Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Highlands, The during CMS and state inspections, most recent first.
Cold Meals and Unmet Egg Preference: Residents reported that hot food was often served cold, tasteless, or needed microwaving, and survey observations found multiple lunch items on several units served lukewarm or cool instead of at safe, appetizing temperatures. A cognitively intact resident with malnutrition-related diagnoses also did not receive eggs over easy as documented on the meal ticket; the eggs were served hard, and both the FSD and RD confirmed they were not prepared to the resident’s preference.
The facility failed to follow infection control practices during a COVID-19 outbreak when testing was not started promptly for residents and HCP on affected units. The facility also failed to ensure staff wore required PPE, including eye protection, gown, N95, and gloves, when caring for a resident on Contact and Droplet Precautions for COVID-19. The resident had immunodeficiency, COPD, and emphysema, and staff were observed entering the room and providing care without the full required PPE.
A resident with dysphagia, cognitive impairment, and significant recent weight loss had a care plan requiring tray setup, cutting food into bite-sized pieces, supervision while eating, and being out of bed in the dining room for meals. Surveyors observed the resident in bed with untouched meals and no staff present during breakfast and lunch, and on one occasion an ST had to cut the food before the resident began eating. The resident lost 19.7 pounds in one month, and the UM and DON acknowledged the meal assistance interventions were not consistently implemented.
A resident with hearing loss and need for personal care did not consistently receive help placing a hearing aid during ADL care, and the care plan/Kardex lacked direction for the device. In addition, another resident with a left humerus fracture and weakness did not receive timely restorative nursing services for upper extremity strengthening and ambulation after therapy discharge, and staff reported no evidence the program had started.
Missing Physician Order for Indwelling Urinary Catheter: A resident with CHF, a hip dislocation, and mild cognitive impairment had a Foley catheter in place, but the chart lacked a physician order for the catheter and its size. Surveyors observed the catheter drainage bag hanging from or hooked to the bed frame, and both an LPN and the DON confirmed that no order was in place.
A resident with brain cancer, hypothyroidism, and anemia had ordered labs for thyroid function and iron studies, but the facility did not obtain the blood work and no results were found in the record. The UM said the labs should have been drawn the next day, and the PA said she was unaware they had not been completed; the ordered tests were intended to guide assessment and possible supplementation.
A resident with diabetes, CHF, venous insufficiency, and PVD had new right lower extremity blisters documented with an Unna Boot treatment plan, but the physician order for the wound care was not entered into the EHR. Another resident with dementia and mobility impairment used an enclosed walker as a restraint, but the MAR/TAR lacked documentation of use frequency, release timing, and positioning checks despite the care plan, consent, and physician order specifying those requirements.
Two residents in the facility did not receive their prescribed medications as ordered, leading to deficiencies in medication administration. One resident with GERD did not receive Pantoprazole Sodium Oral Suspension on multiple occasions, despite it being available in the refrigerator. Another resident with osteoarthritis did not receive Lidocaine Patches for pain management, even though the patches were in stock. Staff failed to notify the physician of missed doses and did not adhere to the facility's medication administration policies.
A facility failed to develop a comprehensive care plan for a resident readmitted after a brief discharge. Despite the resident's complex medical conditions, no new care plan was created upon readmission, as required by facility policy. Interviews revealed the care plan was deleted upon discharge, and the oversight persisted for over a month.
A resident with an indwelling urinary catheter was not provided care according to professional standards, as the catheter was changed routinely without clinical indications, contrary to CDC guidelines and facility policy. Additionally, the prescribed antibiotic, Levaquin, was not administered prior to catheter changes as ordered, which was intended to prevent UTIs. The Unit Manager confirmed the oversight in medication administration.
The facility failed to maintain sanitary conditions in two nourishment kitchens. On the Fifth Floor, a toaster had a buildup of crumbs and a butter packet wrapper, while on the Third Floor, the ice machine had dried debris and rust. Despite daily cleaning claims, there was no specific cleaning policy or schedule, leading to unsanitary conditions.
A resident over the age of 65 with dementia, COPD, and emphysema did not receive the PCV20 vaccination despite having a signed consent and a physician's order. The facility's policy required adherence to CDC guidelines and obtaining consent, but the vaccine was not administered, as confirmed by a corporate nurse. This oversight put the resident at risk for facility-acquired pneumonia.
