MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR
CCN: 225063 · MARLBOROUGH, MA 01752 · Middlesex County
Overview
- Address
- 121 NORTHBORO ROAD, MARLBOROUGH, MA 01752
- Phone
- 5084854040
- Certified beds
- 186
- Avg daily residents
- 171 (92% of beds filled)
- Ownership
- For-profit LLC
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 1967-01-01
- Setting
- Urban
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 3.33 | 3.70 | 3.47 | ≥ 3.48 | Below floor |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 0.34 | 0.65 | 0.35 | ≥ 0.55 | Below floor |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 1.04 | 0.82 | 1.09 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 1.95 | 2.23 | 2.03 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 1.38 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.05 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Resident acuity
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2025-03-11 | 19 | 13 | 6 | 187 | 1 | 187 |
| Cycle 2/3 (prior) | 2023-12-22 | 10 | 7 | 3 | 40 | 1 | 40 |
Deficiencies (40)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2025-10-14 | 2025-09-24 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2025-05-21 | 2025-06-06 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | 2025-05-21 | 2025-06-06 |
| 0742 | 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. | D | 2025-05-21 | 2025-06-06 |
| 0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. | D | 2025-03-19 | 2025-04-14 |
| 0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | 2025-03-19 | 2025-04-14 |
| 0552 | Ensure that residents are fully informed and understand their health status, care and treatments. | D | 2025-03-11 | 2025-04-03 |
| 0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | 2025-03-11 | 2025-04-03 |
| 0641 | Ensure each resident receives an accurate assessment. | D | 2025-03-11 | 2025-04-03 |
| 0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | 2025-03-11 | 2025-04-03 |
| 0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | 2025-03-11 | 2025-04-03 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | 2025-03-11 | 2025-04-03 |
| 0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | D | 2025-03-11 | 2025-04-03 |
| 0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | 2025-03-11 | 2025-04-03 |
| 0726 | 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. | D | 2025-03-11 | 2025-04-03 |
| 0732 | Post nurse staffing information every day. | B | 2025-03-11 | 2025-04-03 |
| 0760 | Ensure that residents are free from significant medication errors. | E | 2025-03-11 | 2025-04-03 |
| 0838 | 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. | F | 2025-03-11 | 2025-04-03 |
| 0880 | Provide and implement an infection prevention and control program. | F | 2025-03-11 | 2025-04-03 |
| 0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | 2024-02-28 | 2024-03-14 |
| 0552 | Ensure that residents are fully informed and understand their health status, care and treatments. | D | 2023-12-22 | 2024-01-18 |
| 0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. | D | 2023-12-22 | 2024-01-18 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2023-12-22 | 2024-01-18 |
| 0658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | 2023-12-22 | 2024-01-18 |
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | 2023-12-22 | 2024-01-18 |
| 0761 | 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. | D | 2023-12-22 | 2024-01-18 |
| 0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | 2023-12-22 | 2024-01-18 |
| 0658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | 2023-11-30 | 2024-01-12 |
| 0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | 2023-11-30 | 2024-01-12 |
| 0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | 2022-12-05 | 2022-12-26 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2022-12-05 | 2022-12-26 |
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | 2022-12-05 | 2022-12-26 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | 2022-12-05 | 2022-12-26 |
| 0695 | Provide safe and appropriate respiratory care for a resident when needed. | D | 2022-12-05 | 2022-12-26 |
| 0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | 2022-12-05 | 2022-12-26 |
| 0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | 2022-12-05 | 2022-12-26 |
| 0730 | Observe each nurse aide's job performance and give regular training. | E | 2022-12-05 | 2022-12-26 |
| 0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | D | 2022-12-05 | 2022-12-26 |
| 0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | 2022-12-05 | 2022-12-26 |
| 0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | 2022-12-05 | 2022-12-26 |
Penalties (1)
| Date | Type | Fine amount |
|---|---|---|
| 2025-03-11 | Fine | $71,202 |
Source: CMS Nursing Home Penalties.
Financial Health (FY 2023)
Payer mix (share of resident days)
Operating performance
Revenue & costs
Balance sheet
Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.
