Marlborough Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Marlborough Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jan 7, 2025

  Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure that a cognitively impaired resident who had wandering behaviors that included wandering into other resident's rooms, and laying in other residents beds had interventions in place to ensure the resident was free from sexual abuse. The failures resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #2 had diagnoses including vascular dementia with anxiety, major depressive disorder and post-traumatic stress disorder. […]

• Actual harm, isolatedF600Apr 15, 2026

  Based on observation (video), interviews, and record/policy review, the facility failed to ensure Resident #1 remained free from abuse when Nurse Aide (NA) #1 deliberately struck the resident's head during transport to the resident's room on 03/12/2026 at ~5:51 PM, causing an actual psychosocial outcome (yelling with audible distress) to a severely cognitively impaired resident (BIMS=6). Specifically, the video shows NA #1 entering the room, striking the top of the resident's cap, then striking the left side of the resident's head with the left hand while passing the roommate's bed; a loud noise is heard immediately before the resident yells. […]

• Actual harm, isolatedF689Jun 20, 2025

  Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure that a resident was properly positioned in a wheelchair while being transported by staff. The resident fell from the wheelchair and suffered multiple serious injuries including a fractured tibia and fibula. The findings include: Resident #1's diagnoses included dementia without behavioral disturbances, difficulty in walking, abnormalities of gait (walking) and mobility (the ability to move or be moved from one place to another) and muscle weakness. A Fall Evaluation dated 8/5/23 identified that although Resident #1 was not a fall risk, he/she had the potential for a fall with/without injury. […]

• Actual harm, isolatedF689Mar 28, 2023

  Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents reviewed for accidents, (Resident #1), the facility failed to implement the plan of care for a resident who was identified as high fall risk and had a fall with an injury. The findings include: Resident #1 was admitted to the facility with diagnoses that included stroke, chronic heart failure, major depressive disorder, and myocardial infarction (heart attack). […]

• No harm, potential for more than minimal, widespreadF922Jun 24, 2025

  Based on observation, review of facility policy/procedures and interviews during the kitchen tour, the facility failed to ensure the 3-day emergency water supply was available and not expired. The findings include: Initial tour of the kitchen on 6/22/25 at 8:18 AM found no expired foods in the refrigerator, or freezer, or in the dry storage area. Reviewed the 3-day emergency food supply. No expired foods noted. 3-day menu in place. Foods are rotated monthly per the Food Service Director (FSD). Water in the dry storage area/3-day emergency food closet, observed with no expiration dates (3 cases of water 32 ounces each, with no expiration dates). According to the FSD, that water was extra, in addition to the 3-day water supply kept in the garage (off the basement) at the facility. […]