A facility failed to accurately code the MDS for a resident, indicating a discharge to a short-term hospital instead of home. This error was confirmed through a review of the resident's progress notes and discharge summary, and acknowledged by the MDS Nurse.
Cold Meals and Unmet Egg Preference
Penalty
Summary
The facility failed to provide food and drink at a safe and appetizing temperature for residents on Units Two, Three, and Five, and failed to honor one resident’s documented meal preference for eggs over easy. The facility policies reviewed stated that food and drinks were to be palatable, attractive, and served at safe and appetizing temperatures, with hot foods held at a minimum of 135 degrees Fahrenheit and cold foods held at or below 41 degrees Fahrenheit. Residents on Unit Two reported that hot food was always cold, tasteless, and often needed to be microwaved, and residents on the units also voiced ongoing concerns in resident council and group meetings that food was cold, eggs were hard, and some items were poorly seasoned or overcooked. During lunch service on the observed date, the tray line began later than the facility’s scheduled time, and meal carts for Units Two, Three, Four, and Five were dispatched later than scheduled. Test trays completed after residents had already received their meals showed multiple hot items at temperatures below the facility’s stated holding standard, including mashed potatoes, green beans, chicken, pork roast, dinner rolls, and desserts that were cool or lukewarm. On Unit Two, the test tray items were described as lukewarm, cool, or room temperature, and on Unit Three and Unit Five, several items were described as slightly warmer than room temperature, lukewarm to cool, or cool. The RD and FSD acknowledged that residents had raised concerns about cold food and that food temperatures were being monitored, but the observations documented that the meals served to residents were not consistently maintained at appetizing temperatures. Resident #11, who was cognitively intact with a BIMS score of 15 and had diagnoses including protein calorie malnutrition, disorders of plasma protein metabolism, and hyponatremia, had a documented preference for eggs over easy. The resident stated that the eggs served were very hard and that he or she did not eat eggs cooked over hard. The surveyor observed breakfast trays on two mornings with eggs that appeared fully fried and hard rather than over easy. The dietary ticket identified the resident’s preference for over easy eggs, and the FSD confirmed that the eggs shown in the picture were cooked through and were not prepared as the resident preferred. The RD also reviewed the picture and agreed that the eggs were not cooked as over easy eggs per the resident’s meal preference.
Infection Control Failures During COVID-19 Outbreak and Isolation Care
Penalty
Summary
The facility failed to follow infection prevention and control practices during a COVID-19 outbreak on Unit Two and Unit Five. The CDC guidance cited in the report stated that, during an outbreak investigation in a nursing home, testing should be performed for all residents and health care personnel on the affected unit(s), with testing recommended immediately and then again 48 hours after the first negative test and 48 hours after the second negative test. The facility’s own outbreak testing documentation did not show that all residents and staff on Units Two and Five were tested until 11/23/25 and 11/24/25, which was later than 24 to 48 hours after the first positive residents were identified on each unit. The facility’s respiratory surveillance listing showed the first COVID-19 positive resident on Unit Five on 11/16/25, the second positive resident on Unit Two on 11/18/25, and a third positive resident on Unit Five on 11/20/25. The listing also showed seven additional residents and one staff member testing positive on Unit Five on 11/23/25, followed by two more staff members testing positive on Unit Five on 11/24/25. During interview, the Regional Director of Clinical Services stated that all residents and staff on Units Two and Five should have been tested after the first positive residents were identified and that outbreak testing had not started until 11/23/25. The facility also failed to ensure required PPE was worn for Resident #69, who was admitted with diagnoses including immunodeficiency, COPD, and emphysema and had a BIMS score of 15. Resident #69 had physician orders and a care plan for Contact and Droplet Precautions for COVID-19, with the resident in a room alone during isolation and services provided in the room. The isolation sign outside the room required hand hygiene, gown, N95 respirator, eye protection, and gloves. However, CNA #1 entered the room with gown, N95, and gloves but no eye protection, stating none was available in the bin. CNA #2 was observed making the resident’s bed and removing dirty linen without a gown, N95 mask, or eye protection, and without observed hand hygiene before exiting. CNA #3 later entered the room without eye protection while assisting the resident to the bathroom. The DON stated that staff entering the room for close contact care and linen changes needed to wear gown, gloves, N95 respirator, and eye protection.
