Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fitchburg Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to implement physician orders and monitor residents, leading to significant deficiencies. A resident was hospitalized due to inadequate fluid restriction management, another did not receive necessary lab tests, and a third had incorrect air mattress settings. These failures highlight lapses in following medical directives and ensuring proper care.
The facility failed to notify the physician of critical lab results for a resident, leading to hospitalization for acute hypokalemia and acute kidney injury. Additionally, the facility did not obtain ordered labs for another resident with chronic kidney disease and heart failure, impacting their care. Interviews revealed lapses in communication and protocol adherence among nursing staff.
The facility failed to develop individualized care plans for residents with PTSD, suicidal ideation, and a cardiac pacemaker. A resident with PTSD had a non-specific care plan, while another lacked a PTSD care plan entirely. A resident with suicidal ideation had no care plan for monitoring mental well-being. Additionally, a resident with a pacemaker had an incomplete care plan, leading to staff confusion about its management.
A facility failed to properly execute an Advanced Directive for a resident. The MOLST form, indicating Do Not Resuscitate and Do Not Intubate orders, was signed by a nurse practitioner and an unauthorized individual, not the resident. The resident had moderately intact cognition and no invoked health care proxy, making the MOLST invalid.
A resident with COPD, chronic respiratory failure, and schizophrenia developed a fungal infection in the groin area, which was not reported to the physician by the facility staff. Despite the resident's complaints and attempts to self-treat, there was no physician's order for antifungal treatment, and the facility's documentation failed to reflect proper notification and treatment.
Two residents in a facility experienced deficiencies in care. One resident on anticoagulants had bruising that was not documented or reported to a physician, despite facility protocols requiring monitoring for such complications. Another resident reported a fungal infection in the groin, but the facility failed to obtain a treatment or notify a physician, despite weekly skin reviews noting antifungal powder application without a corresponding order. These issues reflect a lack of adherence to monitoring and documentation protocols.
A facility failed to conduct a smoking assessment and develop a care plan for a resident who resumed smoking after admission. Despite being listed as requiring supervised smoking, there was no Safe Smoking Evaluation or care plan in place. The resident, with several medical conditions, initially indicated no tobacco use but later resumed smoking without proper documentation or evaluation.
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen therapy management. A resident received oxygen at a higher rate than prescribed, another had expired oxygen tubing and incorrect oxygen settings, and a third lacked a physician's order for oxygen use. These issues were confirmed by staff interviews and observations.
A facility failed to ensure proper medication storage and administration for a resident, resulting in a deficiency. Medication was left unattended at the resident's bedside, contrary to facility policy requiring medications to be stored in locked compartments and administered under supervision. The resident, who was cognitively intact, had a prescription for calcium carbonate tablets, but no self-medication assessment was documented. Staff interviews confirmed the protocol breach.
A resident with hemiplegia and hemiparesis following a stroke experienced a delay in receiving occupational therapy (OT) services due to the facility's reliance on per diem OT staff, who were only available once a month. Despite a doctor's order for OT following complaints of pain and stiffness in the resident's left-hand joints, the evaluation was conducted nearly a month later, exceeding the facility's two-week expectation for therapy screens.
The facility failed to maintain accurate medical records for three residents, leading to discrepancies in oxygen therapy and wound care documentation. One resident received oxygen at a higher rate than ordered, while another had incorrect documentation regarding oxygen tubing changes and antifungal treatment. A third resident's wound dressing changes were inaccurately recorded. Staff interviews confirmed these discrepancies.
The facility failed to provide a safe and clean environment, with five resident rooms having baseboard heaters in disrepair and three shower rooms found dirty with mildew. A resident reported unclean conditions, and the Director of Environmental Services confirmed cleaning expectations were not met. The facility lacked policies for maintaining resident care areas, and the Administrator acknowledged unresolved issues with heater covers.
The facility failed to serve food at safe and appetizing temperatures on Unit A, with several food items found below the required temperature range during a test tray observation. Residents expressed dissatisfaction with the food quality, describing it as cold and lacking variety. The Food Service Director and Administrator acknowledged issues with maintaining food temperatures, citing equipment malfunctions and the absence of a pellet system.
The facility's main kitchen was found to be unsanitary, with fingerprints and smears on freezer and refrigerator doors, and missing protective pieces on freezer handles. Additionally, two cooks were observed handling food without wearing required hair restraints, violating the facility's hygiene policies. The Food Service Director acknowledged the need for a better cleaning schedule and confirmed that all dietary staff should wear hair coverings.
