MARLBOROUGH, MA - A March 2025 federal inspection of Marlborough Hills Rehabilitation & Health Care Center identified multiple safety violations, including a staff member lighting a cigarette for a resident who was actively using supplemental oxygen, missed medication doses over several days due to unavailable equipment, and a failure to test the facility's water system for Legionella bacteria for more than a year.
Staff Member Lit Cigarette While Resident Used Oxygen
During a designated smoking session on March 6, 2025, two state surveyors directly observed an incident that represented a significant fire and burn hazard. A Certified Nurses Aide (CNA) lit a cigarette in the mouth of a resident while the resident was still wearing a nasal cannula connected to a portable oxygen tank.
The resident, identified in the report as Resident #14, had been admitted to the facility in January 2025 with diagnoses including respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and nicotine dependence. According to the inspection report, when the resident noticed the surveyors, they "removed the lit cigarette from his/her mouth, dropped the lit cigarette to the ground, went back into the facility and returned to resume smoking without the oxygen equipment."
The resident confirmed to inspectors what had occurred: "CNA #5 lighted the cigarette in his/her mouth while his/her oxygen was being used via nasal cannula." The resident also reported that "not all staff members reminded him/her to remove the oxygen equipment before going outside to the smoking area."
Why Oxygen and Smoking Creates a Dangerous Combination
Oxygen itself is not flammable, but it is an oxidizer that dramatically accelerates combustion. When concentrated oxygen comes into contact with an ignition source such as a lit cigarette, flames can spread rapidly and burn at significantly higher temperatures than normal. Burns occurring in oxygen-enriched environments tend to be more severe and can happen almost instantaneously.
The nasal cannula and tubing used to deliver oxygen are often made of plastic materials that can ignite and melt when exposed to flame. When this occurs near a patient's face, the resulting burns can affect the nose, lips, airways, and surrounding facial tissue. Such injuries may require extensive medical treatment and can be life-threatening.
The CNA involved told inspectors that "he did not see Resident #14 wearing oxygen when he lit the cigarette in the Resident's mouth," but acknowledged that "he knew that residents were not allowed to smoke while wearing oxygen."
Training Gaps Identified
Inspectors found that the facility's orientation materials for new staff contained no content regarding safe smoking practices for residents. A review of the CNA's educational file "failed to indicate that the CNA demonstrated competency with smoking and oxygen safety." The Regional Nurse confirmed there was "no evidence that safe smoking and oxygen competency was demonstrated by CNA #5 prior to the incident."
The facility's assessment, dated August 14, 2024, did not address the needs of smoking residents or identify the training and competencies needed to safely supervise them. An audit conducted after the incident identified 51 residents out of the facility's 173-resident census as active smokers, making this a significant population requiring specialized safety protocols.
Resident Missed Critical Medications for Days Due to Missing Syringe
A second major violation involved a resident who did not receive prescribed medications for multiple days because the facility lacked the proper syringe needed to administer them through a feeding tube.
Resident #379 had been admitted in February 2025 and received nutrition and medications through a Percutaneous Gastrostomy (PEG) tube due to swallowing difficulties. The resident's prescribed medications included an anticoagulant (blood thinner), an antiseizure medication, an antihypertensive, and psychiatric medications.
According to the inspection report, nursing staff documented on March 5, 2025, that the "syringe for administration not available" and that the Nurse Practitioner and Supervisor had been notified. However, the problem was not resolved for days. Notes from subsequent shifts indicated staff were "awaiting syringe delivery" or following up "with DON for proper syringes."
