Inspection visit
Inspection
Citations
21 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F711 - Physician Visits
Provide a written emergency evacuation plan.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0007GeneralS&S Fpotential for harm
Address patient/client population and determine types of services needed.
- 0029GeneralS&S Fpotential for harm
Develop a communication plan.
- 0030GeneralS&S Fpotential for harm
List the names and contact information of those in the facility.
- 0211GeneralS&S Fpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0225GeneralS&S Fpotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0252GeneralS&S Fpotential for harm
Provide at least two remote exits on each floor or fire section of the building.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F761 - Labeling of Drugs and Biologicals
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.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
F553 - The right to participate in the development and implementation of his or her
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the December 22, 2023 survey of MARLBOROUGH HILLS REHABILITATION & HEALTH CARE CEN?
This was a inspection survey of MARLBOROUGH HILLS REHABILITATION & HEALTH CARE CEN on December 22, 2023. The surveyor cited 21 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MARLBOROUGH HILLS REHABILITATION & HEALTH CARE CEN on December 22, 2023?
Yes, 21 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide a written emergency evacuation plan."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.