Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Reservoir Center For Health & Rehabilitation, The during CMS and state inspections, most recent first.
A resident with ESRD missed a hemodialysis session due to transport issues, and the facility failed to notify the physician, breaching policy. Despite the spouse informing staff, there was no documentation or communication to the healthcare provider, as confirmed by interviews with facility staff.
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents with complex medical needs, including ESRD, COPD, and multiple other conditions. Interviews revealed confusion among staff regarding responsibility for care plan development, leading to non-compliance with facility policy.
A resident with end-stage renal disease missed a dialysis session due to transportation issues, which was not documented or communicated to the physician by the nursing staff. This led to the resident experiencing a change in mental status and requiring emergency dialysis treatment at a hospital. Facility leadership was unaware of the missed session, contrary to expectations.
A resident experienced significant medication errors during admission and re-admission due to incorrect reconciliation of hospital discharge medications. The resident received incorrect dosages of Neurontin and Tacrolimus, contrary to prescribed orders. Facility staff, including nurses and the DON, were unaware of these discrepancies, highlighting a failure in the medication reconciliation process.
The facility failed to implement proper infection control measures during a COVID-19 outbreak, did not provide timely interventions for a resident with C. Diff, and did not ensure safe medication dispensing. Staff on the East One Unit were not required to perform outbreak testing, increasing the risk of COVID-19 transmission. A resident with C. Diff was not provided a commode, leading to shared bathroom use, and staff did not consistently perform proper hand hygiene. Additionally, a nurse instructed a nurse orientee to place a spilled medication tablet back into a medicine cup, and staff failed to adhere to PPE requirements and properly clean a glucometer machine.
A resident with dementia and malnutrition was not provided a dignified dining experience as a CNA stood over them while assisting with a meal, contrary to the facility's policy. The facility's standards require CNAs to sit at eye level when assisting residents, which was confirmed by the Unit Manager and DON.
The facility failed to notify physicians of treatment changes for two residents, as recommended by specialists. One resident's pressure ulcers were not cleansed with soap and water as advised, and another resident's catheter size change was not communicated to the physician. This lack of communication could delay necessary treatment adjustments.
A resident with a gastrostomy tube and malnutrition was not weighed as required by physician orders and facility policy. Despite a significant change in condition, including weight loss, the resident was not weighed on two occasions. Interviews revealed staff were unaware of the weight measurement schedule, leading to non-compliance with care plan requirements.
The facility failed to review and revise comprehensive care plans for two residents by the interdisciplinary team (IDT). One resident with COPD did not have their care plan reviewed after scheduled assessments due to a canceled and unscheduled IDT meeting. Another resident with Schizoaffective Disorder and Congenital Hydrocephalus did not have their care plan reviewed after re-admission, and expressed a desire to discuss discharge options, which had not been addressed by the facility staff.
A resident with moderate cognitive impairment was not involved in discharge planning discussions, despite expressing a desire to return to the community. The facility failed to conduct an Interdisciplinary Team meeting or document a working discharge plan, leading to a deficiency.
The facility failed to follow physician orders for two residents with indwelling urinary catheters, leading to deficiencies in care. One resident did not receive the correct balloon size or a leg bag as ordered, while another resident's catheter was flushed without proper physician orders or documentation. These actions increased the risk of complications for the residents.
A resident with chronic pain conditions did not receive scheduled pain medications on time, leading to unrelieved pain. The medications, including Acetaminophen, Gabapentin, and Tramadol, were administered 3 to 4 hours late. The resident reported a headache with a pain level of 6 out of 10. The Nurse Practitioner was informed of the missed medications but was not aware they were for pain management.
A resident requiring hemodialysis did not receive meals or medication as scheduled on dialysis days, increasing the risk of malnutrition. The facility failed to coordinate meal and medication times with the dialysis schedule, resulting in missed doses of Sevelamer Carbonate, a medication to control phosphorus levels. Staff interviews revealed a lack of communication between nursing and dietary staff regarding the resident's needs.
A resident with a history of suicidal ideation and PTSD did not receive timely behavioral health services after expressing suicidal thoughts and auditory hallucinations. Despite facility policies requiring immediate psychiatric evaluation, the resident experienced delays in receiving psychiatric and psychological care, with no evidence of services provided until weeks after returning from an inpatient psychiatric stay. Interviews with staff revealed a lack of documentation and adherence to care plans, placing the resident at risk for further psychosocial decline.
