Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marlborough Hills Rehabilitation & Health Care Cen during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and total dependence on staff for transfers was moved from bed to wheelchair by two CNAs without the required mechanical lift, despite clear care plan instructions. Both CNAs were aware of the transfer requirements but did not follow them, and the incident was observed by a nurse.
A resident with a history of suicidal ideations and self-injurious behavior repeatedly gained access to metal utensils and attempted self-harm, despite care plan interventions such as plastic utensils, staff supervision, and periodic monitoring. The facility did not revise the care plan to effectively prevent the resident from obtaining potentially harmful items after multiple incidents.
A resident with a history of suicidal ideation and moderate cognitive impairment was able to access and manipulate metal forks on two occasions, despite care plan interventions requiring only plastic utensils and 1:1 supervision during meals. The resident attempted self-harm with the utensils, and staff were unable to determine how the utensils were obtained or ensure the required supervision was provided.
A resident with a history of suicidal ideation and self-injurious behavior experienced multiple episodes of suicidal behavior, including attempts with utensils, but did not receive timely behavioral psychiatric evaluation or adjustments to their care plan. Communication gaps between nursing staff and the behavioral health provider resulted in delayed intervention, despite repeated hospital transfers for suicidal incidents.
A facility failed to include a resident's Health Care Agent (HCA) in the care planning process, despite the resident's Health Care Proxy being invoked due to moderate dementia. The resident, diagnosed with schizoaffective disorder, anxiety disorder, and bipolar disorder, was admitted in June 2024. The facility did not invite the HCA to the December 2024 care plan meeting, as indicated by blank sections on the Care Plan Meeting Invitation and Interdisciplinary Care Plan Meeting Form. Staff interviews revealed a lack of awareness about the invoked Health Care Proxy, leading to the HCA's exclusion from the care planning process.
The facility failed to obtain written consent and provide education on the risks and benefits of psychotropic medications before administering them to a resident with multiple mental health diagnoses. The resident, who was considered self-responsible, did not sign the consent forms until after the surveyor's inquiry, indicating a lapse in following the facility's policy.
A resident with moderately impaired cognition was not included in the care planning process. The facility failed to hold or document any care plan meetings for the resident since their admission, as confirmed by both the resident and the social worker.
The facility failed to implement a care plan for a resident with Multiple Sclerosis, neglecting to apply a left palm guard as ordered for contracture prevention and skin breakdown. Observations and staff interviews revealed a lack of adherence to the care plan, with staff unaware of the requirement and the resident expressing concern about their condition worsening.
The facility failed to ensure that a resident was weighed weekly as ordered by the physician and recommended by the RD following hospitalization and J-tube placement, resulting in delayed identification of significant weight loss. The resident's weights were not documented on the specified dates, leading to a significant weight loss of 27.4 pounds from October to November.
The facility failed to ensure that pharmaceutical services met the needs of each resident by not re-ordering and replacing emergency medication kits (E-Kits) after they were opened and not completing the required documentation for medications removed from the E-Kits. Several E-Kits were found opened without proper documentation, and there was no evidence that the forms were faxed to the pharmacy to reorder the kits.
The facility failed to store medications securely. Escitalopram, a psychotropic medication, was left unsecured on a desk behind the nurses' station after being delivered from the pharmacy. The Unit Manager acknowledged that the medication should have been locked in the medication room until it could be transferred to the correct nursing unit.
The facility failed to maintain accurate documentation for two residents, leading to deficiencies in care. One resident's left palm guard was misplaced and not used despite being documented as applied, while another resident's advanced directive records contained conflicting information and an incomplete MOLST form.
Failure to Follow Care Plan for Mechanical Lift Transfers
Penalty
Summary
Staff failed to consistently implement and follow the care plan interventions for a resident who required the assistance of two staff members and a mechanical lift for all transfers. Despite the care plan and care card specifying the use of a Hoyer lift, two CNAs transferred the resident from bed to wheelchair without using the mechanical lift. The incident was directly observed by a nurse, and both CNAs acknowledged in their statements that they did not use the Hoyer lift, even though they were aware of the resident's transfer requirements. The resident involved had diagnoses including Alzheimer's disease, Major Depressive Disorder, and Anxiety Disorder, with moderate cognitive impairment and complete dependence on staff for care needs, positioning, transfers, and mobility. The failure to use the mechanical lift as specified in the care plan was confirmed through interviews, witness statements, and review of the resident's records, demonstrating a lack of adherence to established transfer protocols for this resident.
