Marlborough Hills Rehabilitation & Health Care Cen

Inspectors wroteBased on interviews and records reviewed, for one of three sampled employee files (Director of Nurses #1), the Facility failed to ensure they implemented and followed their abuse policy related to pre-employment requirements and annual training when a Massachusetts Criminal Offender Record Information (CORI) check was not conducted on Director of Nurses #1, as required, prior to working at the Facility, and the facility was unable to provide documentation to support that DON #1 had received annual abuse prohibition training as required.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #3), who on 6/06/26 alleged he/she had been physically abused by a staff member, the Facility failed to ensure that a summary of the results of the findings from their investigation into the 6/06/26 allegation was submitted to the Massachusetts Department of Public Health (DPH) within five working days, as required.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) whose comprehensive plan of care interventions indicated that he/she required the assistance of two staff members with the mechanical lift for all transfers, the Facility failed to ensure that staff consistently implemented and followed interventions related to transfers, when on 09/17/25, Nurse #1 observed Certified Nurse Aide (CNA)#1 and CNA #2 transfer Resident #1 without the use of a mechanical lift, as required.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who was admitted to the Facility with a history of suicidal ideations and self-injurious behavior, the Facility failed to ensure Resident #1's Comprehensive Care Plan (CPs), which although they included some interventions related to self injurious behaviors, that they were reviewed and/or revised for effectiveness when he/she continued to gain access to objects that he/she used to threaten self harm with.

Inspectors wroteBased on records reviewed, interviews and observation, for one of three sampled residents (Resident #1), who had a history of suicidal ideation with threats of self harm with metal and plastic utensils, the facility failed to ensure they provided an adequate level of staff supervision in an effort to maintain a safe environment for Resident #1, when he/she was able to gain access to a metal fork on two separate occasions to threaten self harm, and although he/she required supervision with meals, the facility had no idea how or when he/she obtained them.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was admitted to the facility with a history of suicidal ideation, self-injurious behavior, paranoia, and agitation, the facility failed to ensure behavioral psychiatric services evaluated him/her in a timely manner, following episodes of suicidal behaviors.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), whose Health Care Proxy was invoked with his/her Health Care Agent (HCA) responsible for health care decision making, the Facility failed to ensure his/her HCA participated in the development and implementation of their person-centered care plans, which included conducting and inviting residents and/or their Representatives (HCA) to an interdisciplinary care plan meeting following the completion of their Quarterly Minimum Data Set (MDS) assessment.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), whose Health Care Proxy was invoked and his/her Health Care Agent (HCA) was very involved in his/her care, the Facility failed to ensure that at the time of his/her discharge from the facility, his/her HCA/Family Member #1 was provided with a Notice of Intent to Discharge which included the necessary information to file an appeal.

Inspectors wroteBased on record review, observations and interview, the facility failed to provide a safe smoking environment for one Resident (#14), of 5 applicable residents, out of a total sample of 34 residents. Specifically, for Resident #14, the facility failed to: -ensure that oxygen was not in use by the Resident when a cigarette placed in the Resident's mouth was lit by staff during a supervised smoking session in the designated smoking area where eight other residents were also present. -ensure that the Resident's oxygen tank and oxygen equipment was prohibited from the designated smoking area.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to prevent and treat a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and prevent further skin and pressure injury for one Resident (#43) out of a total sample of 34 residents. Specifically, for Resident #43, the facility staff failed to: -obtain a Physician's order for the appropriate application, removal, and monitoring of a Controlled Ankle Motion (CAM: orthopedic medical device used for the treatment of severe sprains, fractures in the ankle or foot) boot when the Resident was identified as being at risk for developing pressure ulcers. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to conduct and implement a comprehensive facility wide assessment that was inclusive of resources necessary to provide both emergency and day-to-day care of the population the facility currently serves. Specifically, the facility assessment failed to address the education and competencies for staff to provide a safe smoking environment for 51 residents identified as active smokers, out of a total census of 173.

