Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MARLBOROUGH HILLS REHABILITATION & HEALTH CARE CEN
MARLBOROUGH, MA · 186 certified beds · Last Life Safety survey March 11, 2025
CMS Certification Number 225063 · first certified January 1967
Ownership
Operated by ATHENA HEALTHCARE SYSTEMS · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MA
27 citations — more than 94% of the 341 certified nursing homes in MA. Compared within MA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 11 citations; the earlier surveys in the window averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (March 2026 to May 2026), and past the point by which nine in ten MA facilities have been surveyed. This facility’s last Life Safety survey was March 2025. Facilities in MA are typically surveyed 12–15 months after the last one (median 13), measured over 556 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
5 of the 27 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 27 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in MA, and nationally. Surveyors differ markedly between states, so the MA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 27 |
| Median facility in MA | 11 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 5, 2022 | 1 |
| December 22, 2023 | 15 |
| March 11, 2025 | 11 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0252 | Provide at least two remote exits on each floor or fire section of the building. | 3 | 2025-03-11 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 2 | 2025-03-11 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 2 | 2025-03-11 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2025-03-11 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-03-11 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-03-11 |
| E-0007 | Address patient/client population and determine types of services needed. | 1 | 2023-12-22 |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | 1 | 2025-03-11 |
What the citations cover
- Egress Deficiencies 7
- Emergency Preparedness Deficiencies 5
- Smoke Deficiencies 5
- Miscellaneous Deficiencies 5
- Other 5
| Category | Citations |
|---|---|
| Egress Deficiencies | 7 |
| Emergency Preparedness Deficiencies | 5 |
| Smoke Deficiencies | 5 |
| Miscellaneous Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 11, 2025 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (April 28, 2025) |
| K-0252 | Provide at least two remote exits on each floor or fire section of the building. | Deficient, Provider has date of correction (May 28, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (April 28, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 28, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 28, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 28, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (April 28, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 28, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (April 28, 2025) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (April 28, 2025) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (April 28, 2025) |
December 22, 2023 — 15 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (January 9, 2024) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (January 12, 2024) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (January 9, 2024) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (January 5, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (January 20, 2024) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (January 15, 2024) |
| K-0252 | Provide at least two remote exits on each floor or fire section of the building. | Deficient, Provider has date of correction (February 5, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 26, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 20, 2024) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (January 16, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (January 20, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (January 20, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (January 18, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 15, 2024) |
December 5, 2022 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0252 | Provide at least two remote exits on each floor or fire section of the building. | Deficient, Provider has date of correction (December 19, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.