The facility failed to update the care plan for a resident at high risk for elopement after an incident where the resident attempted to leave the facility. Despite being redirected back, no new interventions were added. Another resident, also at high risk for elopement, did not have a care plan addressing this risk. The facility's policy required such plans, but they were not implemented.
A resident with moderate cognitive impairment and high elopement risk left the facility twice without staff knowledge. The first incident involved the resident being found in the parking lot, and the second incident resulted in the resident being found blocks away with bruises and abrasions. Despite the resident's care plan identifying elopement risk, no new interventions were added after the first incident.
Failure to Implement Physician Orders and Monitor Residents
Penalty
Summary
The facility failed to meet professional standards of practice for three residents, leading to significant deficiencies in care. For Resident #44, the facility did not adequately assess, monitor, and implement a physician's order for fluid restrictions, which was crucial given the resident's chronic kidney disease and congestive heart failure. This oversight contributed to the resident's hospitalization with acute hypoxic respiratory failure, acute renal failure, and septic shock. Additionally, the facility did not follow up on a physician's recommendation for a new prosthetic leg, nor did it implement an order for a bilateral shoulder X-ray, leaving the resident without necessary evaluations and interventions. Resident #29 experienced a deficiency in care due to the facility's failure to obtain ordered laboratory tests. Despite a physician's order for weekly labs to monitor and adjust treatment for hyponatremia, the facility did not conduct these tests over several months. This lack of compliance with physician orders left the resident's condition unmonitored and potentially untreated, as the necessary lab results were not available to guide medical decisions. For Resident #1, the facility did not ensure that the air mattress was set according to the physician's order. Observations revealed that the mattress settings did not match the prescribed settings, which were intended to prevent skin issues. Despite documentation indicating compliance, the actual settings were incorrect, indicating a failure in the facility's processes to ensure adherence to physician orders and proper care for the resident's condition.
Failure to Notify Physician of Critical Lab Results and Obtain Ordered Labs
Penalty
Summary
The facility failed to notify the physician of critical laboratory results for two residents, leading to significant delays in treatment. Resident #12, who was admitted with dementia and chronic obstructive pulmonary disease, had critically high blood urea nitrogen (BUN) and critically low potassium levels reported on 2/26/25. Despite the lab's attempts to alert the facility, the results were not communicated to the physician until the following day, resulting in the resident being hospitalized for acute hypokalemia and acute kidney injury. Interviews revealed that the nursing staff did not follow the protocol for handling critical lab results, and the lab results were not documented in the resident's chart. Resident #44, admitted with chronic kidney disease, diabetes, and heart failure, had physician orders for several lab tests dated 11/8/24. However, the facility failed to obtain these labs, and there was no documentation of the lab results in the resident's medical record. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the labs were not drawn as ordered, and the physician was not notified to obtain new orders. The resident's medical condition required close monitoring, and the failure to conduct the ordered labs could have impacted their care. The deficiencies highlight a breakdown in communication and protocol adherence within the facility, particularly concerning the handling of critical lab results and the execution of physician orders. The lack of timely notification to the physician and the failure to obtain necessary lab tests for residents with serious medical conditions resulted in delayed treatment and potential harm to the residents involved.
Deficiencies in Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized care plans for several residents, leading to deficiencies in addressing their specific medical and psychological needs. Resident #18, who was admitted with PTSD, anxiety, and depression, had a care plan that was not individualized to include specific triggers and interventions for managing PTSD. The Regional Nurse acknowledged that the care plan lacked direction for direct care staff on managing the resident's PTSD and associated behaviors. Resident #11, diagnosed with PTSD, anxiety, and borderline personality disorder, did not have a care plan addressing PTSD. The Regional Nurse confirmed the absence of a care plan for PTSD, which is necessary for residents with such a diagnosis. Similarly, Resident #12, with a history of suicidal ideation, did not have a care plan to monitor mental well-being and physical safety, despite the discharge paperwork indicating a history of suicidal ideation. The Social Worker was unaware of the absence of a care plan for suicidal ideation. Resident #44, who has a cardiac pacemaker, did not have a comprehensive care plan detailing the management and monitoring of the pacemaker. The care plan lacked information on how the pacemaker is monitored, and there was confusion among staff regarding the presence of the pacemaker. The Director of Nurses and Nurse Practitioner both indicated that the medical record should reflect the presence of a pacemaker to ensure staff awareness and proper care.
