Marlborough Hospital
An acute care hospital in Marlborough, Massachusetts 01752
157 Union Street, Marlborough, Massachusetts 01752. (508) 481-5000.
- Medicare participation ended
- Medicare payments cut under the HAC Reduction Program (fiscal year 2026)
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The short answer
Record last released by CMS on Oct 20, 2026.
- 2of 5 CMS’s overall rating
- 3of 5 patient survey rating
- 2 deficiencies cited in the last three years (needs attention)
- 79 beds
Each figure’s source sits beside it, in its section below.
What these words mean4
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
- Condition-level deficiency
- For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.
What did inspectors find?
The last inspection on record was on Jan 23, 2026: a complaint inspection.
2 deficiencies cited in the last three years, 1 of them at condition level, the most serious.
1 deficiency at condition level, the more serious of CMS’s two levels
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
2 deficiencies in 1 month of the last 36. Last cited Mar 2024. Most serious: Condition-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Mar 14, 2024: complaint inspection2 deficiencies
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Patient Rights
“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45980 The Hospital was out of compliance for the Condition of Participation for Patient Rights. Findings included: The Hospital failed to ensure one (Patient #1) of 11 sampled patients were free from all types of harassment. Cross Reference: A-0145”
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Patient Rights: Free From Abuse/Harassment
The inspectors’ words, 1,096 words
“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 45980 Based on interviews and records reviewed, the Hospital failed to ensure patients were free from all types of harassment for one of eleven sampled patients (Patient #1); Patient #1 was a pediatric patient with mental illness in the Hospital ‘s Emergency Department (ED) and was engaged in inappropriate communication via texting by an adult Hospital staff member following ED visits to the Hospital. Findings include: Review of Patient #1 ‘s medical records, indicated that he/she presented to the Hospital ED via police due to suicidal ideation on 11/21/23. Patient #1 has a history of depression and schizophrenia (a disorder that affects a person ’ s ability to think, feel, and behave clearly). Review of the Hospital ‘s Patient Rights and Responsibilities Policy, effective 12/17/2021, indicated that patients have the right to receive care in a safe setting free from all forms of abuse and harassment. Review of the Hospital ‘s Quality Assessment and Performance Improvement Plan dated 2/2024, indicated that communication and education on improvement philosophy, strategies, and tools in multiple venues throughout the organization may include but not limited to: new employee orientation, formal management education in terminology, strategies and tools, regularly scheduled computer-based training on improvement initiatives impacting their clinical accountability and departmental in-service programs tailored to meet the needs of a specific group. The policy further indicated that the Director of Quality, Patient Safety and Regulatory (QPS-R) is an integral member of the Senior Leadership Team focused on evaluating the delivery of care, developing an infrastructure for improvement, and promoting a safety culture. The Director, QPS-R is responsible for collaborating with executives and engaging clinicians in shared accountability for quality and safety. Review of the Progress Note documented by the Attending Physician, dated 11/21/23 at 2:42 P.M., indicated that Patient #1 was focused on coming to the Hospital due to an alleged relationship with an adult staff member. The note further indicated that Patient #1 was hyper fixated on and believed that by coming to the Hospital he/she would be able to see the staff member, later identified as Patient Observer #1. Further review of the medical record indicated Patient #1 had multiple ED visits to the Hospital prior to 11/21/23. Patient Observer #1 had previously been assigned for constant observation for Patient #1 in September 2023. During an Interview on 3/13/24 at 10:00 A.M., the Risk Manager said the Hospital did not perform a Root Cause Analysis (RCA) on the event involving Patient #1 as this was a Human Resources (HR) investigation and would be handled by that department. During an interview on 3/13/24 at 11:09 A.M., the Director of Emergency Services and Critical Care Services said she was called by an outside community service organization notifying her that one of the Hospitals staff members, a patient observer (Patient Observer #1), was sending inappropriate text messages to one of their patients. She said she called the Chief Nursing Officer to make him aware and Patient Observer #1 was put on administrative leave immediately. She said HR was involved in the majority of the investigation. She said the Hospital identified an opportunity for education on code of conduct and patient rights with the patent observers. She said she has been educating ED staff during staff meetings and with staff individually. The Director of Emergency Services and Critical Care Services was unable to provide documentation to support education was fully implemented. She said the Hospital would also be adding this education during Hospital orientation for new hires but was unsure if it had been implemented. She said she was also involved with the education of new patient observers and has added the education to