Failure to Revise Care Plan After Repeated Self-Harm Incidents
Penalty
Summary
A resident with a history of suicidal ideations, major depressive disorder, unspecified dementia, and delusional disorders was admitted to the facility. The resident's care plan included interventions such as providing plastic utensils, frequent staff rounding, weekly psychotherapy, and 1:1 monitoring during meal times. Despite these interventions, the resident was able to access metal utensils on multiple occasions and attempted self-harm, resulting in transfers to the hospital emergency department for evaluation. The care plan was updated after each incident, including the addition of every 15-minute head checks for 72 hours, but the resident continued to obtain items that could be used for self-injury. The facility failed to ensure that the comprehensive care plan was reviewed and revised for effectiveness when the resident continued to gain access to objects used for self-harm. Although some interventions were implemented, there were no additional care plan measures developed or put in place to specifically prevent the resident from obtaining potentially harmful items. Interviews confirmed that the resident was able to access silverware on multiple occasions despite existing care plan interventions.
Failure to Prevent Access to Hazardous Utensils for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for a resident with a history of suicidal ideation and self-harm. Despite care plan interventions specifying the use of only plastic utensils and 1:1 staff supervision during meals, the resident was able to obtain metal forks on two separate occasions. On both occasions, the resident manipulated the metal forks, breaking off prongs and attempting to stab themselves, which resulted in transfers to the hospital emergency department for evaluation. Staff were unable to determine how or when the resident obtained the metal utensils, and the required supervision and monitoring were not effectively implemented. The resident had diagnoses including suicidal ideation, major depressive disorder, unspecified dementia, and delusional disorders, and was assessed as having moderate cognitive impairment. The care plan interventions were in place due to the resident's risk for self-harm, but staff failed to prevent access to hazardous items and did not consistently provide the required supervision. Documentation and investigation following the incidents were also incomplete, as acknowledged by the DON, who did not conduct a full written investigation after the second incident.
Failure to Ensure Timely Behavioral Health Evaluation After Suicidal Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely behavioral psychiatric evaluation and intervention for a resident admitted with a history of suicidal ideation, self-injurious behavior, paranoia, and agitation. The resident experienced multiple episodes of suicidal behavior, including attempts to harm themselves with utensils, and was transferred to the hospital emergency department on several occasions. Despite these incidents, there was no documentation that behavioral psychiatric services evaluated the resident until 13 days after the most recent suicidal episode. Additionally, there was no evidence that the resident's care plan or medications were adjusted in response to these behaviors during this period. The facility's communication process between nursing staff and the behavioral health provider was insufficient, as the nurse practitioner was unaware of the specific suicidal behaviors and attempts involving utensils, despite initialing the behavioral log entries. The nurse practitioner stated that had she been informed of the previous suicidal behaviors, she would have adjusted the resident's plan of care and/or medications earlier. The Director of Nursing was also unaware that the nurse practitioner had not been fully informed of the resident's suicidal behaviors.