Invalid Execution of Advanced Directive
Penalty
Summary
The facility failed to accurately execute an Advanced Directive for a resident, specifically the Massachusetts Medical Order for Life Sustaining Treatment (MOLST). The MOLST form, which indicated Do Not Resuscitate and Do Not Intubate and Ventilate orders, was signed by a nurse practitioner and another individual who was not the resident. There was no evidence in the medical record of a physician's order or documentation indicating that the resident had an invoked health care proxy agent, which would authorize someone else to make health care decisions on their behalf. The resident, who was admitted to the facility with diagnoses including muscle wasting, sepsis, chronic obstructive pulmonary disease, atherosclerotic heart disease, and peripheral vascular disease, had a moderately intact cognition as per the Minimum Data Set assessment. During an interview, the Social Worker confirmed that the resident's health care proxy was not invoked, and the person who signed the MOLST did not have the authority to make health care decisions for the resident, rendering the MOLST invalid.
Failure to Notify Physician of Resident's Skin Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident with a fungal infection in the groin area. The resident, who has a history of COPD, chronic respiratory failure, and schizophrenia, reported the issue to the nursing staff but did not receive the necessary antifungal treatment. The resident attempted to self-treat with over-the-counter powder, which was ineffective. Despite the resident's complaints, there was no physician's order for antifungal powder, and the progress notes did not indicate that the physician was informed of the condition. The facility's weekly skin reviews noted the condition of the resident's groin as pink and indicated that antifungal powder was applied, but there was no evidence of a physician's order for this treatment. The Regional Nurse confirmed that the physician should have been notified of the resident's condition. This oversight represents a failure to adhere to the facility's policy on promptly notifying the physician of changes in a resident's medical condition.
Deficiencies in Monitoring and Treatment for Residents on Anticoagulants and Skin Management
Penalty
Summary
The facility failed to ensure quality care for two residents, leading to deficiencies in monitoring and treatment. For one resident, who was on anticoagulant medication, the facility did not identify or document areas of discoloration consistent with bruising. Despite the resident's use of multiple blood thinners and the presence of red discolorations on their arms, the nursing staff did not report these changes to the physician or document them in the resident's medical records. The facility's policy required monitoring for complications related to anticoagulation therapy, but this was not adhered to, as evidenced by the lack of documentation and communication regarding the resident's condition. Another resident experienced a deficiency in care related to skin management. This resident reported a fungal infection in the groin area, but the facility failed to obtain a treatment for the condition. Although the resident had informed the nursing staff about the issue, there was no physician's order for antifungal powder, and the progress notes did not indicate that the physician was notified of the resident's request for treatment. The weekly skin reviews noted the application of antifungal powder, but there was no corresponding order or documentation to support this treatment. These deficiencies highlight a lack of adherence to the facility's protocols for monitoring and documenting changes in residents' conditions. The failure to communicate and document these issues resulted in inadequate care for the residents, as their medical needs were not properly addressed or managed according to the facility's policies.
Failure to Conduct Smoking Assessment and Develop Care Plan
Penalty
Summary
The facility failed to ensure that a smoking assessment was completed and a care plan was developed for a resident who smoked. The facility's policy requires that residents' smoking status be evaluated upon admission and re-evaluated quarterly or upon significant change. However, for the resident in question, there was no Safe Smoking Evaluation or person-centered care plan for smoking, despite the resident being listed as requiring supervised smoking. The resident was admitted with several medical conditions, including chronic obstructive pulmonary disease and atherosclerotic heart disease, and initially indicated no tobacco use on the Minimum Data Set assessment. Interviews revealed that the resident resumed smoking after feeling better post-admission, but this change was not documented in a care plan or evaluated for safety. The Social Worker acknowledged that a smoking agreement was signed upon admission, but no safe smoking evaluation was conducted. The Administrator added the resident to the supervised smoking list after observing the resident smoking outside, but confirmed that a care plan and evaluation should have been in place. This oversight indicates a lapse in following the facility's smoking policy and ensuring resident safety.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen therapy management. For Resident #18, the facility did not adhere to the physician's order for oxygen therapy, as the oxygen concentrator was set to 4 liters per minute instead of the prescribed 2 liters per minute. This discrepancy was observed by the surveyor and confirmed by Nurse #2, who acknowledged the error after reviewing the resident's physician orders. Resident #18, who has severe cognitive impairment and COPD, stated that only staff adjust the oxygen concentrator settings. Resident #6, diagnosed with COPD and chronic respiratory failure, was observed receiving 4.5 liters per minute of oxygen, exceeding the physician's order of 1 to 3 liters per minute. Additionally, the oxygen tubing was not changed as required, despite the medical record inaccurately indicating it had been replaced. Nurse #5 confirmed these issues during an interview. For Resident #12, who has dementia and COPD, the facility failed to obtain a physician's order for oxygen use, despite the resident using oxygen at night. Nurse #2 and the Assistant Director of Nursing confirmed the absence of a physician's order for Resident #12's oxygen therapy.