A review of the Medication Administration Record revealed the following missed doses:
- Apixaban (anticoagulant): Missed on the mornings of March 6, 7, and 8, and evenings of March 5 and 6 - Levetiracetam (antiseizure medication): Missed on the mornings of March 6, 7, and 8, and evenings of March 5 and 6 - Quetiapine Fumarate (antipsychotic): Missed on the mornings of March 6, 7, and 8, and evenings of March 5 and 6 - Amlodipine Besylate (blood pressure medication): Missed on March 6, 7, and 8 - Additional medications including Folic Acid, Thiamine, Melatonin, and Trazodone were also missed
Medical Implications of Missed Doses
Anticoagulant medications such as Apixaban require consistent dosing to maintain therapeutic blood levels. When doses are missed, patients face an increased risk of blood clot formation, which can lead to serious complications including stroke, pulmonary embolism, or deep vein thrombosis. For patients with a history of blood clots or cardiac conditions, this risk is particularly concerning.
Antiseizure medications like Levetiracetam also require steady blood levels to be effective. Missed doses can lower the medication's concentration in the bloodstream below therapeutic thresholds, potentially triggering breakthrough seizures. Seizures carry their own risks including falls, injuries, aspiration, and in severe cases, status epilepticus—a prolonged seizure that constitutes a medical emergency.
The Director of Nursing told inspectors that she "did not find out until 3/10/25 that the medication administration syringe was not available" and that the resident had not received medications as prescribed for multiple days. She stated that "the facility should have had the syringes available prior to the Resident's admission to ensure that he/she received the medications as ordered."
One nurse supervisor acknowledged that while the Nurse Practitioner had been contacted and advised staff to "call the DON so a syringe could be obtained," she "did not call the DON." Instead, she ordered a syringe from Amazon on the evening of March 7, and the Nurse Practitioner came in on Saturday, March 8, to demonstrate an alternative administration method.
Legionella Water Testing Not Completed for Over 18 Months
Inspectors also identified that the facility had not conducted required annual testing of its water system for Legionella bacteria. The last testing had occurred on August 29, 2023, meaning the facility was approximately 18 months overdue at the time of the March 2025 inspection.
Legionella bacteria can grow in building water systems, particularly in areas where water may stagnate or where temperatures favor bacterial growth. When contaminated water is aerosolized—such as through showers, faucets, or cooling systems—individuals can inhale the bacteria and develop Legionnaires' disease, a severe form of pneumonia.
Nursing home residents represent a particularly vulnerable population for Legionella infection. Individuals over age 50, those with chronic diseases, and those with weakened immune systems face elevated risk of severe illness or death from Legionnaires' disease. The facility's own policy, revised in October 2022, acknowledged that "people [50] years or older...and people with a weakened immune system or chronic disease are at increased risk."
The facility's Legionella policy stated that the facility would "conduct an annual water program assessment with a qualified contractor." The contractor's protocol specified that "environmental sampling of Legionella will be performed annually."
The Director of Physical Plant confirmed to inspectors that testing "should be done every year." The Director of Clinical Operations acknowledged that "Legionella testing was important so that the facility could identify if Legionella exposure to residents was occurring or not" and confirmed that testing "should have been done in 2024 but had not been done."
Additional Issues Identified
The inspection also documented several other violations:
IV Therapy Documentation Failures: For a resident receiving intravenous antibiotics through a PICC line to treat a heart valve infection, staff failed to measure and document the external catheter length and arm circumference as ordered. These measurements are critical for detecting whether the catheter has migrated from its proper position, which could affect treatment effectiveness or cause harm. Required saline flushes were also not documented on numerous occasions.
Dialysis Communication Breakdown: For a resident receiving dialysis three times weekly, inspectors found no evidence of communication between the facility and the dialysis center for any treatment days in January, February, or March 2025. The facility's policy required a communication book to accompany residents to dialysis, documenting vital signs, medications, and any changes in condition.
Medication Transcription Error: A resident received a scabies treatment cream (Permethrin) daily for five consecutive days when only a single application had been ordered. This occurred because the physician's order was incorrectly transcribed into the electronic medical record, exposing the resident to potential adverse reactions from medication overexposure.
Staffing Information Not Properly Posted: The facility failed to post complete daily nursing staff data as required. While the number of nurses and aides per shift was displayed, the actual hours worked by staff members was not included.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marlborough Hills Rehabilitation & Hlth Care Ctr from 2025-03-11 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.