Marlborough Hills Rehabilitation & Hlth Care Ctr
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
the Hoyer lift. Nurse #1 said she immediately reported the incident to the Director of Nursing. During an
interview of 09/17/25 at 3:15 P.M., the Director of Nursing (DON) said Facility staff had not transferred Resident #1 utilizing a Hoyer lift in accordance with his/her plan of care, as required. On 10/14/25, the Facility was found to be in Past Non-Compliance effective 09/24/25, and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) The Facility discussed the area of concern at Quality Assurance Performance Improvement Committee meeting in September 2025 and initiated a Quality Improvement Plan. B) 09/17/25, the Facility implemented disciplinary actions for CNA#1 and CNA #2. C) 09/17/25, the Assistant Director of Nursing (ADON) conducted audits of all residents utilizing mechanical lift for compliance with transfer status, and skin condition to identify inconsistencies against observed head to toe assessments. D) 09/17/25, the Staff Development Coordinator (SDC) initiated education to facility CNAs on providing safe transfers. E) 09/18/25, the SDC initiated education to facility CNAs on the importance of adherence to information on the individual resident Care Cards and upholding safe transfers. F) 09/23/25, the SDC conducted clinical competency assessments on transferring Residents using a mechanical lift for CNA #1 and CNA #2. G) The SDC will conduct follow up audits consisting of random visual observations of mechanical lift transfers three times a week for three months. H) The Facility will continue to monitor compliance at monthly and quarterly Quality Assurance Meetings. I) The Director of Nurses and/or designee are responsible for overall compliance.
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MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR in MARLBOROUGH, MA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 & HLTH CARE CTR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.