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure proper storage and administration of medications for one resident, leading to a deficiency. Specifically, the surveyor observed that medication was left unattended at the bedside of a resident who was cognitively intact and did not reject care. The facility's policy requires that all medications be stored in locked compartments and administered by authorized personnel, who must remain with the resident until the medication is consumed. However, this protocol was not followed, as evidenced by the presence of three medicine cups with 15 tablets, identified as calcium carbonate Tums, left on the resident's bedside table. The resident, admitted in April 2019, had a diagnosis of gastroesophageal reflux disease and was prescribed calcium carbonate tablets to be taken with meals. The medical record did not indicate that a self-medication administration assessment had been completed for the resident. Interviews with nursing staff, including a nurse and the Assistant Director of Nursing, confirmed that the facility's procedure is for nurses to stay with residents during medication administration to ensure all medications are taken, and that medications should not be left at the bedside. This lapse in protocol led to the observed deficiency.
Delayed Occupational Therapy Evaluation for Resident
Penalty
Summary
The facility failed to provide specialized rehabilitative services in a timely manner for a resident who was admitted with hemiplegia and hemiparesis following a stroke. The resident, who had moderate impaired cognition, complained of pain and stiffness in the left-hand joints, prompting a doctor's order for Biofreeze gel and a referral to occupational therapy (OT). However, the OT evaluation was delayed, as the facility did not have an OT on staff and relied on per diem OT staff who were only available once a month. The Assistant Director of Nursing acknowledged that the OT evaluation was conducted nearly a month after the initial complaint, which exceeded the facility's expectation of completing therapy screens within two weeks. The Rehab Director confirmed the lack of an on-staff occupational therapist and stated that residents should be evaluated as soon as possible after a therapy screen request.
Inaccurate Medical Records and Documentation in LTC Facility
Penalty
Summary
The facility failed to ensure the accuracy of medical records for three residents, leading to discrepancies in documentation and care. For one resident with COPD, the oxygen delivery rate was inaccurately documented. The resident was observed receiving oxygen at 4.5 liters per minute, contrary to the physician's order of 2 liters per minute. The Medication Administration Record (MAR) inaccurately reflected the ordered rate, and nursing notes did not document the actual rate being administered. Interviews with nursing staff confirmed the discrepancy, and the resident stated that only staff adjusted the oxygen concentrator. Another resident, also with COPD and other conditions, experienced inaccuracies in documentation related to oxygen therapy and skin treatment. The resident was observed receiving oxygen at a rate higher than ordered, and the oxygen tubing was not changed as documented. Additionally, the resident reported a fungal infection for which no physician's order for antifungal powder was obtained, despite documentation indicating otherwise. Interviews with nursing staff confirmed the inaccuracies in the medical record and the lack of a physician's order for the antifungal treatment. A third resident with peripheral vascular disease and lymphedema had discrepancies in wound dressing documentation. The resident's medical record indicated that wound dressings were changed daily, but observations and interviews revealed that the dressing had not been changed as documented. The Assistant Director of Nursing confirmed that floor nurses were responsible for ensuring wound treatments were completed and documented accurately, highlighting a failure in maintaining accurate medical records and following physician orders.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the condition of several resident rooms and shower areas. Observations revealed that five out of thirteen resident rooms on Unit A had baseboard heaters in disrepair, with missing or damaged covers, exposing sharp edges and heating elements. Additionally, three out of three resident shower rooms were found to be dirty, with black mildew-like substances on the ceilings and grout between tiles, and one shower room had a non-functional exhaust fan, contributing to a musty and humid environment. Interviews with residents and staff corroborated these findings. A resident reported that the shower on Unit C was not kept clean, and the Director of Environmental Services acknowledged that the shower rooms were expected to be cleaned daily, but the exhaust fan in one shower room was not operating consistently. The facility's policies did not address the general maintenance of resident care areas or the upkeep of baseboard heaters, and the Administrator admitted that the facility had identified the issue with baseboard heater covers a year ago but had not completed the necessary replacements.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food provided to residents on Unit A was served at safe and appetizing temperatures. The facility's policy indicated that food should be maintained at proper temperatures, with hot foods served between 120 to 140 degrees Fahrenheit based on resident preference. However, during a test tray observation, it was found that the temperatures of several food items were below the required range, with puree beef at 109.9 degrees, mashed potatoes at 104.4 degrees, puree carrots at 103.6 degrees, and a hot dog at 97.3 degrees. These temperatures were significantly lower than the facility's policy and the Food Service Director's stated expectation of 135 degrees at the time of service. Additionally, the food was described as tepid, bland, and not palatable by the surveyor and residents. Interviews with residents revealed dissatisfaction with the food quality, with complaints about meals being cold and lacking variety. The Food Service Director acknowledged the issue, attributing it to a malfunctioning steam table well and the absence of a pellet system to keep plates warm. The Administrator also noted the need for a pellet system to maintain food temperatures. The deficiency was further supported by a Department of Public Health Consumer Complaint Form and Dining Committee Minutes, which documented resident complaints about food temperatures and quality.
