Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Life Care Center Of Leominster during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment, fully dependent on staff for care, was found with new bruising on the left forearm. When asked, the resident stated that staff had been rough but would not identify who was involved. The Activity Director reported this to the Unit Manager and ADON, who assessed the resident and speculated the bruising might be from wheelchair self-propulsion, despite the resident having self-propelled for a long time without similar bruising. The DON, ADON, and Unit Manager treated the incident as an injury of unknown origin rather than an abuse allegation, and the internal investigation did not include staff or resident interviews, written witness statements specific to rough care, or efforts to identify any involved staff, contrary to facility policy requiring thorough investigation of all alleged violations.
Missing Pneumococcal Vaccine Education and Consent Documentation: The facility failed to document resident/rep education on the benefits and side effects/risks of pneumococcal immunization and failed to maintain consent or declination forms in the medical records for 4 of 5 sampled residents. The facility policy required education, signed consent or declination, and annual re-addressing of refusals, but the records reviewed did not show these elements. The IP stated immunizations are reviewed in MIIS and documented in the chart, and the DON said vaccines should be part of the admission assessment.
Kitchen Freezer Door Not Maintained in Safe Operating Condition: The walk-in freezer door was broken and the gasket around the door had not been repaired, resulting in ice on the freezer floor and heavy frost on food products near the door. The FSD said the door repair was delayed, the Maintenance Director said the problem had been worsening for a while, and a hammer was being used to break ice in the freezer.
Improper Use of Pillows as a Restraint: A resident with severe cognitive impairment, total ADL dependence, and diagnoses including concussion and cervical spinal cord edema was observed in bed with multiple pillows stuffed under the fitted sheet to keep the resident from getting out of bed. A CNA said the pillows were used because the resident moved around a lot, while the UM and DON stated the pillows under the sheet were a restraint. The record did not show a restraint assessment or a physician order for restraint use, and the resident had recent falls out of bed.
A resident with DM2, hemiplegia/hemiparesis, and severe cognitive impairment had a white bandage on the left shin with seepage noted on multiple observations, but the bandage was not dated or initialed. Staff, including the Unit Manager, DON, and an RN, stated that bandages should be dated and initialed so the treatment can be monitored and so staff know who provided it and when. The resident’s skin check noted scattered skin alterations from self-inflicted scratching, and there was no physician order for the lower-extremity treatment.
Failure to Maintain Nebulizer Equipment Care Plan: A resident with COPD and asthma/chronic lung disease was receiving nebulized meds twice daily, but the record lacked an order or care plan for nebulizer machine care, including the mask and tubing. Surveyors observed the mask uncovered on the bedside table, on top of the machine, and hanging from the bed railing, while staff stated the equipment should be changed weekly, dated, and stored in a bag when not in use.
Missing Hospice Plan of Care in Resident Record: A resident with a terminal lung cancer diagnosis was receiving hospice services, but the facility record did not have the hospice agency’s current plan of care available to staff. The Unit Manager and SW could not locate it in the hospice binder, and the DON stated no specific person was assigned to coordinate hospice care, while SW said social services was responsible for referrals, coordination, and keeping the hospice POC available.
A resident's care plan was not updated to reflect the current transfer method recommended by Physical Therapy, despite staff education. Initially requiring a Hoyer Lift, the resident was later assessed to use a sit to stand lift with two staff members. The care plan remained unchanged, as confirmed by the DON.
A resident's bed was positioned flush against the wall, restricting movement and acting as a physical restraint without proper assessment or documentation. The facility's policy requires medical justification and regular reassessment for restraints, which were not followed in this case. Staff interviews revealed a lack of clarity on the decision-making process for the bed's positioning.
A resident with a history of cerebral infarction developed a pressure ulcer on the left lateral malleolus, but the facility failed to apply the physician-ordered Allevyn dressing. Nurse #1 was unaware of the dressing order, and the Treatment Administration Record did not indicate the need for a dressing check every shift. The resident confirmed no dressing was applied, and the DON acknowledged the oversight. The wound team failed to ensure proper documentation and communication of the physician's orders.