Failure to Follow Meal Assistance Care Plan
Penalty
Summary
The facility failed to implement Resident #125’s person-centered care plan for meal assistance. The resident was admitted in July 2025 with diagnoses including dysphagia, oropharyngeal phase, and dysarthria following a nontraumatic intracranial hemorrhage. The MDS indicated the resident was moderately cognitively impaired with a BIMS score of 8 out of 15 and required set up or clean up assistance with eating. The resident’s November 2025 physician orders included House Shakes twice daily, and the care card identified supervision by staff to eat. The resident’s nutrition care plan, revised 11/19/25, identified risk for alteration in nutrition related to acute on chronic medical conditions and significant weight loss, and included interventions to assist to fully set up the meal tray, cut larger items to bite size, and have the resident out of bed and in the dining room for all meals and supervised. The ADL care plan, revised 11/25/25, also identified that the resident required intermittent supervision by staff to eat and encouraged out of bed and to the dining room for meals. The speech evaluation summary of daily skilled services dated 11/20/25 documented staff education, care plan update, positioning out of bed for meals, and assistance to set up the tray. Despite these documented interventions, surveyors observed the resident in bed or seated at the edge of the bed with meal trays placed in front of him/her and no staff present during breakfast and lunch observations. On one occasion, the speech therapist entered the room, observed that the French toast was not cut into bite-sized pieces, and cut it for the resident, after which the resident began eating independently. The resident’s weight summary showed a drop from 165.0 pounds on 10/9/25 to 145.3 pounds on 11/13/25, a loss of 19.7 pounds in one month. During interview, the unit manager stated the resident should be out of bed for meals and that staff were expected to cut the meal into bite-sized pieces, but acknowledged the information had not been communicated to all staff. The DON stated unit managers were responsible for identifying weight loss and following up with necessary interventions, but they had not.
Failure to Support Hearing Aid Use and Delay in Restorative Nursing Services
Penalty
Summary
The facility failed to ensure that residents maintained their ADL abilities when there was no medical reason for decline. For one resident with documented hearing loss, age-related cognitive decline, and a need for assistance with personal care, staff did not consistently assist with applying the hearing aid during morning care. The resident’s MDS indicated hearing was adequate with a hearing device in place, but the care plan did not include an intervention for the hearing device, and the care Kardex also lacked direction for staff to provide it. During observation, the resident stated he/she could not hear and needed the hearing aid. On one occasion, a staff member left the dining room and returned with the hearing aid, after which the resident said he/she could hear. On another occasion, the resident again indicated inability to hear until the CNA provided the hearing aid. The CNA stated she was unaware the resident had a hearing aid and said it should have been listed in the Care Kardex so she would know to place it for the resident. The UM confirmed the resident required assistance with personal care, was hard of hearing, required a hearing aid, and should have had a hearing deficit care plan and linked Kardex entry. For another resident admitted with diagnoses including left humerus fracture, lack of coordination, difficulty walking, muscle weakness, history of falling, chronic pain, and polyneuropathy, the facility did not initiate the Restorative Nursing Program in a timely manner after discharge from therapy. The restorative communication tool dated 10/28/25 identified upper extremity strengthening and ambulation goals, and PT discharge documentation stated the restorative program was established. However, the resident reported not receiving rehabilitation services after moving units, and the UM stated there was no evidence the resident had received restorative nursing services. The resident later said he/she had continued to question when rehabilitation services would begin and did not feel like he/she had been getting exercise. The DON stated the expectation was that the resident would receive restorative nursing services according to the plan of care.
