Cycle 1
Health 2025-03-11 · Fire 2025-03-11
19 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Marlborough, MA
Marlborough Hills Rehabilitation & Hlth Care Ctr
1-star overall rating with 1-star inspections with $71,202 in total fines with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
121 Northboro Road, Marlborough, MA
(508) 485-4040
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
186
Certified beds
Average residents
171
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Athena Healthcare Systems
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
24 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.34
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.33
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.93
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.47
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,100
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.70% · Performance 22.51% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.11% · Performance 9.79% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.42
Baseline 21.57% · Performance 29.24% · Measure score 8.42 · Achievement 8.42 · Improvement 0
Adjusted total nurse staffing
2.70
Baseline 4.23 hours · Performance 3.85 hours · Measure score 2.70 · Achievement 2.70 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.34% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 15.29% · Lower 95% interval 7.79% |
| Discharge to community | 49.54% |
50.57%
1 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 38.64% · Lower 95% interval 37.29% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 68 · Denominator 68 |
| Falls with major injury | 1.47% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 68 |
| Discharge self-care score | 43.18% |
53.69%
10.5 pts worse
|
Numerator 19 · Denominator 44 |
| Discharge mobility score | 40.91% |
50.94%
10 pts worse
|
Numerator 18 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 7.35% |
2.29%
5.1 pts worse
|
Numerator 5 · Denominator 68 · Adjusted rate 5.91% |
| Healthcare-associated infections requiring hospitalization | 9.79% |
7.12%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 19.61% · Lower 95% interval 6.43% |
| Staff COVID-19 vaccination coverage | 7.65% |
8.2%
0.5 pts worse
|
Numerator 13 · Denominator 170 |
| Staff flu vaccination coverage | 20.22% |
42%
21.8 pts worse
|
Numerator 37 · Denominator 183 |
| Discharge function score | 54.55% |
56.45%
1.9 pts worse
|
Numerator 24 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 29.41% |
25.2%
4.2 pts better
|
Numerator 10 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.9
0.3 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.0 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.6 · Expected 2.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
92.2%
4.4 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 96.8% · Q3 96.6% · Q4 96.8% · 4Q avg 96.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.4% |
94.8%
2.4 pts worse
|
95.5%
3.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.5%
1 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 2.6% · Q3 3.4% · Q4 3.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
12.0%
11.2 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
5.2%
About the same
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 5.7% · Q3 5.0% · Q4 3.4% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.2% |
19.2%
10 pts worse
|
19.6%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 29.7% · Q3 28.0% · Q4 29.5% · 4Q avg 29.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 40.6% |
22.5%
18.1 pts worse
|
16.7%
23.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.8% · Q2 39.6% · Q3 38.9% · Q4 40.2% · 4Q avg 40.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.2% |
17.7%
8.5 pts worse
|
16.3%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.4% · Q2 17.3% · Q3 25.7% · Q4 21.6% · 4Q avg 26.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.5% |
17.6%
8.9 pts worse
|
14.9%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.6% · Q2 16.8% · Q3 40.9% · Q4 14.0% · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.5% |
1.0%
2.5 pts worse
|
1.0%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 3.6% · Q3 2.5% · Q4 2.7% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
2.0%
0.5 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.7% · Q3 3.4% · Q4 0.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
21.7%
2.4 pts worse
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 24.8% · Q3 19.7% · Q4 27.2% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.6%
0.7 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 6.7% · Q3 2.1% · Q4 2.1% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.0% |
77.1%
2.1 pts worse
|
81.7%
6.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 62.9% · Q2 77.8% · Q3 81.2% · Q4 76.2% · 4Q avg 75.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
11.8%
0.9 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 14.0% · Expected 14.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.0% |
77.7%
27.7 pts worse
|
79.7%
29.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.4% |
25.8%
4.6 pts worse
|
23.9%
6.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.4% · Observed 32.0% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-22 · Fire 2023-12-22
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
15 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2022-12-05 · Fire 2022-12-05
14 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-03-11
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2025-05-28
F · Potential for more than minimal harm
2025-03-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-03-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-03-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-03-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-03-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-03-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-03-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-03-11
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-03-11
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-04-28
F · Potential for more than minimal harm
2023-12-22
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-01-09
F · Potential for more than minimal harm
2023-12-22
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-01-05
F · Potential for more than minimal harm
2023-12-22
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-01-09
F · Potential for more than minimal harm
2023-12-22
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-12-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-20
F · Potential for more than minimal harm
2023-12-22
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-01-15
F · Potential for more than minimal harm
2023-12-22
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2024-02-05
F · Potential for more than minimal harm
2023-12-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-01-11
F · Potential for more than minimal harm
2023-12-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-20
F · Potential for more than minimal harm
2023-12-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-01-16
F · Potential for more than minimal harm
2023-12-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-20
F · Potential for more than minimal harm
2023-12-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-01-20
F · Potential for more than minimal harm
2023-12-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-12-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-26
E · Potential for more than minimal harm
2023-12-22
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-01-18
D · Potential for more than minimal harm
2022-12-05
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2022-12-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-24
D · Potential for more than minimal harm
2025-05-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-21
F742 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-03-19
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-19
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-14
J · Immediate jeopardy
2025-03-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-03
G · Actual harm
2025-03-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-03-11
F838 · Administration Deficiencies
Health
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.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-03-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-03
E · Potential for more than minimal harm
2025-03-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-11
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-11
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-11
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-04-03
B · Minimal harm
2025-03-11
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-03
D · Potential for more than minimal harm
2024-02-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-14
D · Potential for more than minimal harm
2023-12-22
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-12-22
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-12-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-12-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-12-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-12-22
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-12-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-11-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-11-30
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-01-12
E · Potential for more than minimal harm
2022-12-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-12-26
E · Potential for more than minimal harm
2022-12-05
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-12-05
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-12-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-12-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-12-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-12-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-12-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-12-05
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-12-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-12-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-12-26
Penalties and ownership
What sits behind the stars
$71,202
2025-03-11
Fine
Fine · fine $71,202
Fine
Ownership
Athena Health Care Systems Ma Iii LLC
5% Or Greater Direct Ownership Interest · Organization
Santilli, Lawrence
5% Or Greater Indirect Ownership Interest · Individual
Mosier, Michael
5% Or Greater Indirect Ownership Interest · Individual
Chakalos-Santilli, Valerie
5% Or Greater Indirect Ownership Interest · Individual
Athena Health Care Associates, Inc.
Operational/Managerial Control · Organization
Curtis, Diane
5% Or Greater Indirect Ownership Interest · Individual
Mosier, Michael
W-2 Managing Employee · Individual
Rezendes, Lorrie
5% Or Greater Indirect Ownership Interest · Individual
Santilli, Lawrence
Corporate Officer · Individual
Senra, Priscilla
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Reservoir Center For Health & Rehabilitation, The
Marlborough, MA
3-star overall rating with 3-star inspections with $3,145 in total fines with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Alliance Health at Coleman
Northborough, MA
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Beaumont Rehab & Skilled Nursing Ctr - Northboro
Northborough, MA
5-star overall rating with 4-star inspections with 3 recent health deficiencies
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