The facility failed to act on the Consultant Pharmacist's recommendations for two residents, resulting in unaddressed medication regimen changes. One resident's recommendations included discontinuing an antihistamine and an acetylcholinerase inhibitor, while another resident's recommendations involved changes to a pain reliever, NMDA receptor antagonist, anti-seizure medication, and discontinuation of a probiotic and multivitamin. Interviews revealed inconsistent follow-up processes for addressing these recommendations.
A resident received an antibiotic eye ointment for ten days instead of the prescribed seven days due to a failure in the electronic medication record system. The nurse who entered the order stated that the system did not discontinue the order as intended, resulting in unnecessary medication administration.
A resident over 65 years old was not offered an updated COVID-19 vaccination upon admission, despite being eligible and willing to receive it. The facility's policy required offering vaccines and documenting education and consent, but interviews revealed a lack of evidence that the resident was offered the vaccine.
Failure to Investigate Resident’s Allegation of Rough Care and Unexplained Bruising as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of rough handling and associated bruising in a resident with severe cognitive impairment. The resident, admitted in December 2022 with diagnoses including dementia, depression, and anxiety, was dependent on staff for care. A Quarterly MDS dated 03/19/26 documented severe cognitive impairment. On 04/07/26, a skin assessment identified new bruising on the resident’s left inner and outer forearm. The facility submitted a report through the Health Care Facility Reporting System noting small bruises on the resident’s left forearm and completed an internal investigation that characterized the bruising as an injury of unknown origin, suggesting it might have been caused by wheelchair self-propulsion. According to the Activity Director’s written statement and interview, during lunch on 04/07/26 she observed bruises on the resident’s left forearm and asked how they occurred. The resident responded that “they were rough with me” and stated not wanting to get anyone in trouble, and would not identify which staff member was involved. The Activity Director immediately informed the Unit Manager and the ADON. The Unit Manager confirmed that she was told the resident had said someone had been rough with care and that she and the ADON assessed the resident. The Unit Manager reported that the resident was unable to tell them what happened, and although they considered self-propulsion of the wheelchair as a possible cause, she acknowledged the resident had been self-propelling for a long time without similar bruising. The ADON acknowledged that on 04/07/26 she was aware the resident had alleged staff had been rough with care and that rough handling could have caused the bruising. The DON stated she was notified of the new bruising and, together with the ADON and Unit Manager, concluded the bruises were from self-propulsion, and she did not investigate the matter as an allegation of abuse by staff. The facility’s internal investigation contained no documentation that staff were interviewed or asked for written statements specific to the allegation of rough care, and no efforts were documented to identify an accused staff member or to interview other residents on the unit. The Administrator later stated she had not been informed of the resident’s allegation of rough care at the time and that the incident had been handled only as an injury of unknown origin rather than as an abuse allegation, resulting in the absence of a thorough abuse investigation as required by the facility’s policy on incident and reportable event management.
Missing Pneumococcal Vaccine Education and Consent Documentation
Penalty
Summary
The facility failed to implement its policies and procedures for flu and pneumonia vaccinations by not documenting education, consent, or refusal for pneumococcal immunization in the medical records of 4 out of 5 sampled residents. The facility policy titled "Pneumococcal Vaccine Policy for Residents" dated 7/8/25 stated that education is to be provided to the resident and/or representative regarding benefits and side effects or risks, that each resident should be offered pneumococcal immunization unless medically contraindicated or previously immunized, and that consents and declinations are to be documented using the Med-Pass form and placed in the medical record. The policy also stated that refusals are to be re-addressed annually and those conversations captured in the medical record. Review of the residents' immunization records showed that 4 of the 5 sampled residents' records did not indicate education was provided to the resident and/or representative regarding benefits and side effects or risks, and 4 of the 5 records did not contain consents or declinations using the informed consent for pneumococcal vaccine. During interview, the Infection Preventionist stated that immunizations are reviewed in MIIS on admission, documented in the medical record, and that residents and/or representatives are educated regarding benefits and side effects/risks, with consent forms used for offering or declination of immunizations. The DON stated that vaccines should be part of the admission assessment and expected immunizations to be part of the information gathering on admission.
