F 0656 Review of Resident #1's medical record indicated he/she returned to the facility on [DATE REDACTED].

Level of Harm - Minimal harm or Review of Resident #1's Comprehensive Care Plan, indicated there was a new focus area, dated 04/03/25 potential for actual harm which included that Resident #1 had a history of suicidal attempts; most recently on 03/28/25.

Residents Affected - Few -The Care Plan interventions included:

*Monitor the need for psychosocial, psychiatric support,

*Psychotherapy weekly for one month and then as needed,

* Staff to provide frequent rounding on the resident.

Review of Resident #1's Nursing Progress Note, dated 04/05/25, indicated Resident #1 was observed with a plastic knife in his/her right hand and a [superficial] cut to his/her left forearm; Resident #1 made continual suicidal ideation statements and was transferred to the Hospital ED for an evaluation.

Review of Resident #1's Nursing Progress Note, dated 04/10/25, indicated Resident #1 returned from the hospital.

Review of Resident #1's Dementia Care Plan, indicated Resident #1 had suicidal ideations and suicide attempts, a new intervention was added for 1:1 monitoring by staff during meal times, was initiated on 04/11/25.

Review of Resident #1's Nursing Progress Note, dated 05/08/25, indicated Resident #1 had taken a metal fork and broke off three of the four prongs and attempted to stab him/herself. The Note indicated Resident #1 was transferred to the Hospital ED for an evaluation and returned to the facility later that evening.

Review of Resident #1's Care Plan for history of suicidal attempts, indicated a new intervention was added

on 05/08/25 for every 15-minute head checks [per staff, 15 head checks were for 72 hours only].

Despite Resident #1's Care Plan interventions that he/she was only to have plastic utensils, and for staff supervision during meal times, on two separate occasions he/she was able gain access to and physically alter a metal fork then use it to threaten self harm. There were no additional care plan interventions developed or implemented that focused on how to prevent Resident #1 from gaining access to items he/she could use to inflect self harm.

During an interview on 05/21/25 at 1:33 P.M., the Director of Nurses (DON) said that Resident #1 was placed

on every 15-minute head checks for 72 hours following each incident and Resident #1 was no longer on them. The DON said that despite the interventions in Resident #1's care plan, he/she was able to obtain silverware on multiple occasions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 7 225063 Department of Health & Human Services Printed: 08/26/2025 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 05/21/2025

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 0689 During an interview on 05/21/25 at 1:51 P.M., Nurse #1 said she was on duty on 03/28/25 during the 7:00 A. M. - 3:00 P.M. (day shift) and Resident #1 was on her assignment. Nurse #1 said Resident #1 was weepy, Level of Harm - Minimal harm or and he/she pulled a metal fork, which had only one prong left, out from the side of his/her wheelchair and potential for actual harm made the gesture of stabbing him/herself with it. Nurse #1 said Resident #1 was transferred to the Hospital ED for an evaluation. Residents Affected - Few

Review of Resident #1's medical record indicated he/she was readmitted to the facility on [DATE REDACTED].

Review of Resident #1's Dementia Care Plan, initiated on 04/03/25, indicated Resident #1 had suicidal ideation's and suicide attempts, a new intervention for 1:1 monitoring by staff during meals was initiated on 04/11/25.

Review of Resident #1's Nursing Progress Note, dated 05/08/25, indicated Resident #1 had taken a metal fork and broke off three of the four prongs and attempted to stab him/herself. The Note indicated Resident #1 was transferred to the Hospital ED for an evaluation and returned to the facility later that evening.

During an interview on 05/21/25 at 1:51 P.M., Nurse #1 said she worked the day shift on 05/08/25. Nurse #1 said Resident #1 was found in his/her room with a metal fork, which had only one prong left, and made the gesture of stabbing him/herself in the chest. Nurse #1 said Resident #1 refused to tell her where he/she got

the fork from. Nurse #1 said Resident #1 did not sustain any injury. Nurse #1 said Resident #1 was supposed to have only plastic ware and 1:1 staff supervision for all meals.

On 05/21/25 at 8:02 A.M., the surveyor observed Resident #1 coming out of his/her room, propelling his/her wheelchair into the hallway. Resident #1 was able to independently self propel his/her wheelchair down the hallway to the unit dining room.

During an interview on 05/21/25 at 9:00 A.M., Resident #1 said he/she did not want to be at the facility but added that he/she was not going to escape or anything like that.

Although Resident #1's Care Plan interventions included that he/she was to be provided with plastic ware only for meals, that staff were to provide 1:1 supervision during meals, both of which were to prevent him/her from having access to metal utensils, Resident #1 was still able on two separate occasions, undetected by staff, to gain possession of and physically manipulate a metal fork, which he/she then in the presence of staff, used to threatened self harm.

During an interview on 05/21/25 at 1:33 P.M., the Director of Nurses (DON) said she spoke with staff following the incident on 05/08/25 and a room search of Resident #1's room was conducted and nothing was found. The DON said she should have completed a full, written investigation following the incident on 05/08/25 and did not. The DON said that despite the interventions in Resident #1's care plan, he/she was able to obtain and manipulate silverware on two occasions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 225063 Department of Health & Human Services Printed: 08/26/2025 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 05/21/2025

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 0742 During an interview on 05/21/25 at 1:33 P.M., the Director of Nurses (DON) said she was not aware that Nurse Practitioner #1 was unaware of Resident #1's suicidal behaviors on 03/28/25 and 04/05/25. The DON Level of Harm - Minimal harm or said it was her understanding that NP #1 had been involved in Resident #1's plan of care since his/her potential for actual harm admission to the facility.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 225063