Missing Physician Order for Indwelling Urinary Catheter
Penalty
Summary
Appropriate care for residents with indwelling urinary catheters was not provided for one resident with a Foley catheter in place. Resident #10 was admitted with diagnoses including congestive heart failure and dislocation of the right hip, and the MDS indicated mild cognitive and memory impairment and the presence of an indwelling urinary catheter. During surveyor observations, the resident was seen lying or reclining in bed with the catheter drainage bag hanging from or hooked to the bed frame, with clear yellow urine in the tubing and the bag covered with a privacy cover. Review of the resident’s physician orders showed no order for the placement of the indwelling urinary catheter and no order identifying the catheter size. During interview, a nurse stated there was no physician order in place for the catheter and that medications, treatments, and procedures required a physician order; the nurse also stated she did not know the catheter size because no order identified it. The DON later stated the resident should have had a physician order for the indwelling urinary catheter, but no such order was in place.
Labs Ordered for Resident with Anemia Were Not Obtained
Penalty
Summary
The facility failed to ensure that laboratory services were completed as ordered for one resident out of a sample of 31. Resident #88, who was admitted in May 2025 with diagnoses including malignant neoplasm of the brain, hypothyroidism, and anemia, had a care plan that included obtaining labs as ordered due to risk for re-hospitalization and increased nutrient needs. On 10/29/25, the PA documented that blood work would be ordered to assess for iron deficiency anemia and to consider supplementation. The resident’s November 2025 physician orders included TSH, free T3, T4, B12, folate, ferritin, serum iron, and TIBC, effective 10/29/25. The medical record did not show results for any of these ordered tests. During interview, UM #2 stated the blood work should have been drawn the next day and had not been obtained as ordered. The PA stated she was unaware the labs had not been obtained and that the results were important because supplementation would have been based on them. The Regional Director of Clinical Services stated laboratory services had been in the facility several times since 10/30/25 and the resident’s labs should have been drawn the next day after the order.
Incomplete wound order documentation and missing restraint monitoring records
Penalty
Summary
Medical records were incomplete and inaccurate for two residents. For one resident with diabetes, CHF, venous insufficiency, and PVD, the facility documented new right lower extremity wounds on the wound observation tool and weekly skin integrity tool, including three unroofed blisters on the right medial shin with minimal clear drainage and an Unna Boot treatment plan twice weekly. However, the November 2025 physician orders did not contain the wound treatment order for the right lower extremity wounds, even though the DON stated she assessed the wounds, performed wound care, and obtained the physician order for the Unna Boot at that time. The resident was cognitively intact with a BIMS score of 15. The resident and UM #1 both confirmed the presence of the right shin wound and Unna Boot treatment, and UM #1 stated there was no treatment order in the medical record at that time. The DON stated the order should have been entered into the EHR when obtained, but it had not been entered. For another resident with metabolic encephalopathy, vascular dementia with anxiety, muscle weakness, and difficulty walking, the facility used an enclosed framed wheeled walker as a restraint to promote safe ambulation and prevent injury related to falls. The care plan and informed consent described the restraint use, including checks every hour and release every two hours, and the physician order summary reflected those instructions. However, review of the November 2025 MAR and TAR showed no documentation of the frequency of use, release of the restraint device, or positioning checks. UM #3 confirmed there was no evidence nursing staff recorded the restraint documentation, and the DON stated her expectation was that staff document the duration of use, release timing, and positioning checks.
Medication Administration Deficiencies for Two Residents
Penalty
Summary
The facility failed to administer medications according to professional standards of practice for two residents, leading to deficiencies in medication administration. Resident #51, diagnosed with gastroesophageal reflux disease (GERD) and dementia, did not receive the prescribed Pantoprazole Sodium Oral Suspension on multiple occasions in June and July 2024. The medication was available in the refrigerator, but staff failed to administer it and did not notify the physician of the missed doses, as required by the facility's policy. Similarly, Resident #13, who has osteoarthritis and dementia, did not receive the prescribed Lidocaine External Patches for pain management on several occasions from March to June 2024. The facility's records indicated that the patches were either pending arrival or unavailable, yet the patches were observed to be in stock in the facility's Central Supply storage room. Staff failed to document the reasons for the missed doses and did not take appropriate actions to ensure the medication was administered as ordered. Interviews with facility staff, including the Unit Manager and Nurse #1, revealed that the medications were indeed available but were not administered due to oversight. The Director of Nursing confirmed that the facility's policies regarding medication administration and missed doses were not adhered to by the nursing staff, contributing to the deficiencies identified during the survey.