Kitchen Freezer Door Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to maintain kitchen equipment in safe operating condition when the walk-in freezer door was not functioning properly. During the initial kitchen walkthrough, the surveyor observed ice covering the freezer floor near the door, making it slippery, and food products next to the door were covered in a thick layer of frost that extended from the floor up to the height of the door and onto the shelf beside it. A metal hammer was also observed on top of the ice machine, and the Food Service Director stated it was used to break the ice in the freezer. The Food Service Director stated the warmer gasket around the freezer door had been broken and that repair was delayed until after a facility cookout because the door would need to be removed for a prolonged period. The Administrator later produced an order form for the needed parts, which had been ordered on 7/25/25 and arrived on 8/4/25. The Maintenance Director stated the freezer door had been broken for a while and had been getting worse over time, and he said the Food Service Director asked him to wait to fix it because there was a lot of food product in the freezer. The Food Service Director later said he was unaware the parts had arrived and stated it would not take long to fix the freezer.
Improper Use of Pillows as a Restraint
Penalty
Summary
The facility failed to ensure one resident was assessed for and free from restraints when pillows were stuffed under the fitted sheet to keep the resident in bed. The resident was admitted in April 2025 with diagnoses including concussion, edema of the cervical spinal cord, and protein calorie malnutrition. The most recent MDS indicated severe cognitive impairment, inability to complete the Brief Interview for Mental Status exam, and total dependence on staff for all activities of daily living. On observation, the resident was awake in bed and twisting and turning while multiple pillows were seen stuffed under the fitted sheet from the top to the bottom of the bed, creating a large mound higher than the resident. A CNA stated that the resident moved around in bed a lot and that the pillows were used to keep the resident in bed. During another observation, staff removed the pillows from under the fitted sheet, and the Unit Manager stated the pillows could not be tucked under the fitted sheet and that they were considered a restraint. The resident’s record did not show a restraint assessment, and there was no physician order for restraint use. The resident’s falls care plan included increased supervision when restless, and incident reports showed falls out of bed on 7/11/25 and 8/21/25. The DON stated the resident wiggled around and moved a lot in bed, that frequent checks should be completed, and that pillows under the sheets were a restraint.
Failure to Date and Initial a Bandage
Penalty
Summary
The facility failed to follow professional standards of nursing practice for one resident by not dating and initialing a bandage on the left lower extremity. Resident #50 was admitted in July 2025 with diagnoses including type 2 diabetes mellitus and hemiplegia and hemiparesis following cerebral infarction. The most recent MDS indicated a BIMS score of 99, showing severe cognitive impairment, and that the resident required staff assistance with activities of daily living. During observations on 8/19/25 and 8/20/25, Resident #50 was seen in a wheelchair with a white bandage on the left shin that had seepage beginning to saturate the bandage, and there were no dates or initials on the bandage at any of the observed times. The weekly skin check dated 8/14/25 noted scattered skin alterations to both arms and lower legs from self-inflicted scratching, and the physician’s orders did not include a treatment order for the lower extremities due to self-inflicted scratching. In interviews, the Unit Manager, DON, and a nurse stated that bandages should be dated and initialed so the treatment can be monitored and so staff know who provided it and when.