A resident with chronic pain did not receive scheduled pain medications on time due to a nurse signing off on the administration without actually giving the medications. The resident, who was cognitively intact and dependent on staff, reported a headache with a pain scale of 6 out of 10 during a medication pass. The facility's policy required timely administration, which was not followed in this instance.
A surveyor and a nurse discovered expired Famotidine tablets in a medication cart, which were not removed as per the facility's medication storage policy. The nurse confirmed that the expired medication should have been taken out and handed to the Unit Manager, instead of being accessible for resident use.
A facility failed to notify the state mental health authority for a resident review after a significant change in mental condition. The resident, admitted with Anxiety Disorder, Depression, and Unspecified Psychosis, was severely cognitively impaired and had not been evaluated by a Level II PASRR. Despite a psychiatric evaluation revealing depression, anxiety, and psychosis, with persistent delusions and hallucinations, the facility did not request a Level II evaluation.
Failure to Notify Physician of Missed Dialysis Session
Penalty
Summary
The facility failed to notify a resident's physician of a missed hemodialysis session, which is a critical treatment for individuals with End Stage Renal Disease (ESRD). The resident, who was dependent on hemodialysis three times a week, missed a scheduled session due to transportation issues. Despite the resident's spouse informing the nursing staff of the missed session upon their return to the facility, there was no documentation in the medical record to indicate that the physician was notified of this significant event. Interviews with facility staff, including the Evening Nurse Supervisor, Nurse Practitioner, and the Director of Nurses, revealed that none were aware of the missed dialysis session or that the physician had not been informed. The facility's policy requires that any change in a resident's condition, such as a missed medical treatment, be communicated to the resident's healthcare provider. The failure to notify the physician of the missed dialysis session represents a breach of this policy and a deficiency in the facility's duty to ensure proper medical oversight and continuity of care for the resident.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that baseline care plans were developed and implemented within 48 hours of admission for two residents. Resident #1, admitted in September 2024, had multiple complex medical conditions including End Stage Renal Disease requiring hemodialysis, a history of heart transplant, chronic anemia, diabetes mellitus, and multiple pressure injuries. Despite these significant health issues, there was no documentation of baseline or comprehensive care plans addressing these needs within the required timeframe. Similarly, Resident #2, admitted in October 2024, had conditions such as urinary tract infection, acute on chronic respiratory distress, COPD, malnutrition, and urinary retention with an indwelling catheter. Again, there was no evidence of care plans developed within 48 hours to address these immediate care needs. Interviews with facility staff revealed a lack of clarity and responsibility regarding the development of baseline care plans. The Evening Supervisor admitted to only addressing fall risk and activities of daily living in care plans upon admission, while the Assistant Director of Nurses indicated that the Unit Manager is typically responsible for developing these plans. The Director of Nurses confirmed that it is the nurses' responsibility to initiate and complete baseline care plans, with management conducting chart audits to ensure compliance. Despite these expectations, the facility did not meet its policy requirements, resulting in the deficiency.
Failure to Ensure Dialysis Care Due to Missed Session
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with end-stage renal disease who required hemodialysis three times a week. The resident missed a dialysis session due to a transportation issue, as the transportation company was unable to assist in getting the resident out of the car. The resident's family member informed the facility's nursing staff that the dialysis treatment was missed, but there was no documentation in the resident's medical record to indicate that the physician was notified of the missed session. Subsequently, the resident experienced a change in mental status and was found unresponsive, leading to an emergency transfer to the hospital. The hospital's emergency department report indicated the resident had an altered mental status, was hypoxic, and required emergent dialysis treatment due to elevated potassium levels. Interviews with the nurse practitioner, physician, and nursing leadership revealed that none were aware of the missed dialysis session, and the facility's expectation was that the nursing staff should have informed the resident's physician of the missed session.
Medication Reconciliation Errors in Resident Admission and Re-admission
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during both admission and re-admission processes. Upon admission, the resident, who had a history of end-stage renal disease, heart transplant, chronic anemia, and diabetes mellitus, was prescribed Neurontin to be taken three times a week on dialysis days. However, the facility's physician's orders incorrectly instructed the administration of Neurontin three times a day, every day, resulting in the resident receiving nine doses instead of the prescribed one dose over a period of several days. Additionally, the resident was prescribed Nitroglycerin ointment to be applied twice daily as a scheduled dose, but it was administered as needed, contrary to the hospital discharge summary. Upon re-admission, the resident's medication reconciliation process failed again, leading to a duplicate order for Tacrolimus, which was administered at twice the prescribed dosage. The facility's staff, including the nurses and the Director of Nursing, were unaware of these discrepancies, and the medication reconciliation form indicated no issues had been identified. The facility's policy required two licensed nurses to complete and sign the medication reconciliation, but this process was not effectively implemented, resulting in significant medication errors for the resident.