Failure to Include Health Care Agent in Care Planning
Penalty
Summary
The facility failed to ensure the participation of a resident's Health Care Agent (HCA) in the development and implementation of the resident's person-centered care plan. The resident, who was admitted in June 2024 and diagnosed with schizoaffective disorder, anxiety disorder, and bipolar disorder, had their Health Care Proxy invoked due to moderate dementia, as determined by their physician in October 2024. Despite this, the facility did not invite the HCA to the care plan meeting held in December 2024, as evidenced by the blank sections on the Care Plan Meeting Invitation and the Interdisciplinary Care Plan Meeting Form, which indicated no invitation was sent or declined, and no attendance was recorded. Interviews with facility staff revealed that the Social Worker was unaware of the invocation of the Health Care Proxy until the day of the survey. The facility's policy requires that care plans be developed with input from the resident and/or their representative, and be evaluated and revised quarterly. However, the lack of documentation and communication with the HCA led to their exclusion from the care planning process, contrary to the facility's policy and expectations set by the Administrator.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident had the right to make healthcare decisions by not obtaining written consent and providing education on the risks and benefits of psychotropic medications before administration. Specifically, for Resident #43, who was admitted with diagnoses including Psychotic Disorder with Hallucinations, generalized Anxiety Disorder, major Depressive Disorder, and Schizophrenia, the facility did not obtain informed written consent for the administration of Risperidone and Sertraline. The resident had moderately impaired cognition but was considered self-responsible and capable of making their own medical decisions. Despite the facility's policy requiring informed consent before administering psychotropic medications, the clinical record showed no evidence of such consent being obtained before the medications were administered from October to December 2023. Interviews with nursing staff and the Director of Nurses confirmed that the responsibility for obtaining consent lay with the nurse completing the admission paperwork. However, the consent forms were only signed by the resident on December 22, 2023, after the surveyor's inquiry, indicating a lapse in following the facility's policy and ensuring the resident's right to make informed healthcare decisions.
Failure to Include Resident in Care Planning Process
Penalty
Summary
The facility failed to include a resident in the care planning process as required. Specifically, the facility staff did not provide evidence of a care plan meeting for a resident who was admitted in October 2023. The resident, who had moderately impaired cognition with a BIMS score of 10 out of 15 and no invoked Health Care Proxy, reported not participating in or being invited to any care plan meetings since admission. The medical record review confirmed the absence of a care plan meeting following the resident's admission and the comprehensive MDS assessment on October 9, 2023. Interviews with the social worker revealed that there was no sign-in sheet or progress note indicating that a care plan meeting had been held for the resident. The social worker admitted that the resident was not invited to any care plan meetings and that no such meetings were held with the interdisciplinary team since the resident's admission. This failure to hold a care plan meeting was contrary to the requirements following the MDS assessment.
Failure to Implement Care Plan for Contracture Prevention
Penalty
Summary
The facility failed to implement a care plan for a resident with Multiple Sclerosis and muscle weakness, specifically neglecting to apply a left palm guard as ordered for contracture prevention, skin breakdown prevention, and to increase range of motion. The resident's care plan and physician's orders clearly indicated the need for the palm guard to be applied during morning care and removed during evening care. However, observations on multiple occasions revealed that the resident was not wearing the palm guard, and staff interviews confirmed a lack of awareness and adherence to the care plan requirements. The resident expressed concern about the lack of use of the palm guard, noting that their left hand was curling back up, indicating a regression in their condition. Staff members, including a CNA and a nurse, were either unaware of the palm guard requirement or could not recall the last time it was used. The nurse was unable to locate the palm guard in the resident's room and had to contact the rehabilitation department to obtain a new one, highlighting a significant lapse in the continuity of care and adherence to the prescribed treatment plan.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility staff failed to ensure that a resident was weighed weekly as ordered by the physician and recommended by the registered dietitian (RD) following hospitalization and Jejunostomy tube (J-tube) placement. This failure resulted in the delayed identification of a significant weight loss for the resident. The facility's policy required weekly weights for newly admitted residents with a new feeding tube and those with a physician's order for weekly weights. However, the resident's weights were not documented on the specified dates in October and November, as required by the physician's orders and facility policy. The resident, who was admitted in October 2023, had diagnoses including artificial openings of the gastrointestinal tract, dysphagia, and moderate protein-calorie malnutrition. The resident's history and physical indicated poor intake by mouth, failed speech-language pathology evaluations, and the need for a J-tube for enteral nutrition. The RD recommended weekly weights for four weeks, followed by monthly weights. Despite these recommendations, the resident's weights were not recorded on the specified dates, leading to a significant weight loss of 27.4 pounds from October to November. Interviews with the RD revealed that she was unaware that the resident had not been weighed as ordered until she ran the weight report for November. The RD emphasized the importance of regular weight monitoring for calculating nutritional and hydration needs for tube feeding. The lack of documented weights prevented timely identification and intervention for the resident's significant weight loss, highlighting a failure in adhering to the facility's weight monitoring policy and physician's orders.
