Fitchburg Healthcare

Inspectors wroteBased on observations, interviews, and record review, for one Resident (#43) out of a total sample of 27 residents, the facility failed to provide effective pain management consistent with professional standards of practice, resulting in persistent pain, inability to sleep, and inability to participate in scheduled occupational therapy (OT) sessions for the Resident. Specifically, the facility failed to: -ensure that an order from the Nurse Practitioner (NP) to administer Oxycodone (opioid pain medication) IR (immediate release) to the Resident every six hours as needed (PRN) for pain was implemented and administered when previous scheduled and PRN Oxycodone orders were ended/stopped. -communicate recommendations for pain management received from the Resident's Palliative Care Team on 2/4/26 to the Physician/NP until 2/6/26. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that one Resident (#12) out of total sample of 27 residents, on one (Three West) of four units observed, was afforded a dignified dining experience. Specifically, for Resident #12, the facility failed to ensure the Resident was positioned per preference and that staff were seated and not standing over the Resident while assisting him/her to eat.

Inspectors wroteBased on record review, and interview, the facility failed to notify the Provider when test results were outside the parameters ordered, for one Resident (#13), out of a total sample of 27 residents. Specifically, the facility failed to notify the Provider as ordered, when Resident #13's finger stick blood sugar (FSBS) reading was greater than 301 mg/dL (milligrams/ deciliter), putting the Resident at risk of complications related to hyperglycemia.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean and homelike environment for one Resident (#14) out of a total sample of 27 Residents, on one unit (Two East) out of four units observed. Specifically, the facility staff failed to ensure that Resident#14's enteral tube feeding (nutritional supplement provided through a tube into the stomach) pole (where the feeding pump is attached) and privacy curtain located next to the feeding pump/pole equipment was maintained in a clean and sanitary manner.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all residents residing on one Unit (Three West) out of four total resident units observed, including Resident #113, were free from physical restraints implemented for staff convenience pertaining to restricting wandering residents. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that a person-centered care plan relative to eating assistance and supervision was implemented for one Resident (#110) out of a total sample of 27 residents. Specifically, for Resident #110, the facility failed to implement continual supervision by one (staff) and assist of one staff as needed to set up meals as required, when the Resident experienced a significant weight decline and was care planned for feeding assistance and supervision.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure activities of daily living (ADL's- activities related to personal care which includes washing, dressing, and oral hygiene) were provided for one Resident (#136) out of a total sample size of 27 residents. Specifically, for Resident #136, the facility failed to provide assistance with oral hygiene when the Resident required assistance to complete oral hygiene due to weakness and hemiparesis (weakness of one side of the body), placing the Resident at risk for dental complications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide respiratory care and services in accordance with professional standards of practice for one Resident (#27) out a total sample of 27 residents. Specifically, the facility failed to: -For Resident #27, obtain a Physician's order for a baseline oxygen flow rate, oxygen titration liter flow range and portable oxygen flow rate when the Resident was diagnosed with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, placing the Resident at risk for respiratory complications related to oxygen use.

Inspectors wroteBased on observations, interview, and record review, the facility failed to administer medications per professional standards of practice resulting in two significant medication errors for one Resident (#136) out of a total sample of 27 residents. Specifically for Resident #136, the facility staff failed to hold (not administer) administration of: -Amlodipine Besylate (used to treat high blood pressure) medication for six days between 1/1/26 - 1/31/26 as ordered, for a Systolic Blood Pressure (SBP) less than 110 millimeters of Mercury (mmHg), placing the Resident at risk for cardiac compromise. -Enalapril Maleate (used to treat high blood pressure) medication for five days between 1/1/26 - 1/31/26 per Physician's order, for a SBP less than 110 mmHg, placing the Resident at risk for cardiac complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medication was stored in a safe and sanitary manner in the medication carts on one (2 West) of four medication carts observed. Specifically, the facility failed to ensure that staff was not storing medications in an unsafe and unsanitary manner when:-staff stored one pre-poured medication cup containing resident medications in the top drawer of the 2 [NAME] medication cart.-and a second medication cup containing pre-poured, unlabeled medications was also observed in the top drawer of the 2 [NAME] medication cart.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide assistance for one Resident (#136) out of a total sample of 27 residents, in accessing routine dental services. Specifically, the facility failed to evaluate whether Resident #136 wished to obtain access to routine dental care, placing the Resident at risk for delayed routine dental services and impaired oral health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#12) out of a total sample of 27 residents. Specifically, for Resident #12, the facility staff failed to appropriately follow Enhanced Barrier Precautions (EBP's - the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), when providing high contact care for the Resident, increasing the risk of organism transmission to the Resident, staff, and other residents within the facility.