Infection Control and Medication Dispensing Deficiencies
Penalty
Summary
The facility failed to implement proper infection control measures on the East One Unit during a COVID-19 outbreak. Staff on this unit were not required to perform outbreak testing, contrary to the facility's policy and Massachusetts Department of Public Health guidelines, which mandate testing of exposed staff and residents every 48 hours until no new cases are identified for seven days. The Infection Preventionist admitted to not realizing that staff on the affected unit were required to perform outbreak testing, which increased the risk of COVID-19 transmission. The facility also failed to implement timely and effective interventions to prevent the transmission of Clostridium Difficile (C. Diff) for a resident actively being treated for the infection. The resident, who was frequently incontinent of bowel, was not provided with a commode upon returning from the hospital, resulting in the use of a shared bathroom with other residents. Additionally, staff did not consistently perform hand hygiene with soap and water after exiting the resident's room, as required for C. Diff precautions. The lack of paper towels in the shared bathroom further hindered proper hand hygiene practices. Furthermore, the facility did not ensure that medications were dispensed in a safe and sanitary manner. During a medication pass, a nurse instructed a nurse orientee to place a spilled medication tablet back into a medicine cup, potentially contaminating the medication. Additionally, staff failed to adhere to PPE requirements for Droplet Precautions, as observed when a CNA entered a room without wearing the necessary eye protection. The facility also did not properly clean and disinfect a glucometer machine after use, increasing the risk of infection transmission.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident diagnosed with dementia and malnutrition. The resident, who was moderately cognitively impaired, was observed lying in bed with the head elevated during a breakfast meal. A Certified Nurses Aide (CNA) was seen standing over the resident while assisting with the meal, which is contrary to the facility's policy. The facility's CNA Standard of Care Information Sheet, updated in March 2023, specifies that each resident should be treated with dignity and respect, and that CNAs should sit at eye level when assisting residents with meals. During an interview, the Unit Manager confirmed that the CNA should have been seated next to the resident. The Director of Nursing also stated that CNAs are trained to sit while assisting residents with meals, as per the facility's standards.
Failure to Notify Physicians of Treatment Changes
Penalty
Summary
The facility failed to notify the Physician or Nurse Practitioner (NP) of necessary changes in treatment for two residents, based on recommendations from specialist medical practitioners. For one resident, the facility did not inform the Physician/NP of a recommended change in treatment from a Wound Care Consultant. The resident had two Stage Four pressure ulcers, and the Wound Care Specialist recommended cleansing the ulcers with soap and water instead of normal saline to reduce bacterial load and promote healing. However, the facility continued using normal saline, and there was no evidence that the Physician/NP was notified of this recommendation. In another case, the facility failed to notify the Physician of a change in treatment for a resident following a Urology consultation. The resident had a change in the size of their indwelling urinary catheter, as recommended by the Urologist. Despite this change, there was no documentation indicating that the Physician was informed, and the resident's treatment plan was not updated accordingly. The facility's policy requires informing the resident's healthcare provider of any changes in condition, but this was not adhered to in this instance. These deficiencies highlight a lack of communication between the facility staff and the residents' healthcare providers, which could potentially delay necessary treatment adjustments. The facility's failure to notify the appropriate medical personnel of specialist recommendations for treatment changes increased the risk of complications for the residents involved.
Failure to Implement Weight Monitoring for Resident with G-tube
Penalty
Summary
The facility failed to implement the care plan for a resident who was readmitted with a gastrostomy tube and a diagnosis of malnutrition. The facility's policy required weight measurements to be obtained and documented upon admission, re-admission, monthly, or significant change in condition. Despite this, the resident was not weighed on two occasions as ordered by the physician, specifically on 9/20/24 and 9/27/24. This oversight occurred even though the resident had experienced a significant change in condition, including weight loss and a new pressure ulcer. Interviews with facility staff revealed a lack of awareness and adherence to the weight measurement schedule. A Certified Nurse Aide (CNA) responsible for the resident's care was unsure of the frequency of required weight measurements, and a nurse confirmed that the resident had not been weighed as ordered. The facility's weight record corroborated the absence of weight measurements for the specified dates, indicating a failure to follow the physician's orders and the facility's own policy.
