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Marlborough Hills: Suicide Risk Communication Failures MA
Suicidal behaviors in elderly residents require immediate assessment and ongoing monitoring....
Latest reports, citations, and penalties from CMS data
Suicidal behaviors in elderly residents require immediate assessment and ongoing monitoring....
Two residents received incorrect medications that posed serious health risks....
This incident represents a fundamental failure in the facility's duty to protect vulnerable residents from harm....
These committees must meet regularly to review data, investigate incidents, and implement corrective measures to ensure resident safety and well-being....
The violations centered on fundamental nursing care tasks that are considered standard practice in long-term care facilities....
On February 26, 2025, Resident 103 called police from the facility, reporting that she felt unsafe due to a CNA's behavior....
on the inspection date, the Director of Nursing (DON) stated she was completely unaware that R15 had experienced any bruising....
Inspectors found various prescription and over-the-counter medications improperly stored where residents could access them without supervision....
The facility had only submitted the basic Facility Reported Incident (FRI) form to the state agency, which contained minimal information about the incident....
## Regulatory Violations Found The inspection revealed that the facility failed to properly manage the use of bed side rails according to federal standards....
The violations centered around unlabeled, unrefrigerated perishable foods that posed risks of foodborne illness and pest attraction....
The Nursing Home Administrator confirmed during a June 27, 2024 interview that all five quarterly MDS assessments were indeed completed late....
Inspection records revealed that staff failed to administer prescribed breathing treatments on multiple occasions in March 2025....
One resident with atrial fibrillation, cardiomyopathy, and heart failure experienced repeated delays in receiving critical medications throughout June 2024....
Two residents experienced dangerous delays in receiving ordered laboratory work that could have detected serious health problems....
Multiple staff members interviewed during the overnight inspection confirmed the staffing crisis....
The most concerning violations involved the mishandling of urinary catheter equipment and oxygen tubing, both of which require strict sanitation procedures....
## Leadership Failures Compound Initial Violation The abuse incident was significantly worsened by systematic failures in the facility's response....
However, federal surveyors identified a fundamental flaw in the facility's approach....
The resident's medical condition required strict avoidance of fatty and greasy foods....