Fitchburg Healthcare

In the surveyor’s words

From the most serious findings on record at Fitchburg Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF697Feb 11, 2026

  Based 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. […]

• Actual harm, isolatedF656Jan 11, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose plan of care indicated he/she required extensive assistance of two staff members with the use of a mechanical lift for all transfers, the Facility failed to ensure staff implemented and followed interventions from Resident #1's Plan of Care related to transfers and staff assistance. On 11/07/22, although Certified Nurse Aide (CNA) #3 asked the Unit Manager for assistance with transferring Resident #1 from a shower chair into bed with the mechanical lift, CNA #3 had already begun to transfer him/her, and Resident #1 was suspended up and over the shower chair, before the Unit Manager was fully in the room and in close enough proximity to provide hands on assistance. […]

• Actual harm, isolatedF689Jan 11, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required extensive assistance of two staff members and the use of a mechanical lift for all transfers, the Facility failed to ensure he/she was provided with the required level of staff assistance and that assistive equipment (lift pad) was positioned correctly by staff, in an effort to maintain Resident #1's safety during a mechanical lift transfer to prevent incidents/accidents resulting in an injury. […]

• No harm, potential for more than minimal, widespreadF568Oct 15, 2021

  Based on interviews with one Resident (#50) and Business Office staff members, the facility failed to issue quarterly statements relative to Personal Need Accounts (PNA) to residents who had a PNA. Resident #50 was admitted to the facility in May 2021. During an interview on 10/12/21 at 11:15 A.M., Resident #50 said he/she did not know if he/she had a PNA. Resident #50 said he/she did not know how much money he/she had and was concerned about obtaining certain items. Resident #50 said he/she did not get any type of statement regarding his/her money. During an interview on 10/14/21, the Payroll Manager and the Business Office Manager (BOM) said the activity staff used to hand out the quarterly statement for the resident PNAs, but the activity staff was no longer involved. […]

• No harm, potential for more than minimal, patternF689Dec 30, 2025

  Based 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. Findings include: Review of the Facility policy titled, Care Plan, comprehensive Person-centered, revised 01/2024, indicated a comprehensive, person-centered care plan will be developed for each resident. […]