Failure to Review and Revise Care Plans by IDT
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team (IDT) for two residents. Resident #40, who was admitted with Chronic Obstructive Pulmonary Disease (COPD), had a comprehensive review assessment completed on 5/24/24 and a quarterly review assessment on 8/17/24. However, there was no evidence that the comprehensive care plan was reviewed and revised by the IDT following these assessments. The Social Worker (SW) indicated that an IDT meeting was scheduled but not rescheduled after being canceled, and another meeting was never scheduled. Resident #9, admitted with Schizoaffective Disorder and Congenital Hydrocephalus, had a comprehensive MDS assessment completed on 7/8/24. The resident was transferred to the hospital on the same day and returned to the facility later. The care plans were initiated on 7/8/24, but there was no evidence of the plan of care being reviewed with the resident after re-admission. The resident expressed a desire to explore discharge options but had not discussed this with the facility staff. The SW confirmed that there was no evidence of the resident's participation in care plan meetings or discussions about the plan of care.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, leading to a deficiency. The facility's policy required an Interdisciplinary Team (IDT) meeting within two to three business days of admission to address discharge planning, involving the resident and relevant staff members. However, for the resident in question, there was no evidence that such a meeting occurred or that the resident was involved in discussions about discharge planning. The resident, who was moderately cognitively impaired, expressed a desire to return to the community with support services. Despite this, the facility did not engage the resident in discharge planning discussions or assess their needs for community services. The resident's plan of care was revised to remain in the facility without documented reasons, and there was no evidence of a working discharge plan or communication with the resident's previous group home. Interviews with the Social Worker and Director of Nursing revealed that the resident had previously lived in a group home and had supportive family involvement. However, the facility did not document any evaluation for discharge planning or discussions with the resident about their goals. The lack of documentation and involvement of the resident in discharge planning led to the deficiency identified by the surveyors.
Deficiencies in Urinary Catheter Care
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice for two residents with indwelling urinary catheters, increasing their risk for complications. For one resident, the staff did not follow physician orders to insert the Foley catheter with the correct balloon size and failed to switch the catheter bag from straight drainage to a leg bag when the resident got out of bed in the morning. The resident, who was cognitively intact, reported that the staff had not offered a leg bag, and a nurse confirmed that the balloon size was incorrect and that the leg bag was not provided as ordered. For another resident, the facility staff did not obtain a physician order that included indications, type, and amount of solution required to flush and irrigate the resident's indwelling urinary catheter. The resident's treatment administration record showed that the catheter was flushed on two occasions without documentation of the indications or procedure used. The staff development coordinator confirmed that a physician order was necessary for catheter flushing, including specific instructions, which were not present in this case. The facility's policy on urinary catheterization required physician orders for catheter placement and irrigation, which were not adhered to in these instances. The staff's failure to follow these orders and document the necessary information for catheter care led to deficiencies in the care provided to these residents, as observed and reported by the surveyors.
Untimely Administration of Pain Medications
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, resulting in unrelieved pain due to the untimely administration of physician-ordered pain medications. The resident, who was admitted with conditions including Paralytic Syndrome, Chronic Pain, and Diabetic Neuropathy, was cognitively intact and dependent on staff for activities of daily living. The resident's medication regimen included Acetaminophen, Gabapentin, and Tramadol, which were scheduled to be administered at specific times throughout the day. However, on the day of the incident, these medications were not administered as scheduled during the morning medication pass. Nurse #1 signed off on the administration of the medications but admitted during an interview that they had not been given at the scheduled times, resulting in a delay of 3 to 4 hours. The resident reported experiencing a headache with a pain level of 6 out of 10 on the numeric pain scale. The Nurse Practitioner was informed of the missed medications but was not initially aware that they were the resident's pain medications. The resident had previously agreed with the Nurse Practitioner to take the medications on schedule to avoid unrelieved pain, as they were particular about not receiving opioid medications.
