Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Copley At Stoughton Nursing Care Center during CMS and state inspections, most recent first.
A resident with dementia, repeated falls, and Medicaid as primary payor was care planned for LTC placement and covered by the facility’s bed-hold/return policy. After the resident’s legs buckled while being assisted off the toilet, a family member, believing the resident had fallen, called police and EMS to request ED evaluation. Nursing staff told EMS there was no MD order for transfer and that the facility was not transferring the resident, and EMS records note the facility requested the resident not be sent back. The nursing supervisor, DON, and administrator subsequently treated the EMS transfer as a family-initiated discharge/AMA departure, without a physician discharge/transfer order or discharge paperwork, and determined the resident was not allowed to return, despite the resident’s payor source and the facility policy requiring residents be permitted to return after hospitalization.
The facility failed to implement Enhanced Barrier Precautions for a resident with a urinary catheter, as a nurse did not perform hand hygiene or wear a gown during high-contact care. Additionally, the facility lacked an effective water management program to prevent Legionella growth, with no documentation of testing or monitoring. These deficiencies indicate a failure to maintain a safe environment for residents.
A facility failed to act on a Consultant Pharmacist's recommendation to add a stop date to a resident's as-needed Ativan order. The recommendation, made in July 2024, was not addressed, and the physician/prescriber response section was left blank. The Unit Manager was unaware of the recommendation, and the issue remained unresolved despite being included in pending recommendations lists provided in subsequent months.
A resident with dementia and anxiety was prescribed PRN antianxiety medications without adherence to the facility's policy of limiting use to 14 days or providing a documented rationale for extended use. The MAR showed multiple administrations of Ativan, but the medical record lacked necessary documentation for extending its use. A unit manager was aware of the need for stop dates on PRN orders.
A facility failed to ensure a resident's representative was involved in medical decisions, as required by policy. Despite a diagnosis of dementia and a physician's determination of incapacity, the resident signed a MOLST form without their health care proxy's involvement. The facility's policy mandates that the representative be involved when a resident lacks decision-making capacity, but this was not followed.
Two residents in a facility experienced deficiencies in their care plans. One resident, with a history of falls, had multiple incidents without new interventions being implemented, and their care plan was not updated. Another resident, with a neurogenic bladder, had a Foley catheter changed due to ineffectiveness, but the care plan was not revised to reflect this change. Interviews with staff confirmed the lack of updates to the care plans, highlighting a failure to adhere to facility policies.
The facility failed to provide care according to professional standards for two residents. One resident's implanted central line catheter was not identified or documented, and there were no orders for its care. Another resident had Foley catheters inserted without documented orders specifying the size of the catheter and retention balloon. Interviews revealed a lack of communication and documentation, and the facility's policies on orders were not followed.
The facility failed to complete and transmit discharge MDS assessments for two residents within the required timeframe, resulting in a delay of over 120 days. Both residents were admitted for short-term skilled rehabilitation services and discharged, but their MDS assessments were not submitted in a timely manner, as confirmed by the MDS Nurse and DON.
The facility failed to accurately code MDS assessments for three residents, leading to deficiencies in documenting hospice care, fall history, and antipsychotic medication use. A resident with heart failure and dementia was not coded for hospice care or a prognosis of less than six months, while another resident's fall with injury was missed. Additionally, a resident with a psychotic disorder was inaccurately coded as not receiving antipsychotic medication.