Failure to Implement Comprehensive Care Plan for Readmitted Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was readmitted after a brief discharge. The facility's policy requires that a comprehensive care plan be developed within seven days after the completion of a comprehensive assessment. However, upon the resident's readmission in June 2024, no evidence was found that a new care plan was created, despite the resident's complex medical conditions, including diabetes, asthma, and congestive heart failure. Interviews with the MDS Nurse revealed that the resident's care plan was deleted from the medical record upon discharge, and the resident was classified as an interrupted stay due to the short duration of the discharge. The MDS Nurse acknowledged that a comprehensive person-centered care plan should have been in place immediately upon the resident's readmission to ensure proper care and services. The absence of a care plan persisted from mid-June to late July 2024, indicating a significant oversight in the facility's care planning process.
Failure to Follow Catheter Care Protocols and Medication Administration
Penalty
Summary
The facility failed to provide care and services according to professional standards for a resident with an indwelling urinary catheter, who was at risk for developing a urinary tract infection (UTI). The staff did not change the catheter based on clinical indications such as infection, obstruction, or a compromised closed system, as recommended by the CDC guidelines and the facility's own policy. Instead, the catheter was changed routinely on specific dates without documented clinical indications for these changes. Additionally, the facility staff failed to administer the prescribed antibiotic, Levaquin, to the resident prior to the catheter changes as ordered by the physician. The medication was intended to be given a few hours before each catheter change to help prevent infections, but records show that it was not administered on the specified dates before the catheter changes. The Unit Manager confirmed the oversight and acknowledged that the resident should have received the antibiotic as ordered to prevent UTIs.
Sanitation Deficiencies in Facility's Nourishment Kitchens
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in two nourishment kitchens, specifically on the Fifth Floor and the Third Floor (Garden Terrace). On the Fifth Floor, a toaster was observed with a buildup of crumbs and a butter packet wrapper inside, indicating a lack of proper cleaning and maintenance. Despite daily cleaning claims by the Housekeeping Supervisor, there was no specific policy for cleaning kitchenettes, and the issue persisted throughout the day. On the Third Floor, the ice machine in the Garden Terrace Unit nourishment kitchen was found in unsanitary conditions. The water and ice dispenser had dried white debris, rust, and crusty buildup on various parts, including the grate, drain pan, and spout. The Housekeeping Supervisor acknowledged the lack of a written cleaning schedule or logs and admitted that the dispenser had not been cleaned thoroughly, which could lead to bacterial growth. Staff used this dispenser daily to provide residents with ice and water, highlighting the importance of maintaining cleanliness.
Failure to Administer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer a Pneumococcal Vaccination to a resident, identified as Resident #51, who was over the age of 65 and had a history of dementia, COPD, and emphysema. Despite having a consent form signed for the Pneumococcal Vaccination in August 2021 and a physician's order in July 2024 to administer the vaccine per CDC guidelines, the resident did not receive the PCV20 vaccination. This oversight was confirmed during an interview with Corporate Nurse #1, who acknowledged the absence of evidence in the clinical record indicating that the resident had received the required vaccination. The facility's policy, dated September 2023, required adherence to CDC recommendations for Pneumococcal Vaccination timing and mandated that education be provided to the resident or their representative, with a signed consent form. However, the facility did not follow through with the administration of the vaccine, as indicated by the lack of documentation in the resident's clinical record. This failure to administer the vaccine put the resident at risk for developing facility-acquired pneumonia.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect the status of a resident. Specifically, the MDS inaccurately indicated that the resident was discharged to a short-term hospital, while the resident was actually discharged home. This discrepancy was identified through a review of the resident's Nurses Progress Note and Discharge Summary assessment, both of which confirmed the resident's discharge home. During an interview, the MDS Nurse acknowledged the error, stating that the MDS had been inaccurately coded.
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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 Fitchburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fitchburg Healthcare | 0.8 mi | ★★★★★ | 17 | 0 |
| Fitchburg Rehabilitation And Nursing Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Leominster Rehabilitation And Nursing Center | 4.5 mi | ★★★★★ | 6 | 0 |
| Life Care Center Of Leominster | 4.6 mi | ★★★★★ | 15 | 0 |
| Wachusett Manor | 8.7 mi | ★★★★★ | 8 | 0 |
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