Marlborough Hills Rehabilitation & Health Care Cen
MARLBOROUGH HILLS REHABILITATION & HEALTH CARE CEN in MARLBOROUGH, MA — inspection on May 21, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
225063
Form Approved OMB
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
Review of Resident #1's medical record indicated he/she was readmitted to the facility on [DATE].
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.
225063
Form Approved OMB
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
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
potential for actual harm admission to the facility.
225063
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MARLBOROUGH, MA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MARLBOROUGH HILLS REHABILITATION & HEALTH CARE CEN or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.