Cycle 1
Health 2024-10-02 · Fire 2024-10-02
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Marlborough, MA
Reservoir Center For Health & Rehabilitation, The
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
400 Bolton Street, Marlborough, MA
(508) 481-6123
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
144
Certified beds
Average residents
135
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
National Health Care Associates
Operator or chain grouping
Approved since
1990-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.61
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
2.23
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.55
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.66
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,147
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.17% · Performance 22.28% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.41% · Performance 9.27% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.79
Baseline 34.38% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 0
Adjusted total nurse staffing
1.36
Baseline 3.54 hours · Performance 3.46 hours · Measure score 1.36 · Achievement 1.36 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.03% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 194 · Observed rate 12.89% · Lower 95% interval 8.51% |
| Discharge to community | 49.54% |
50.57%
1 pts worse
|
No Different than the National Rate · Eligible stays 190 · Observed rate 39.47% · Lower 95% interval 39.33% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.35% |
95.27%
4.1 pts better
|
Numerator 152 · Denominator 153 |
| Falls with major injury | 0.65% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 153 |
| Discharge self-care score | 49.35% |
53.69%
4.3 pts worse
|
Numerator 38 · Denominator 77 |
| Discharge mobility score | 63.64% |
50.94%
12.7 pts better
|
Numerator 49 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 3.27% |
2.29%
1 pts worse
|
Numerator 5 · Denominator 153 · Adjusted rate 2.47% |
| Healthcare-associated infections requiring hospitalization | 9.27% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 150 · Observed rate 12.67% · Lower 95% interval 6.48% |
| Staff COVID-19 vaccination coverage | 6.54% |
8.2%
1.7 pts worse
|
Numerator 10 · Denominator 153 |
| Staff flu vaccination coverage | 67.42% |
42%
25.4 pts better
|
Numerator 120 · Denominator 178 |
| Discharge function score | 67.53% |
56.45%
11.1 pts better
|
Numerator 52 · Denominator 77 |
| Transfer of health information to provider | 98.15% |
95.95%
2.2 pts better
|
Numerator 106 · Denominator 108 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 43.53% |
25.2%
18.3 pts better
|
Numerator 37 · Denominator 85 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.9
1.2 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.9 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
92.2%
2.3 pts better
|
93.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 87.8% · Q2 94.0% · Q3 98.3% · Q4 97.5% · 4Q avg 94.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.2% |
94.8%
4.4 pts better
|
95.5%
3.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.5%
0.3 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.4% · Q3 3.3% · Q4 1.7% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.0% |
12.0%
About the same
|
11.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 9.6% · Q3 7.8% · Q4 15.6% · 4Q avg 12.0% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
5.2%
1.7 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.7% · Q3 3.7% · Q4 2.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.8% |
19.2%
3.6 pts worse
|
19.6%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 21.1% · Q3 24.1% · Q4 26.6% · 4Q avg 22.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.2% |
22.5%
1.7 pts worse
|
16.7%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 23.8% · Q3 23.5% · Q4 21.5% · 4Q avg 24.2% · 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 | 4.1% |
17.7%
13.6 pts better
|
16.3%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 5.3% · Q3 4.2% · Q4 3.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
17.6%
10.5 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 9.1% · Q3 7.8% · Q4 7.1% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.0%
0.1 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
2.0%
1.6 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.7% |
21.7%
11 pts worse
|
19.8%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 35.8% · Q3 31.1% · Q4 30.2% · 4Q avg 32.7% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.6%
1.4 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.2% · Q3 3.6% · Q4 2.5% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.9% |
77.1%
0.8 pts better
|
81.7%
3.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.0% · Q2 80.9% · Q3 71.9% · Q4 82.7% · 4Q avg 77.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
11.8%
1.2 pts worse
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 13.8% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.3% |
77.7%
12.6 pts better
|
79.7%
10.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
25.8%
4.4 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 31.7% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-11 · Fire 2023-07-11
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-10-26 · Fire 2021-10-26
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-10-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-02
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-11-14
F · Potential for more than minimal harm
2021-10-26
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-12-20
F · Potential for more than minimal harm
2021-10-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-20
D · Potential for more than minimal harm
2021-10-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-12-20
D · Potential for more than minimal harm
2021-10-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-20
D · Potential for more than minimal harm
2021-10-26
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2021-12-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-15
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 2024-11-08
D · Potential for more than minimal harm
2024-10-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-02
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-02
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 2024-11-04
D · Potential for more than minimal harm
2024-10-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-02
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-02
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 2024-11-04
D · Potential for more than minimal harm
2024-10-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-02
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 2024-11-04
B · Minimal harm
2024-10-02
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2024-11-04
F · Potential for more than minimal harm
2023-07-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-02
E · Potential for more than minimal harm
2023-07-11
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 2023-08-02
D · Potential for more than minimal harm
2023-07-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-08-02
G · Actual harm
2021-10-26
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 2021-12-15
E · Potential for more than minimal harm
2021-10-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-12-15
E · Potential for more than minimal harm
2021-10-26
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 2021-12-15
E · Potential for more than minimal harm
2021-10-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-15
E · Potential for more than minimal harm
2021-10-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2021-12-15
E · Potential for more than minimal harm
2021-10-26
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2021-12-15
E · Potential for more than minimal harm
2021-10-26
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-26
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-26
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-26
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-26
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-26
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-26
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2021-12-15
Penalties and ownership
What sits behind the stars
$3,145
2023-07-24
Fine
Fine · fine $3,145
Fine
Ownership
Vk Health Facilities LLC
5% Or Greater Direct Ownership Interest · Organization
Bokow, Barry
Corporate Director · Individual
Gilmartin, Thomas
Corporate Director · Individual
Idumwonyi, Eghosa
Operational/Managerial Control · Individual
Ostreicher, Marvin
Corporate Director · Individual
Shaller, Caitlin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Marlborough Hills Rehabilitation & Hlth Care Ctr
Marlborough, MA
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
#2
Alliance Health At Marie Esther
Marlborough, MA
4-star overall rating with 4-star inspections with $7,901 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Sudbury Pines Extended Care
Sudbury, MA
2-star overall rating with 2-star inspections with 24 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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