Sanitation and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the main kitchen, where all food items are prepared and plated before being served to residents. Observations revealed that the reach-in freezers and refrigerators had large areas of fingerprints and smears, and the freezer doors lacked plastic protective pieces, leaving exposed metal edges that could collect debris. The facility's policy on sanitation and infection control, which requires the Dietary Manager to supervise all sanitation procedures and develop a cleaning schedule, was not adequately followed. The Food Service Director acknowledged the need for a better cleaning schedule and confirmed that the freezer and refrigerator doors should be cleaned every shift. Additionally, the facility did not ensure that kitchen staff adhered to sanitary standards during food handling. Two cooks were observed handling food without wearing appropriate hair restraints, such as hair nets or beard nets, as required by the facility's personal hygiene policy. Cook #1 plated food items without a beard net, and Cook #2 prepared sandwiches without a cap or hair net. The Food Service Director and the Administrator both stated that all dietary staff were expected to wear hair coverings in the kitchen, indicating a lapse in adherence to the facility's hygiene policies.
Failure to Update and Implement Elopement Care Plans
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident who was at high risk for elopement after an incident where the resident attempted to leave the facility. The resident, diagnosed with hereditary ataxia, mild cognitive impairment, and repeated falls, was found outside in the parking lot after an argument with a roommate. Despite being redirected back into the facility, no new interventions were added to the resident's care plan to address the elopement risk. A subsequent incident occurred where the resident left the facility unattended and returned with bruises and abrasions, yet the care plan remained unchanged. Another resident, diagnosed with Alzheimer's Disease and assessed to be at high risk for elopement, did not have an individualized comprehensive care plan addressing the risk of elopement. The facility's policy required that care plans include strategies and interventions for residents identified at risk for wandering or elopement, but this was not implemented for the second resident. The Director of Nurses acknowledged that a care plan should have been developed once the risk was identified.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent two incidents of elopement involving a resident who was assessed as being at high risk for elopement and was moderately cognitively impaired. On two separate occasions, the resident was able to leave the facility without staff knowledge. The first incident occurred when the resident was found in the parking lot adjacent to the facility, unescorted by staff. The second incident involved the resident being found a couple of blocks away from the facility with bruises and abrasions. The resident, admitted in July 2023, had diagnoses including hereditary ataxia, mild cognitive impairment, difficulty in walking, and repeated falls. The resident's care plan, reviewed in April 2024, identified the risk of elopement and included an intervention to make staff aware of this risk. However, after the first elopement incident, no new interventions were added to the care plan to prevent future occurrences. Interviews with staff revealed that the resident was able to exit through a back door that was not alarmed until later in the evening. Staff were unaware of the resident's absence until it was reported by a roommate. The Director of Nurses acknowledged that had she been aware of the resident's location during the first incident, additional interventions such as a wander guard bracelet and increased safety checks would have been implemented.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 497 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fitchburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fitchburg Healthcare | 1.4 mi | ★★★★★ | 17 | 0 |
| Highlands, The | 1.8 mi | ★★★★★ | 9 | 0 |
| Leominster Rehabilitation And Nursing Center | 2.8 mi | ★★★★★ | 6 | 0 |
| Life Care Center Of Leominster | 3 mi | ★★★★★ | 15 | 0 |
| River Terrace Rehabilitation And Healthcare Ctr | 7.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.