Failure to Maintain Nebulizer Equipment Care Plan
Penalty
Summary
The facility failed to provide respiratory care services consistent with professional standards of practice for one resident who had COPD and asthma/chronic lung disease and was receiving nebulized medications twice daily. The resident’s record included physician orders for Brovana inhalation nebulization solution and budesonide suspension, and the MAR showed the medications were being administered via nebulizer. However, the resident’s medical record did not contain a physician’s order or care plan for the care of the nebulizer machine, including the tubing or mask. Surveyors observed an uncovered nebulizer mask resting on the bedside table contents, later observed uncovered on top of the nebulizer machine, and then hanging from the resident’s bed railing. The tubing was dated 8/1/25 during the observations. Facility staff stated that nebulizer masks and tubing are changed weekly on Sunday night, that the tubing should be dated and labeled, and that the masks should be stored in a respiratory bag or plastic bag by the resident’s bed when not in use. The DON also stated the tubing and masks are changed weekly unless soiled and must be stored in a plastic bag by the bed and dated.
Missing Hospice Plan of Care in Resident Record
Penalty
Summary
The facility failed to ensure that a current hospice plan of care was present in the medical record and coordinated with facility staff for one resident. Resident #11 was admitted with diagnoses including malignant carcinoid tumor of the bronchus and lungs, had an MDS assessment showing a BIMS score of 13 out of 15 indicating cognitive intactness, and was receiving hospice services. The medical record included a physician order to admit the resident to contracted hospice services and a facility care plan noting the resident had a terminal prognosis and had signed onto contracted hospice, but the record did not show the hospice agency’s plan of care was available to facility staff. During interviews, the Unit Manager and Social Worker #1 were unable to locate the hospice plan of care in the hospice binder, and Social Worker #1 stated she would contact the hospice agency to have it sent to the facility. Later that morning, Social Worker #1 provided a copy of the hospice plan of care after contacting the hospice agency by email and stated it should be available to staff in the facility. The DON stated no specific person was assigned to coordinate hospice care in the facility, and Social Worker #2 stated social services was responsible for making hospice referrals, coordinating care, and ensuring the hospice plan of care was available in the facility.
Failure to Update Resident Care Plan with Current Transfer Method
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident who was assessed by the Physical Therapy Department to require a sit to stand mechanical lift for transfers. Initially, the resident's care plan indicated the use of a Hoyer Lift with two staff members for assistance. However, after an evaluation by Physical Therapy, it was determined that the resident could be safely transferred using a sit to stand lift with two staff members. Despite this assessment and subsequent education provided to the nursing staff, the care plan was not updated to reflect the new transfer method. The resident, admitted in November 2023, had diagnoses including generalized weakness, obesity, and anxiety. The Physical Therapy Department documented the resident's progress and educated the nursing staff on the updated transfer method on two occasions. However, the care plan continued to reflect the outdated transfer method, indicating a lapse in updating the resident's care plan to align with the most current assessment and recommendations. This oversight was confirmed during an interview with the Director of Nurses, who acknowledged that the care plan should have been updated but was not.
Failure to Assess and Document Physical Restraint Use
Penalty
Summary
The facility failed to provide an environment free from physical restraints for one resident, identified as Resident #56, out of a sample of 23 residents. The deficiency was observed when the resident's bed was positioned flush against the wall on the left side, restricting the resident's ability to exit the bed from that side. This positioning was not supported by a physician's order, nor was there any documented assessment or re-evaluation of the need for such a restraint. The facility's policy on physical restraint use requires that any restraint must be medically justified, documented, and reassessed regularly, none of which were adhered to in this case. Resident #56, who was admitted to the facility in February 2018, has diagnoses including dementia and developmental delay. The resident was observed multiple times with the bed positioned against the wall, and interviews with staff revealed a lack of clarity on the decision-making process for this arrangement. The CNA and Unit Manager both acknowledged the restriction caused by the bed's position, and the DON confirmed that no restraint assessment or physician's order was in place. The DON also noted that the bed's position was intended to prevent falls, but admitted that proper documentation and assessment were lacking.
