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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.