MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR
Inspection History Overview
Health Violations by Year
2025 17 violations
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Ensure that residents are fully informed and understand their health status, care and treatments.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure each resident receives an accurate assessment.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Post nurse staffing information every day.
Ensure that residents are free from significant medication errors.
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Provide and implement an infection prevention and control program.
2024 1 violations
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
2023 9 violations
Ensure that residents are fully informed and understand their health status, care and treatments.
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Ensure services provided by the nursing facility meet professional standards of quality.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
2022 47 violations
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Observe each nurse aide's job performance and give regular training.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Assess the resident when there is a significant change in condition
PASARR screening for Mental disorders or Intellectual Disabilities
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide activities to meet all resident's needs.
Provide appropriate foot care.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
2021 20 violations
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure that residents are free from significant medication errors.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Provide routine and 24-hour emergency dental care for each resident.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide and implement an infection prevention and control program.
Provide and implement an infection prevention and control program.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
2019 36 violations
Ensure that residents are fully informed and understand their health status, care and treatments.
Allow residents to self-administer drugs if determined clinically appropriate.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate foot care.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Provide safe and appropriate respiratory care for a resident when needed.
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
2018 32 violations
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Allow residents to self-administer drugs if determined clinically appropriate.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Keep residents' personal and medical records private and confidential.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Ensure each resident receives an accurate assessment.
PASARR screening for Mental disorders or Intellectual Disabilities
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide activities to meet all resident's needs.
Assist a resident in gaining access to vision and hearing services.
2017 1 violations
Make sure that a working call system is available in each resident's bathroom and bathing area.
2016 11 violations
Ensure each resident receives an accurate assessment by a qualified health professional.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide care by qualified persons according to each resident's written plan of care.
Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing.
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Ensure that residents are safe from serious medication errors.
Develop policies and procedures for influenza and pneumococcal immunizations.
Provide routine and 24-hour emergency dental care for each resident.
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
2015 3 violations
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide care by qualified persons according to each resident's written plan of care.
Detailed Inspection Reports
Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online. Each report contains the complete investigation details, resident care findings, and corrective action requirements.
Fines and Penalties by Year
2025 1 penalties totaling $68,309
2022 1 penalties totaling $125,366
2021 2 penalties totaling $15,463
2019 1 penalties totaling $116,055
2018 2 penalties totaling $156,277
Fire Safety Deficiencies
No description available