Inspectors wroteBased on record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure completion of annual water sampling for Legionella placing residents at risk for exposure to Legionella bacterium (a bacteria which lives in fresh water and can cause pneumonia like or flu like illnesses).

Inspectors wroteBased on interview, and record review, the facility failed to ensure that two Residents (#379 and #42) out of a total sample of 34 residents, were free from significant medication errors. Specifically, the facility failed to: 1. For Resident #379, ensure the appropriate medication administration syringe was available to administer Physician ordered medications through the Resident's Percutaneous Gastronomy (PEG) tube (a tube that provides a direct route to the stomach for delivering nutrition, fluids and medication to a person who is unable to eat or drink through their mouth) resulting in missed doses of the ordered medications. 2. [...]

Inspectors wroteBased on record review, and interview, the facility failed to ensure that residents and/or their representatives were informed and given necessary information to make health care decisions including the risks and benefits of psychotropic (any drug that affects behavior, mood, thoughts, or perception) medications prior to their use for one Resident (#108) out of a total sample of 34 residents. Specifically, for Resident #108, the facility failed to obtain informed consent from the Resident's invoked (made active) Health Care Proxy (HCP - a legal document that allows you to appoint someone you trust to make medical decisions on your behalf if you are unable to do so) with notification of the risks and benefits for the use of Abilify ( antipsychotic medication) prior to administering the medication to the Resident.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of misappropriation to the State Agency timely, for one Resident (#14) out of a total sample of 34 Residents. Specifically, the facility failed to ensure that an incident report form was submitted to the State Agency within two hours as required, of the Director of Nursing (DON) being notified of an allegation of misappropriation of Resident #14's personal property on 2/27/25.

Inspectors wroteBased on interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) Assessments for three Residents (#132, #64, and #81) out of a total sample of 34 Residents. Specifically, the facility failed to: 1. For Resident #132, accurately code that the Resident was taking a diuretic medication during the observation period for the MDS assessment, while the Resident was in the facility. 2. For Resident #132, accurately code that the Resident was receiving oxygen therapy during the observation period for the MDS assessment, while the Resident was in the facility. 3. For Resident #64, accurately code that the Resident was taking an anticoagulant medication during the observation period for the MDS assessment, while the Resident was in the facility. 4. [...]

Inspectors wroteBased on record review, and interview, the facility failed to provide the resident and/or their representative with a summary of the baseline care plan for one Resident (#279), out of a total sample of 34 residents. Specifically, the facility failed to provide the Resident's Representative and invoked Health Care Proxy (HCP) with a written summary of the baseline care plan, medications, and dietary instructions when the Resident was determined to lack capacity for medical decision making.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Resident (#176), of two applicable residents, out of a total sample of 34 residents. Specifically, for Resident #176, the facility failed to: -measure and document the external catheter length to ensure the PICC line had not migrated (moved from the heart to another area, which could have a significant impact on treatment, or cause serious harm). -measure and document arm circumference. -document ordered Normal Saline (NS) flushes.

Inspectors wroteBased on record review, and interview, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#109), of one applicable resident, out of a total sample of 34 residents, who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop functioning properly). Specifically, the facility failed to communicate and maintain ongoing documentation with the dialysis center to ensure that the dialysis center and the facility received the most current information pertaining to Resident #109.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure that nursing staff possessed the appropriate competencies and skills to assure resident safety when providing nursing and related services for one Resident (#14), out of a total of 51 residents who smoke as identified through smoking assessments. Specifically, for Resident #14, Certified Nurses Aide (CNA) #5 failed to demonstrate competency in skills and techniques necessary to provide safe smoking care and services during assigned smoking sessions when CNA #5 lit a cigarette in the Resident's mouth while he/she was using oxygen.

Inspectors wroteBased on observation, and interview, the facility failed to post nursing staff data daily, at the beginning of each shift, relative to licensed and unlicensed nursing staff directly responsible for resident care per shift as required. Specifically, the facility failed to post nursing staff data that included the actual hours worked for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nurses Aides (CNAs).