Failure to Ensure Proper Management of Emergency Medication Kits
Penalty
Summary
The facility failed to ensure that pharmaceutical services were available to meet the needs of each resident. Specifically, the facility did not re-order and replace emergency medication kits (E-Kits) after they were opened, nor did they complete the required documentation for medications removed from the E-Kits. During an observation, several E-Kits, including an IV Kit, a Super Kit, a Coumadin Kit, an Anaphylactic Kit, and an Insulin Kit, were found opened without proper documentation indicating what medications were removed, for which resident, and by which nurse. Additionally, there was no evidence that the forms were faxed to the pharmacy to reorder the kits. Nurse #2 confirmed that the emergency kits on the First Floor [NAME] Wing were the only emergency medication kits in the facility and contained medications not available on other units. The nurse also acknowledged that the required forms were not completed and faxed to the pharmacy, and the facility staff could not provide a policy for managing the E-Kits when requested by the surveyor. This lack of documentation and reordering process led to a failure in ensuring that pharmaceutical services met the needs of the residents.
Failure to Secure Medications
Penalty
Summary
The facility failed to store medications in a safe and secure manner as required. Specifically, the staff did not secure the medication Escitalopram, a psychotropic medication used to treat depression, after it was delivered from the pharmacy. On 12/21/2023 at 9:17 A.M., the surveyor observed two blister pack medication cards containing thirty tablets of Escitalopram laying unsecured on a desk behind the nurses' station on the East Wing. During an interview, the Unit Manager stated that the medication had been delivered at 4:00 A.M. and belonged to a resident who had moved to a different nursing unit. The Unit Manager acknowledged that it was the nurse's responsibility to take the medication to the correct unit and that it was unsafe to leave the medication out in the open where any resident or visitor could access it. The Unit Manager admitted that the medication should have been locked in the medication room until it could be transferred to the appropriate unit.
Documentation Failures in Resident Care
Penalty
Summary
The facility failed to maintain accurate documentation for two residents, leading to deficiencies in care. For one resident with Multiple Sclerosis and muscle weakness, the facility staff erroneously documented the application of a left palm guard, which had been misplaced and was not being used by the resident. Despite physician orders and care plans indicating the need for the palm guard to prevent skin breakdown and contracture, observations and interviews revealed that the resident had not used the device for approximately one month. Staff members, including a CNA and a nurse, were unaware of the device's status and admitted to incorrect documentation in the Treatment Administration Record (TAR). For another resident with Mild Neurocognitive Disorder, End Stage Renal Disease, and Diabetes Mellitus Type II, the facility failed to maintain accurate records related to Advanced Directive planning. The resident's clinical record contained conflicting documentation regarding their code status, with some notes indicating Full Code and others indicating Do Not Resuscitate (DNR)/Do Not Intubate (DNI). The Medical Orders for Life Sustaining Treatment (MOLST) form was incomplete and not signed by the resident's Health Care Proxy (HCP), leading to confusion about the resident's resuscitation status. The Unit Manager confirmed the discrepancies and the lack of a completed MOLST form, which should have been reviewed and signed by the HCP. These documentation failures highlight significant lapses in the facility's adherence to its policies and procedures for both splint/orthotic device management and advanced directive planning. The inaccuracies in the residents' records could potentially impact the quality of care and the residents' health outcomes.
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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 Marlborough
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Reservoir Center For Health & Rehabilitation, The | 2.1 mi | ★★★★★ | 11 | 0 |
| Alliance Health At Coleman | 3.7 mi | ★★★★★ | 10 | 0 |
| Beaumont Rehab & Skilled Nursing Ctr - Northboro | 4.2 mi | ★★★★★ | 0 | 0 |
| Alliance Health At Marie Esther | 4.2 mi | ★★★★★ | 7 | 0 |
| Beaumont Rehab & Skilled Nursing Ctr - Westboro | 4.4 mi | ★★★★★ | 10 | 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 July 2026) and official state health department websites.