her portion of their orientation but was unable to provide documentation that this was implemented. The Director of Emergency Services and Critical Care Services said she oversees the patient observers who mainly work in the ED. She said patient observers have a review on performance every 2 years. During an interview on 3/14/24 at 10:03 A.M., the Employee Relation Partner from HR indicated that the Director of Emergency Services and Critical Care Services made her aware of a staff member texting inappropriate/suggestive messages to a patient that was previously in the Hospital ‘s care. She said this prompted an HR investigation. She said that Patient Observer #1 admitted to texting with Patient #1. She said Patient Observer #1 disclosed messages sent to Patient #1 during his interview with HR; the text messages were inappropriate and Patient Observer #1 admitted it was wrong what he was doing and should not have engaged in messaging the Patient. The Employee relation partner indicated the investigation also identified another patient observer (Patient Observer #2) who aided Patient #1 in texting Patient Observer #1. The Employee Relation Partner indicated that the investigation resulted in Patient Observer #1 and Patient Observer #2 being terminated from their position at the Hospital. The Employee Relation Partner said as part of her investigation, video footage from the ED was reviewed and Patient Observer #2 could be seen using her personal phone, putting it between her and Patient #1, and Patient #1 was visibly distressed when the call ended. The Employee Relation Partner said it was identified during the Hospital investigation that the call on Patient Observer #2 ’ s phone was placed to Patient Observer #1 to facilitate communication with Patient #1 and Patient Observer #1. She said there was a meeting after the investigation which identified opportunities for improvement and the need for more robust education on boundaries between Hospital staff and patients. She indicated that she recommended that the education be rolled out system wide. During an interview on 3/14/24 at 11:33 A.M., the Chief Compliance and Privacy Officer indicated that she was involved in the investigation with Human Resources. She said there was a meeting that was held on 2/27/24 with HR to discuss the investigation. She said the Hospital identified a need for more education on code of conduct and that training would be added to yearly required education for all employees as well as for new employees during orientation. She said that the Director of Quality was not involved in this meeting. The Chief compliance and Privacy Officer indicated that the education has not been implemented. The Hospital failed to ensure Patient #1 was free from harassment of the Hospital staff and the Hospital failed to implement interventions to prevent a like occurrence.”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jan 23, 2026 | Complaint inspection | No deficiencies cited |
| Mar 14, 2024 | Complaint inspection | 2 deficiencies cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 2 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 1 better and 0 worse of 6; safety of care, 0 better and 0 worse of 4; readmission, 0 better and 2 worse of 6.
- Patients rate it 3 of 5 in CMS’s patient survey (555 surveys completed, Oct 1, 2024 to Sep 30, 2025): 59% rated it 9 or 10 out of 10, and 60% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), no different than national benchmark; catheter urinary tract infections (CAUTI), no different than national benchmark; C. diff infections, no different than national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 11.9%, heart failure 9.8%, pneumonia 12.6%, COPD 7.1%, stroke 14.3%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 14.4%, heart failure 21.1%, pneumonia 17.5%, COPD 22.3%, hip or knee replacement 5.2%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 226 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 5% left before being seen.
- 58% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 0.97 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 2 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 3 of 5 |
Is it certified, and in good standing?
- CMS’s Provider of Services file records that its Medicare participation ended on Jan 1, 2026 (CMS’s reason: “Voluntary - merger, closure”).
- Ownership: voluntary non-profit - private.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- Cited at For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. in the last three years: it didn’t meet a whole condition of Medicare’s rules for hospitals.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- CMS cut its Medicare payments by 1% for fiscal year 2026 under the Hospital-Acquired Condition Reduction Program, which does so for the quarter of hospitals that fare worst on conditions patients get in hospital.
- 2 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
| Date | What | Detail |
|---|---|---|
| Medicare payment reduction (HAC Reduction Program) | Fiscal year 2026: 1% of Medicare payments |
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 3 of 5.
- 57% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- CMS’s ownership file has no owners listed for this hospital.
- CMS’s Provider of Services file records 1 change of ownership.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
How does it compare nearby?
- Of the 14 hospitals CMS lists in Middlesex County, 10 have an overall star rating from CMS: 2 rated 5 of 5, 2 rated 4 of 5, 3 rated 3 of 5, 2 rated 2 of 5, 1 rated 1 of 5.
- CMS rates this one 2 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.