Inspectors wroteBased on observation, interviews and records reviewed, for one of three sampled residents (Resident #1), who resides on a secured Dementia unit, has a known behavior that includes physical aggression and has been involved in multiple resident to resident physical and verbal altercations, the Facility failed to ensure that they provided him/her with an adequate level of staff supervision on the unit to maintain residents safety in an effort to prevent resident to resident altercations, therefore placing him/her and other residents on the unit at risk for injury.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who was severely cognitively impaired, the Facility failed to ensure he/she was treated in a respectful and dignified manner, when during the provision of care, two staff members overheard Certified Nurse Aide (CNA) #1 interacting with Resident #1, during which CNA #1 used profanities and spoke to him/her in a raised, very loud tone of voice.

Inspectors wroteBased on record review, policy review and interview, the facility failed to ensure that Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) were accurate for one Resident (#111) out of a total sample of 24 residents. Specifically, for Resident #111 the facility failed to have the Resident evaluated for the capacity to make medical decisions following a decline/change in their cognitive status.

Inspectors wroteBased on interview, record and policy review, the facility failed to notify the Physician/Non-Physician Practitioner (NPP/ Nurse Practitioner [NP]) of a significant change in condition for two Residents (#23 and #111) out of a total sample of 24 residents. Specifically, the facility staff failed to notify the Physician/NPP: 1. For Resident #23, when the blood sugar reading was greater than 400 mg/dL (milligrams per deciliter). 2. For Resident #111, when the blood sugar reading was less than 70 mg/dL and greater than 401 mg/dL.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a Preadmission and Resident Review Level I (initial PASRR - initial pre-screening completed prior to admission to a Nursing Facility that assess for Serious Mental Illness[SMI] or Developmental Disabilities[DD]) screen was completed prior to admission to the facility for five Residents (#59, #90, #113, #56, and #111) out of a total sample of 24 residents.

Inspectors wroteBased on interview, and record review, the facility failed to the facility failed to provide care and services consistent with professional standards of practice for two Residents (#113 and #91) out of a total sample of 24 residents. Specifically, the facility failed to: 1. For Resident #113, ensure that Physician orders were obtained for a recommended Hemoglobin A1C (HbA1c - test used to identify Diabetes [disease that affects how the body uses blood sugar]) lab to be drawn as recommended by the Behavioral Health Nurse Practitioner (NP) for the Resident on medications for mental health conditions. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a resident-centered, meaningful, and engaging activity program for one Resident (#11) out of a total sample of 24 residents. Specifically, the facility failed to ensure that staff offered and encouraged engagement in activities identified as being preferences for Resident #11.

Inspectors wroteBased on observation, record and policy review, and interview, the facility failed to provide care and services as required for an indwelling urinary/Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine outside the body) for one Resident (#23) out of a total sample of 24 residents. Specifically, for Resident #23, the facility staff failed to: 1. verify the correct size indwelling urinary catheter as ordered by the Physician and ensure the verified size urinary catheter was in place. 2. to obtain an appointment with a Urologist as requested by the Nurse Practitioner (NP) to prevent catheter related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper nutrition and hydration care and services for one Resident (#64) out of a total sample of 24 residents. Specifically, for Resident #64, the facility failed to appropriately monitor daily fluid intake and follow the care plan to ensure that the Resident maintained fluid restriction amounts as ordered by the Physician.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for one Resident (#64) out of a total sample of 24 residents. Specifically, for Resident #64, the facility failed to: -ensure that the Resident who had a chronic pulmonary diagnosis was administered the appropriate liter per minute (LPM - flow rate) of supplemental Oxygen [O2] as ordered by the Physician. -routinely assess and monitor that the Resident's oxygen delivery device was set at the prescribed liter flow rate.

Inspectors wroteBased on record and policy review, and interview, the facility failed to complete ongoing communication with the contracted dialysis center related to dialysis care and services for one Resident (#91) out of one applicable resident, out of a total sample of 24 residents. Specifically, for Resident #91, the facility failed to: -ensure that dialysis communication forms included updated information on the Resident's dialysis care and services. -maintain communication with the dialysis center related to an elevated laboratory result for the Resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Physician orders were in place for lab work for one Resident (#120) out of a total of two residents reviewed for infection control. Specifically, for Resident #120, the facility failed to obtain Physician orders prior to completing Vancomycin (an antibiotic) trough laboratory (labs that measure the amount of Vancomycin in the blood stream to ensure it is at a therapeutic level) draws.

Inspectors wroteBased on record and policy review, and interview, the facility failed to ensure that specialized rehabilitation services were provided to one Resident (#21) out of a total sample of 24 residents. Specifically, for Resident #21, the facility failed to ensure that a speech and language therapy evaluation was completed timely, when it was identified the Resident was having difficulty swallowing.

