Fitchburg Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Fitchburg Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF658Mar 7, 2025

  Based on observation, record review and interview, the facility failed to meet professional standards of practice for three Residents (44, #29, and #1) out of a total of 20 sampled residents. Specifically, 1. For Resident #44, the facility failed to: a.) adequately assess, monitor, and implement a physician order for fluid restrictions (limiting the amount of fluid a person takes in) from August 2024 to March 2025. Subsequently, Resident #44 was hospitalized in February 2025, and admitted to ICU (intensive care unit) with diagnosis of acute hypoxic respiratory failure, acute renal failure and septic shock., b.) failed to follow up on physician recommendations for new prosthetic leg, and c.) failed to implement a physician order for bilateral shoulder X-ray. 2. […]

• Actual harm, isolatedF773Mar 7, 2025

  Based on observation, record review and interview, the facility failed to notify the Physician of critical labs for two residents (#12, and #44) out of a total of 20 sampled residents. Specifically: 1. For Resident #12, the facility failed to alert the Physician of critically high BUN (measures how much blood urea nitrogen is in your body and can may indicated a problem with kidneys or liver) and critically low potassium (measures the electrolyte potassium in the blood that is essential for proper muscle and nerve function) results, which resulted in a delay of treatment and hospitalization for acute hypokalemia and acute kidney injury. 2. For Resident #44, the facility failed to obtain laboratory services as ordered by the Physician. Findings include: 1. […]

• Actual harm, isolatedF580Mar 26, 2024

  Based on interview, record and policy review, the facility failed to notify the Physician/Non-Physician Practitioner (NPP: Nurse Practitioner) of a significant change in medical condition and an elopement for two Residents (#60 and #62) out of a total sample of three closed records reviewed. Specifically, the facility staff failed to: 1. For Resident #60, identify a serious change in condition and acute decline in mental status, and notify the Physician/ NPP timely, resulting in the Resident further decompensating and being transferred to the hospital. 2. […]

• Actual harm, isolatedF684Mar 26, 2024

  Based on interview and record review, the facility failed to provide treatment, services and care that met professional standards of quality for one Resident (#60) out of a total sample of three discharged residents, resulting in a decline in medical status and hospitalization with sepsis (a life-threatening medical emergency that occurs when an infection triggers the body's immune system to damage its own organs and tissues). Specifically, the facility staff failed to: 1. Recognize, assess, and manage pulmonary symptoms that indicated a significant change in condition for Resident #60 who had multiple pulmonary diagnoses that required immediate and appropriate interventions for symptom management. 2. […]

• Actual harm, isolatedF686Mar 26, 2024

  Based on observation, interview, record and policy review, the facility failed to provide necessary care and services to treat pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and prevent further skin and pressure injury for two Residents (#22 and #4), out of two applicable residents, out of a total sample of 17 residents. Specifically, the facility staff failed to: 1. Offload Resident #22's heels per the Physician's Order for treatment of an existing right heel ulcer, and prevent skin decline in his/her left heel. 2. […]