MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR
Open-data reference.
MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR is a for profit - limited liability company facility in MARLBOROUGH, MA with 186 certified beds and a 1-star overall CMS rating. The facility has 40 deficiency records on file. Total penalties: $71K.
121 NORTHBORO ROAD, MARLBOROUGH, MA 01752
Phone: 5084854040
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 225063
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 186
- Residents
- 171
- In Hospital
- No
- County
- Middlesex
- Last Inspection
- Mar 11, 2025
Staffing Data
- RN Hours
- 0.34 (nat'l avg: 0.68)
- LPN Hours
- 1.04
- CNA Hours
- 1.95
- Total Nursing Hours
- 3.33 (nat'l avg: 3.89)
- PT Hours
- 0.05
- Nursing Turnover
- 30.8%
- RN Turnover
- 45.5%
What the CMS Record Reveals About MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR
MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR operates 186 certified beds in MARLBOROUGH, MA with approximately 171 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (2★), and quality measures (2★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 40 deficiency records from recent surveys, of which 2 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $71K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.33 total nursing hours per resident day (national average 3.89), with RN coverage at 0.34 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 30.8%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (40 most recent)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 24, 2025
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.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 6, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 6, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 6, 2025
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Apr 14, 2025
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Category: Resident Rights Deficiencies
Corrected: Apr 14, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 3, 2025
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.
Category: Administration Deficiencies
Corrected: Apr 3, 2025
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Apr 3, 2025
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 3, 2025
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.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 3, 2025
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 3, 2025
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 3, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 3, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 3, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 3, 2025
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 3, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 3, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Category: Resident Rights Deficiencies
Corrected: Apr 3, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 14, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 18, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Jan 18, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jan 18, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 18, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 18, 2024
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Category: Resident Rights Deficiencies
Corrected: Jan 18, 2024
Ensure that residents are fully informed and understand their health status, care and treatments.
Category: Resident Rights Deficiencies
Corrected: Jan 18, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 12, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 12, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Dec 26, 2022
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 26, 2022
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 26, 2022
Observe each nurse aide's job performance and give regular training.
Category: Nursing and Physician Services Deficiencies
Corrected: Dec 26, 2022
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Dec 26, 2022
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 26, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 26, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 26, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 26, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 26, 2022
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 26, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 26.5% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 5.2% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 3.5% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.5% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.8% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.5% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 96.6% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 75.0% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.1% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 26.2% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 29.2% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 92.4% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 50.0% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.9% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 24.1% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 40.6% | Yes |
Penalty History 1 penalties totaling $71K
| Date | Type | Amount |
|---|---|---|
| Mar 11, 2025 | Fine | $71K |
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Understanding Nursing Home Data
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County Health Data
Health outcomes, access, and quality metrics for Middlesex on PlainHealth
Frequently Asked Questions
What is the overall CMS rating for MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR?
What are the staffing levels at MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR?
How many beds does MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR have?
Does MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR have any deficiencies on record?
Has MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR received any fines or penalties?
Who owns MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR?
When was MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR last inspected?
What quality measures are tracked for MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.