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had a diagnosis that included paraplegia (paralysis of the legs and lower body) and required physical assistance from staff for mobility and positioning, the Facility failed to ensure they maintained a complete and accurate medical record, related to Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Flow Sheets and Positioning Sheets, when daily documentation by CNA's (for all three shifts) was not consistently completed and flow sheets were often left completely blank. Findings Include: Review of the Facility's Policy tilted Nursing Documentation, dated February 20216, indicated the licensed nursing personnel documents information related to the resident's condition and care provided in the resident's medical record. [...]

Inspectors wroteBased on policy review, record review and interview, the facility failed to ensure that one Resident (#43), out of a total sample of 33 residents, had the right to make healthcare decisions. Specifically, -For Resident #43, the facility failed to obtain written consent from, and provide education on the risks and benefits related to the use of an anti-psychotic (medication primarily used to manage psychosis) medication and an anti-depressant (medication used to treat depression) medication prior to administering psychotropic (any drug that affects behavior, mood, thoughts or perception) medication. Findings Include: Review of the facility policy titled Psychotropic Medication Informed Consent, revised February 2016, indicated the following: -Prior to administering psychotropic medication, the facility shall obtain the informed written consent of the resident. [...]

Inspectors wroteBased on record review and interview, the facility failed to include one Resident (#43) out of a total sample of 33 residents, in the care planning process. Specifically, the facility staff was unable to provide evidence of a care plan meeting for Resident #43, and that he/she had been invited to and/or participated in a care plan meeting as required. Findings Include: Resident #43 was admitted to the facility in October 2023. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had moderately impaired cognition as evidenced by Brief Interview for Mental Status (BIMS) score of 10 out of 15, and no Health Care Proxy (HCP- legal document that designates a Resident Representative to make medical decisions) was invoked (Physician documentation of resident incapacity to make medical decision). [...]

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to implement a care plan for one Resident (#87) out of a total sample of 33 residents. Specifically, the facility staff failed to ensure that Resident #87's left palm guard was applied daily as ordered for contracture prevention, prevent skin breakdown and to increase range of motion (ROM).

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide or arrange for care and services that accepted standards of quality dictate should have been provided for one Resident (#43) out of a total sample of 33 residents. Specifically, the facility staff failed to ensure that Resident #43 was weighed weekly as ordered by the Physician and recommended by the Registered Dietitian (RD) post hospitalization and Jejunostomy tube (J-tube- tube placed through the skin of the abdomen into the midsection of the small intestine to deliver food and medicine) placement, which resulted in delayed identification of a significant weight loss for the Resident.

Inspectors wroteBased on observation and interview, the facility failed to ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were available to meet the needs of each resident. Specifically, the facility failed to ensure: -that emergency medication kits (E-Kits) were re-ordered and replaced by the Pharmacy after being opened. -that appropriate documentation was completed as required for medications removed from the E-Kits.

Inspectors wroteBased on observation and interview, the facility failed to store medications in a safe, and secure manner as required. Specifically, the facility staff failed to secure the medication Escitalopram (a psychotropic medication used to treat Depression) in a secure manner after the medication was delivered from the Pharmacy.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to maintain accurate documentation for two Residents (#87 and #26) out of 33 residents sampled. Specifically: 1. For Resident #87, the facility staff erroneously documented that a left palm guard was being applied when the device had been misplaced and was not being used by the Resident. 2. For Resident #26, the facility staff failed to maintain accurate records related to Advanced Directive planning for the Resident.

Inspectors wroteBased on records reviewed and interviews for two of four sampled residents (Resident #1 and Resident #4), the Facility failed to ensure they received nursing care and services that met professional standards of practice when, 1) after Nurse#1 found Resident #1 on the floor after an unwitnessed fall from his/her wheelchair, Nurse #1 did not immediately attend to or assess him/her for the potential for injury, but instead instructed staff to transfer him/her up off the floor, before adequately assess him/her and 2) Nurse #2 attempted to administer medications to Resident #4, however Nurse #2 had not prepared and/or dispensed the medications herself, was unaware of what the medications were, and admitted that the nurse from the previous shift had dispensed them and asked her to administer them to the resident.