Improper Discharge and Refusal to Readmit Resident After Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right and ability to return following a hospital evaluation, and the improper treatment of a hospital transfer as a voluntary discharge. The resident, admitted in April 2024 with dementia, history of UTIs, anxiety, repeated falls, and anemia, had a care plan indicating long-term care placement. The resident’s MassHealth Eligibility Form showed Medicaid as the primary payor on the day of transfer, meaning a bed hold should have been in place under facility policy, which states that residents must be permitted to return following hospitalization or therapeutic leave regardless of payor source. On the day of the incident, the resident was in the bathroom with a nurse when the resident’s legs buckled while being assisted off the toilet, and the nurse lowered the resident to the floor. A family member, who heard a loud bang and believed the resident had fallen, called the local police and EMS to have the resident evaluated in the ED, noting that the resident had recently fallen and been hospitalized two days earlier for chronic vertebral fractures. The nurse reported telling EMS there was no physician’s order for transfer and that the facility was not transferring the resident, and did not know which hospital EMS would use. EMS documentation indicated that the family requested ED evaluation and that facility staff requested the resident not be sent back and stated they would not accept the resident back. Following the transfer, the nursing supervisor, DON, and administrator treated the resident’s departure as a discharge initiated by the family and as having left against medical advice, despite there being no physician’s order for discharge or transfer and no discharge paperwork provided. The supervisor stated she was told by administration that the resident was considered discharged and not allowed to return. The DON and administrator both stated that the family had discharged the resident by calling police and EMS and initiating the ED transfer, and the administrator stated that because the family initiated the discharge, the facility did not have to readmit the resident despite the resident’s payor source. A police report documented that when the resident returned from the ED a few hours later, facility staff stated the resident had been transferred AMA and was discharged from the facility, and the facility would not accept the resident back, contrary to the facility’s bed-hold and return policy and the requirement to permit return after hospitalization.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two main deficiencies. Firstly, the staff did not implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. The resident, who had severe cognitive impairment and a Foley catheter, was observed by a surveyor to have an EBP sign posted at their room. However, a nurse failed to perform hand hygiene before donning gloves and did not wear a gown while providing high-contact care, such as repositioning the resident and examining the catheter. The nurse admitted to not noticing the EBP sign and not being informed about the precautions, which was confirmed by the unit manager and the infection preventionist. Secondly, the facility did not have an effective water management program in place to prevent the growth of Legionella and other waterborne pathogens. The Director of Maintenance, who was new to the facility, could not provide documentation of a water management program prior to his hire. The administrator presented a binder for a program that was supposed to be in place, but there was no testing or monitoring documentation available for the specified period. Additionally, the infection preventionist had not participated in the water management program, indicating a lack of oversight and implementation. These deficiencies highlight the facility's failure to adhere to infection control protocols and maintain a safe environment for residents. The lack of proper precautions for residents with indwelling devices and the absence of a documented water management program pose significant risks for the transmission of infections and diseases.
Failure to Address Pharmacist's Medication Recommendations
Penalty
Summary
The facility failed to act promptly on recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for a resident with dementia and anxiety. The resident was admitted in February 2024, and during a review in July 2024, the Consultant Pharmacist recommended adding a stop date to the resident's as-needed Ativan order. This recommendation was not addressed, and the physician/prescriber response section on the recommendation form was left blank. Interviews revealed that the Unit Manager was unaware of the pharmacist's recommendations from July, and the Consultant Pharmacist confirmed that the recommendation was included in a list of pending recommendations provided to the facility in both August and September 2024. Despite these notifications, the facility did not act on the recommendation, resulting in a deficiency related to the management of the resident's medication regimen.
Failure to Limit PRN Antianxiety Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility did not limit the use of as-needed antianxiety medications to 14 days or provide a documented clinical rationale and duration for extending their use beyond 14 days. The facility's policy on psychotropic medication use, dated July 2022, requires that PRN orders for such medications be limited to 14 days unless extended with proper documentation. However, the medical record for the resident in question did not show compliance with this policy. The resident, who was admitted in February 2024 with diagnoses including dementia and anxiety, had physician's orders for Alprazolam and Ativan, both antianxiety medications, on an as-needed basis without specified end dates. The Medication Administration Record (MAR) indicated multiple administrations of Ativan over several months, but no administration of Alprazolam. Despite this, there was no documentation in the resident's medical record to justify the extended use of Ativan beyond the 14-day limit. During an interview, a unit manager acknowledged awareness of the requirement for stop dates on as-needed psychotropic medication orders.
Failure to Involve Resident's Representative in Medical Decisions
Penalty
Summary
The facility failed to ensure that a resident's representative was able to make medical decisions on behalf of the resident, as required by the facility's policy on advance directives. The resident, who was admitted with a diagnosis of dementia, had a physician determine that they lacked the capacity to make or communicate health care decisions. Despite this, the resident signed a Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form without the involvement of their designated health care proxy (HCP), who had been activated due to the resident's cognitive impairment. The facility's policy requires that the interdisciplinary team assess a resident's decision-making capacity and involve the resident's representative if the resident is determined to lack capacity. However, in this case, the resident's MOLST form was completed and signed by the resident themselves, rather than their HCP, which was a deviation from the policy. During an interview, a unit manager acknowledged that the HCP should have reviewed and signed the MOLST form, indicating a lapse in following the established procedures for residents who are unable to make their own medical decisions.