Ownership & Corporate Structure
Chain: ATHENA HEALTHCARE SYSTEMS
- Chain ID
52- Facilities in chain
- 24
- Legal business name
- MARLBORO HILLS MA SNF LLC
Owner / manager organizations (2)
| Organization | Role | Association |
|---|---|---|
| ATHENA HEALTH CARE SYSTEMS MA III LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 06/01/2014 |
| ATHENA HEALTH CARE ASSOCIATES, INC. | OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2014 |
Owner / manager individuals (8)
| Name | Role | Association |
|---|---|---|
| CHAKALOS-SANTILLI, VALERIE | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 07/01/2015 |
| CURTIS, DIANE | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 06/01/2014 |
| MOSIER, MICHAEL | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 06/01/2014 |
| REZENDES, LORRIE | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 04/26/2017 |
| SANTILLI, LAWRENCE | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 07/01/2018 |
| SENRA, PRISCILLA | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 12/15/2020 |
| SANTILLI, LAWRENCE | CORPORATE OFFICER | since 07/01/2018 |
| MOSIER, MICHAEL | W-2 MANAGING EMPLOYEE | since 06/01/2014 |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- No
- Hospital-based
- No
- Resident / family council
- Resident
- Sprinkler systems
- Partial
- Abuse citation flag
- No
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Penalties (
nh-penalties), vintage 2026, downloaded 2026-04-14 , 16,915 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows. - Skilled Nursing Facility Cost Report (
snf-cost-report), vintage 2023, downloaded 2026-04-14 , 14,120 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 113 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Cost Report | Cost per Resident Day ($) | $29 | metrics.cost_per_resident_day |
| Cost Report | Current Ratio | 0.18 | metrics.current_ratio |
| Cost Report | fiscal_year | 2,023 | fiscal_year |
| Cost Report | Medicaid Day Share (%) | 89.4% | metrics.medicaid_day_share |
| Cost Report | Medicare Day Share (%) | 3.6% | metrics.medicare_day_share |
| Cost Report | Net Income ($) | $-533,923 | metrics.net_income |
| Cost Report | Net Patient Revenue ($) | $18,523,041 | metrics.net_patient_revenue |
| Cost Report | Occupancy Rate (%) | 84.0% | metrics.occupancy_rate |
| Cost Report | Operating Margin (%) | -6.2% | metrics.operating_margin |
| Cost Report | Total Assets ($) | $29,904,383 | metrics.total_assets |
| Cost Report | Total Costs ($) | $1,755,270 | metrics.total_costs |
| Cost Report | Total Fund Balances ($) | $-11,058,286 | metrics.fund_balance |
| Cost Report | Total Liabilities ($) | $40,962,669 | metrics.total_liabilities |
| Cost Report | Total Margin (%) | -2.8% | metrics.total_margin |
| Provider Information | Abuse Icon | N | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 1.08991 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 2.03208 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 0.35072 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 3.47271 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 3.05848 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Partial | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 170.7 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 0.82100 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.23130 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.64713 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 3.69943 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 3.26066 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | 1.8 | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | 1.7 | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | 2.7 | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | 2.8 | Chain Average Staffing Rating |
| Provider Information | Chain ID | 52 | Chain ID |
| Provider Information | Chain Name | ATHENA HEALTHCARE SYSTEMS | Chain Name |
| Provider Information | City/Town | MARLBOROUGH | City/Town |
| Provider Information | CMS Certification Number (CCN) | 225063 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | N | Continuing Care Retirement Community |
| Provider Information | County/Parish | Middlesex | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 1967-01-01 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 1 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 42.3418 | Latitude |
| Provider Information | Legal Business Name | MARLBORO HILLS MA SNF LLC | Legal Business Name |
| Provider Information | Location | 121 NORTHBORO ROAD,MARLBOROUGH,MA,01752 | Location |
| Provider Information | Long-Stay QM Rating | 2 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -71.585 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | N | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 1 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 186 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | — | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | 24 | Number of Facilities in Chain |
| Provider Information | Number of Fines | 1 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.31054 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 0.95129 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 1 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | For profit - Limited Liability company | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 121 NORTHBORO ROAD | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | MARLBOROUGH HILLS REHABILITATION & HLTH CARE CTR | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 090 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 2 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 187 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 6 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 1 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 13 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2025-03-11 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 187 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 19 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 7 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2023-12-22 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 40 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 3 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 40 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 10 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.19080 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 45.5 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 1.38036 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 1.04432 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 1.94708 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.04906 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 0.33604 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 3.32745 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | 2 | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | — | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | Special Focus Status |
| Provider Information | Staffing Rating | 2 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | MA | State |
| Provider Information | Telephone Number | 5084854040 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 71202.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 2.93054 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 1 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 30.8 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 150.250 | Total Weighted Health Survey Score |
| Provider Information | Urban | Y | Urban |
| Provider Information | With a Resident and Family Council | Resident | With a Resident and Family Council |
| Provider Information | ZIP Code | 01752 | ZIP Code |