Inspectors wroteBased on records reviewed and interviews for one of four sampled residents (Resident #4), the Facility failed to ensure they maintained a complete and accurate medical record related to nursing documentation in his/her Medication Administration Record (MAR).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure sufficient nursing staff levels to provide nursing and related services to assure resident safety and maintain the highest practicable well-being for each resident as determined by resident assessments, individual plans of care, and considering the number and acuity of the facility's resident population, in accordance with the Facility Assessment. Specifically, the facility failed to ensure sufficient nursing staff levels to: 1) provide adequate supervision, assistance, and opportunities for meaningful activity engagement for one Resident (#108) of 32 total sampled residents, which resulted in the Resident wandering alone in his/her room and sustaining a fall, 2) ensure sufficient nursing staff levels to provide a) timely A.M. [...]

Inspectors wroteBased on record review, and interview, the facility failed to ensure annual evaluations for Certified Nurse Aides (CNA) were completed for four out of five sampled CNAs.

Inspectors wroteBased on record review, and interview, the facility failed to ensure its staff completed a baseline care plan for one Resident (#157), out of 32 sampled residents within 48 hours of admission to the facility. Specifically, the facility failed to ensure its staff completed the baseline care plan to include the Resident's risk for wandering and elopement when the Resident was identified as being at risk for wandering and elopement and had a history of wandering.

Inspectors wroteBased on record review and interview, the facility failed to ensure that its staff developed and implemented a plan of care for one Resident (#88), out of a total sample of 32 residents. Specifically, the facility failed to develop a plan of care for smoking for Resident #88.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff provided quality of care, according to plans of care and professional standards of practice, for two Residents (#123 and #85) out of 32 sampled residents relative to non-pressure related skin conditions. Specifically, the facility failed to ensure its staff: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that its staff provided an environment that was as free of accident hazards as possible, adequate supervision and assistance for one Resident (#108), out of 32 sampled residents. Specifically, the facility failed to ensure that its staff provided a safe environment, continual supervision, and physical assistance, according to the Resident's plan of care to prevent an avoidable accident, resulting in a sustained fall by the Resident.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that its staff provided respiratory care in accordance with professional standards of practice and the plan of care for one Resident (#85), out of 32 sampled residents, relative to Oxygen administration. Specifically, the facility failed to ensure that its staff: a) obtained a Physician order for Oxygen liter flow when the Resident no longer required continuous use of Oxygen and began using supplemental Oxygen as needed (PRN), and b) documented evidence that instructions were provided to the Resident on how to participate in his/her own respiratory care or that the Resident was monitored for his/her ability to independently manage the use of Oxygen.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff provided care and services consistent with professional standards for one Resident (#51), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), out of 32 total sampled residents. Specifically, the facility failed to ensure complete and accurate communication documentation with the dialysis facility as required.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that its staff provided appropriate treatment interventions for one Resident (#108), out of a sample of 32 residents, who was diagnosed with Dementia, according to the Resident's plan of care. Specifically, the facility failed to ensure that its staff offered the Resident opportunities for social engagement or preferred diversional activities when the Resident was observed to wander alone in his/her room.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure accurate documentation in the clinical record for two Residents (#60 and #88) out of 32 total sampled residents. Specifically, the facility failed to ensure its staff completed accurate documentation related to 1) a continuous therapeutic feeding via a gastrostomy tube (g-tube: inserted through the abdomen to deliver nutrients directly into the stomach) for one Resident (#60) and 2) a smoking assessment for one Resident (#88) regarding the use of a smoking apron when smoking, awareness of when smoking was allowed to occur, and his/her ability to hold a cigarette.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure its staff offered the appropriate pneumococcal vaccine to three Residents (#86, #159 and #470) at risk for developing facility acquired pneumonia, out of five applicable sampled residents.