Failure to Coordinate Dialysis Care and Nutrition
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident requiring hemodialysis, specifically in coordinating meal and medication times with the dialysis treatment schedule. The resident, who was admitted with conditions including end-stage renal disease and moderate protein-calorie malnutrition, was not offered breakfast or food to take on dialysis days. This oversight increased the resident's risk for malnutrition and weight loss, as meals were not provided before leaving for dialysis, nor was food taken to the dialysis center. Additionally, the facility did not administer a dialysis support medication, Sevelamer Carbonate, as scheduled and with food as required. The medication, intended to control serum phosphorus levels, was supposed to be given three times a day with meals. However, the resident missed doses on several occasions, and the medication was not administered at the correct times, particularly on dialysis days when the resident was not present for the scheduled administration. Interviews with staff revealed a lack of communication and coordination between nursing and dietary staff regarding the resident's meal and medication needs on dialysis days. The Food Service Director indicated that meals were prepared but not delivered to the resident due to a lack of notification from nursing staff. The Director of Nursing acknowledged that the medication should have been administered with meals and that the resident's meal schedule should have been adjusted to accommodate dialysis treatment days.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to provide timely behavioral health services to a resident with a known history of suicidal ideation and post-traumatic stress disorder. The resident, who was admitted with diagnoses including schizoaffective disorder, PTSD, major depression, and suicidal ideation, expressed suicidal thoughts and auditory hallucinations shortly after admission. Despite the facility's policy requiring immediate psychiatric evaluation or emergency room referral if psychiatric services were unavailable, the resident did not receive timely psychiatric care. The resident was placed on one-to-one supervision and was eventually sent for emergency psychiatric evaluation due to the unavailability of psychiatric services within the facility. After returning from an inpatient psychiatric stay, the resident continued to express suicidal ideation and depressive symptoms. However, there was a significant delay in providing psychiatric and psychological services, as the resident was not seen by behavioral health services until several weeks after returning to the facility. Interviews with facility staff, including the social worker, unit manager, and director of nursing, revealed a lack of documentation and evidence of timely psychiatric follow-up and one-to-one supportive therapy as outlined in the resident's care plan. The facility's failure to adhere to its policies and provide necessary behavioral health services placed the resident at risk for further psychosocial decline.
Medication Administration Error for Resident with Chronic Pain
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of pain medications. The resident, who was cognitively intact and dependent on staff for activities of daily living, had a history of chronic pain and neuropathic pain, requiring scheduled pain medications. On a particular day, Nurse #1 signed off on the administration of Acetaminophen, Tramadol, and Gabapentin as given, although these medications had not been administered to the resident at the scheduled times. This was observed during a medication pass when the resident reported a headache with a pain scale of 6 out of 10, and Nurse #1 administered Tramadol at that time. The facility's policy required medications to be administered safely and timely, within an hour before or after the scheduled time. However, Nurse #1 did not adhere to this policy, as she had not administered the 8:00 A.M. Acetaminophen, the 9:00 A.M. Tramadol, and the 8:00 A.M. Gabapentin medications by the time of the surveyor's observation. The Director of Nursing confirmed that it was not the facility's practice to sign off medications as given when they were not administered, indicating a breach in the facility's medication administration policy.
Expired Medication Found in Medication Cart
Penalty
Summary
The facility failed to adhere to its medication storage policy by not removing expired medications from a medication cart. During an observation by a surveyor and a nurse, 13 individually packaged Famotidine tablets with an expiration date of 9/23 were found in the top drawer of a medication cart on the second floor nursing unit. The nurse acknowledged that the expired medication should not have been in the cart and should have been removed and given to the Unit Manager, rather than being available for administration to residents.
Failure to Notify State Mental Health Authority After Significant Change in Condition
Penalty
Summary
The facility failed to notify the state mental health authority for a resident review after a significant change in mental condition occurred for one resident. Specifically, the facility did not request a Preadmission Screening and Resident Review Level II screen (PASRR) after the resident received a diagnosis of Psychosis and experienced limitations in major life activities due to mental illness. The resident was admitted with diagnoses of Anxiety Disorder, Depression, and Unspecified Psychosis, and was severely cognitively impaired as indicated by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Despite these conditions, the resident had not been evaluated by a Level II PASRR. The initial PASRR Level I screen, completed prior to admission, indicated no diagnosis of mental illness or treatment history for mental illness in the past two years, and no limitations in major life activities due to mental illness. However, a psychiatric evaluation conducted later revealed the resident experienced depression, anxiety, and psychosis, with staff reporting persistent delusions and hallucinations. The evaluation recommended increasing antipsychotic medication and initiating an antidepressant. The social worker, who was new to the facility, acknowledged that a Level II evaluation should have been requested following the diagnosis of Psychosis, but it had not been done.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marlborough
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marlborough Hills Rehabilitation & Health Care Cen | 2.1 mi | — | 1 | 0 |
| Alliance Health At Marie Esther | 2.6 mi | — | 1 | 0 |
| Sudbury Pines Extended Care | 5.7 mi | — | 0 | 0 |
| Alliance Health At Coleman | 5.8 mi | — | 10 | 0 |
| Whittier Westborough Transitional Care Unit | 5.8 mi | — | 0 | 0 |
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