Failure to Apply Physician-Ordered Wound Dressing
Penalty
Summary
The facility failed to provide appropriate care for a resident with a pressure ulcer, as evidenced by the absence of a wound dressing as ordered by the physician. The resident, who was admitted with a history of cerebral infarction and was at risk for pressure ulcers, developed an unstageable deep tissue injury on the left lateral malleolus. The physician had ordered an Allevyn dressing to be applied every five days, but during an observation, it was found that no dressing was in place, and the wound was showing signs of deterioration with blood-tinged drainage. Nurse #1, who was responsible for the resident's care, was unaware of the dressing order and had not checked the resident's wound the previous day. The Treatment Administration Record (TAR) did not indicate the need for a dressing check every shift, leading to the oversight. The resident confirmed that no dressing had been applied to the wound, and the Director of Nursing (DON) acknowledged that a dressing should have been in place as per the physician's order. The Assistant Director of Nursing (ADON) explained that the wound team, which included the DON, ADON, Unit Manager, and a Physical Therapist, conducted weekly rounds to discuss treatment orders. However, there was a lapse in communication and documentation, as the physician's orders were not properly entered into the electronic medical record (EMR), resulting in the failure to apply the necessary wound dressing and monitor the wound as required.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were acted upon as required for two residents. For one resident, the facility did not review or respond to the pharmacist's recommendations to discontinue an antihistamine and an acetylcholinerase inhibitor. Despite the pharmacist's recommendations being communicated, there was no documented evidence that the physician or facility staff took any action. For another resident, the facility did not review or respond to the pharmacist's recommendations regarding changes to the administration of a mild pain reliever, a NMDA receptor antagonist, an anti-seizure medication, and the discontinuation of a probiotic and multivitamin. The resident had been routinely refusing these medications, yet the facility failed to act on the pharmacist's suggestions to adjust the medication regimen. Interviews with facility staff revealed a lack of a consistent process for ensuring that pharmacist recommendations were addressed. The Director of Nursing admitted that the follow-up process was inconsistent, and there was no documented evidence that the recommendations were reviewed or acted upon by the physician or facility staff, as required.
Excessive Duration of Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medication. Specifically, a resident was administered an antibiotic eye ointment for an excessive duration. The physician had ordered the medication to be administered for seven days, but it was given for ten days. This discrepancy was identified during a review of the medication administration records, which showed that the medication was administered three times a day from the start date and continued beyond the prescribed duration. The error was attributed to a failure in the electronic medication record system, as noted by the nurse who entered the order. The nurse stated that she had input the order for a seven-day duration, but the system did not automatically discontinue the order after the specified period. The Director of Nursing confirmed that the order should have been discontinued after seven days, but it remained active, leading to the unnecessary administration of the medication.
Failure to Offer COVID-19 Vaccination to Eligible Resident
Penalty
Summary
The facility failed to provide education, assess eligibility, and offer COVID-19 vaccinations to Resident #24, who was eligible for an updated vaccine. The facility's policy required that residents be offered the COVID-19 vaccine unless medically contraindicated or already immunized, and that documentation of education and vaccination status be maintained. However, Resident #24, who was over 65 years old and had received previous COVID-19 vaccinations, was not offered an updated vaccine since their admission in November 2023, despite being eligible according to CDC guidance. Interviews with the Director of Nursing (DON) and the Infection Preventionist (IP) revealed that the facility's process involved reviewing vaccination history upon admission and documenting consent or refusal. However, the IP admitted that there was no evidence that Resident #24 had been offered the vaccine. Resident #24 confirmed not being offered a COVID-19 vaccination since admission and expressed willingness to receive a booster if offered.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 474 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Leominster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Leominster Rehabilitation And Nursing Center | 1.9 mi | ★★★★★ | 6 | 0 |
| Fitchburg Rehabilitation And Nursing Center | 3 mi | ★★★★★ | 0 | 0 |
| River Terrace Rehabilitation And Healthcare Ctr | 4.4 mi | ★★★★★ | 0 | 0 |
| Fitchburg Healthcare | 4.4 mi | ★★★★★ | 17 | 0 |
| Highlands, The | 4.6 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Life Care Center Of Leominster.
100% money-back within 48 hours.
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.