Deficiencies in Care Plan Implementation for Fall Risk and Catheter Management
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents, leading to deficiencies in addressing their physical, psychosocial, and functional needs. For one resident, the facility did not implement effective interventions to address the resident's risk for falls, despite multiple incidents. The resident, who was admitted with diagnoses including repeated falls, concussion, and dementia, experienced four falls after admission. The facility's incident reports for these falls did not indicate new interventions to prevent future falls, and the resident's care plan was not updated to reflect additional fall prevention measures. Another resident, admitted with neuromuscular dysfunction of the bladder, had issues with the management of an indwelling urinary catheter. The resident was treated for a urinary tract infection and had a Foley catheter in place, which was later changed to a larger size due to ineffectiveness. However, the care plan was not updated to reflect this change, and there was no physician's order indicating the new catheter size. This oversight was confirmed during an interview with a nurse who was unaware of the catheter's specifications until physically checking it. The facility's policies on falls and comprehensive person-centered care plans were not adhered to, as evidenced by the lack of updated interventions and care plans following significant changes in the residents' conditions. Interviews with nursing staff and management revealed that the care plans were not revised as required, contributing to the deficiencies identified during the survey.
Deficiencies in Documentation and Care for Medical Devices
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for two residents. For Resident #77, the facility did not identify and provide care for an implanted central line catheter. Despite the resident's hospital discharge paperwork indicating the presence of an implanted port, the initial and re-admission assessments failed to document this. Interviews with nursing staff revealed that the implanted central line catheter was not identified or documented, and there were no orders for its care and maintenance. For Resident #37, the facility did not ensure that physician's orders for the insertion of indwelling Foley catheters, including the size of the device, were obtained and documented in the medical record on three occasions. The resident, who had severe cognitive impairment and a history of neuromuscular dysfunction of the bladder, had a Foley catheter inserted without documented orders specifying the size of the catheter and retention balloon. Interviews with nursing staff and the nurse practitioner indicated a lack of communication and documentation regarding the catheter changes. The facility's policies on medication and treatment orders, as well as verbal orders, were not followed, leading to deficiencies in the care provided to these residents. The Director of Nursing acknowledged that the expected procedures for documenting and obtaining orders for the care and maintenance of medical devices were not adhered to, resulting in the deficiencies identified during the survey.
Delayed MDS Transmission for Discharged Residents
Penalty
Summary
The facility failed to complete and transmit discharge assessments for two residents, resulting in a significant delay in the encoding and transmission of the Minimum Data Set (MDS) assessments. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 Manual, the MDS must be transmitted electronically no later than 14 calendar days after the care plan completion date. However, for both residents involved, the discharge MDS was not completed until approximately four months after their discharge from the facility. Resident #25 was admitted for short-term skilled rehabilitation services and discharged to the community, while Resident #42 was admitted for similar services and discharged to the hospital. In both cases, the MDS assessments were not submitted for over 120 days post-discharge. During interviews, MDS Nurse #1 acknowledged the delay, and the Director of Nursing confirmed that the expectation was for the MDS assessments to be encoded and transmitted in a timely manner.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of their care. Resident #80, who was admitted with diagnoses including heart failure, cerebral infarction, and dementia, was not accurately coded on the 9/4/24 MDS to reflect a prognosis of less than six months, despite having a Hospice Certification of Terminal Illness indicating such a prognosis. The MDS Nurse cited difficulties in obtaining timely documentation as a reason for the inaccurate coding. Resident #93, admitted with heart failure and dementia, had multiple inaccuracies in their MDS assessments. The 3/1/24 MDS failed to indicate that the resident was receiving hospice care, despite a Hospice Certification of Terminal Illness confirming hospice initiation. Additionally, the 5/29/24 MDS inaccurately recorded the resident's fall history, missing documentation of a fall with injury. The 8/28/24 MDS also failed to reflect the resident's prognosis of less than six months, similar to the issue with Resident #80. The MDS Nurse acknowledged missing documentation and difficulties in obtaining necessary records in time. Resident #76, with a diagnosis of a psychotic disorder, was inaccurately coded on the 8/21/24 MDS regarding the use of antipsychotic medication. Despite physician orders and medication administration records indicating daily administration of Olanzapine, the MDS incorrectly stated that no antipsychotic medications were received. The MDS Nurse admitted the error in coding, acknowledging that the resident was indeed receiving antipsychotic medication.
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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.
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Nursing homes near Stoughton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blue Hills Health And Rehabilitation Center | 1 mi | — | 4 | 0 |
| New England Sinai Hospital Transitional Care Unit | 2.1 mi | — | 0 | 0 |
| Alliance Health At West Acres | 2.6 mi | — | 6 | 0 |
| Brockton Post Acute Care | 3 mi | — | 0 | 0 |
| The Guardian Center | 3.2 mi | — | 2 | 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 August 2026) and official state health department websites.