 01752

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 0880 -As part of the assessment process itself, environmental sampling of Legionella will be performed annually to determine any possibility of colonization (establishment of a bacterial population on a surface), including the Level of Harm - Minimal harm or possibility of extensive biofilm (a community of bacteria that adheres to a surface in a slimy matrix of potential for actual harm substances) involvement in the area of concern.

Residents Affected - Many -Four samples should be taken from the facility. Sampling locations should change from year to year based off the assessment of this plan or risk areas identified.

-Sampling should be conducted by a water management consultant or may be taken by internal staff.

During a follow-up interview on 3/5/25 at 12:47 P.M., the Director of Clinical Operations said that facility testing for Legionella should have been done in 2024 but had not been done. The Director of Clinical Operations said that Legionella testing was important so that the facility could identify if Legionella exposure to residents was occurring or not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 35 225063