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that administration of Pneumococcal Vaccination was provided timely to one Resident (#113) out of a total sample of five residents. Specifically, for Resident #113, the facility failed to ensure a Pneumococcal Vaccination was administered timely after the Resident and/or Resident Representative consented to receive the Pneumococcal Vaccination.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that Minimum Data Set (MDS) Assessments were coded accurately for four Residents (#70, #90, #113, and #56) out of a total sample of 24 residents and for one Resident (#124) out of a total sample of three closed records. Specifically, the facility failed to: 1. for Residents #70, #90, #113, ensure the Brief Interview of Mental Status (BIMS-cognitive test) and Patient Health Questionnaire-9 (PHQ-9-Depression questionnaire) interviews were attempted when the Residents were identified as at least sometimes being understood on the most recent MDS Assessment, 2. for Resident #124, ensure the Resident's discharge MDS Assessment was coded accurately related to the Resident's discharge 3. for Resident #56, code the use of a medication used for pain management and ensure the BIMS and PHQ-9 interviews were completed.

Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to implement the plan of care for two Residents (#67 and #47) out of a total sample of 26 residents. Specifically, the facility staff failed to: 1. For Resident #67, develop a person-centered care plan that included measurable objectives related to bilateral hand contractures (when muscles, tendons, joints or other tissues tighten or shorten causing loss of movement). 2. For Resident #47, implement a Physician's order to weigh weekly when the Resident had been identified as having failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity).

Inspectors wroteBased on observations, interview and record review, the facility failed to provide Activities of Daily Living (ADLs - bathing, dressing, grooming) care for two Residents (#110 and #53), out of a total sample of 26 Residents. Specifically, the facility staff failed to ensure that Resident #110 and Resident #53 were provided grooming to remove facial hair per their preference/comfort.

Inspectors wroteBased on observation, record review, policy review, and interview the facility failed to provide care and treatment in accordance with professional standards of practice for one Resident (#34) out of a total sample of 26 residents. Specifically, the facility staff failed to: -notify the Physician and implement the facility policy when the Resident had a weight gain of 14.76% in one month. -apply ace wraps (bandages used to help reduce swelling) to edematous (abnormally swollen with fluid) lower extremities (legs) as ordered when the Resident presented with 3+ edema (depression mark of 5 to 6 millimeters left in the edematous area when pressed with the finger tips that rebounds in 60 seconds) in both lower extremities.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure its staff provided foot care for one Resident (#34), out of a total sample of 26 residents. Specifically, the facility staff failed to ensure Diabetic foot care was provided to maintain good foot health per facility policy and professional standards.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff provided an environment as free of accident hazards as possible for two Residents (#26 and #106) out of 26 total sampled residents. Specifically, the facility staff failed to: 1. Provide continual supervision for Resident #26 which resulted in the Resident obtaining metal silverware, walking into an unoccupied third floor resident room, forcing the window fully open using the silverware, and removing the screen when the Resident had a recent history of exit seeking and attempted elopement through his/her own third floor bedroom window at the facility, increasing the Resident's risk for injury. 2. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to provide indwelling Foley catheter (also known as urinary catheter - a tube placed through the urethra into the bladder to drain urine) care, per professional standards for two Residents (#24 and #105) out of 6 applicable residents from a total sample of 26 residents. Specifically, the facility staff failed to ensure that the indwelling urinary catheter tubing for Residents #24 and #105 was securely placed as required to prevent possible dislodgement and trauma.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to provide care for one Resident (#1), out of two applicable residents sampled, in a total sample of 26 residents, related to a peripheral venous catheter (a small flexible tube placed into a peripheral vein to administer intravenous (in the vein) therapy. Specifically, the facility staff failed to: - obtain a Physician's order to insert and change a peripheral venous catheter. - obtain Physician approval to leave a peripheral venous catheter in place for longer than 7 days.

Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to provide care for one Resident (#122), who required hemodialysis (a process for purifying the blood of a person whose kidneys are not working normally) out of one applicable sampled resident, in a total sample of 26 residents. Specifically, the facility staff failed to provide care according to professional standards for the Resident's Arteriovenous Fistula (AV Fistula-a surgically created passageway between an artery and a vein, usually located in the arm and used as an access to administer hemodialysis treatments).

Inspectors wroteBased on record review and interview, the facility failed to identify triggers that may cause re-traumatization for one Resident (#106) with a diagnosis of Post-Traumatic Stress Disorder (PTSD), out of one applicable sampled residents.

Inspectors wroteBased on review of the facility's Licensed Nurse staff schedule and interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Specifically, facility staff failed to provide at least eight consecutive hours of RN services in the facility over one 24-hour period, when no Nurse staffing waivers were in place.

Inspectors wroteBased on policy review, record review and interview, the facility failed to obtain Physician ordered laboratory specimens for Hemoglobin A1C (Hgb A1C-a blood test that measures the average sugar level over the past three months) for two Residents (#106 and #34) with diagnoses of Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar), out of a sample of 26 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to adhere to food safety requirements in preventing hair contamination of food being prepared for facility residents. Specifically, the facility failed to ensure that three staff members working in the food preparation area of the kitchen, wore hair restraints to contain their hair during meal preparation.