Deficiency Records for Fitchburg Rehabilitation and Nursing Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Fitchburg Rehabilitation and Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-01 | 2023-02-13 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-10-18 | 2022-11-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-18 | 2022-11-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-18 | 2022-11-08 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-10-18 | 2022-11-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-18 | 2022-11-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-18 | 2022-11-08 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-10-07 | 2022-10-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-07 | 2022-10-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-10-07 | 2022-10-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-07 | 2022-10-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-07 | 2022-10-25 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-10-07 | 2022-10-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-18 | 2021-08-31 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-05-20 | 2021-06-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-05-20 | 2021-06-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-20 | 2021-06-30 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-05-20 | 2021-06-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-20 | 2021-06-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-20 | 2021-06-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-05-20 | 2021-06-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-20 | 2021-06-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-20 | 2021-06-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-05-20 | 2021-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-20 | 2021-06-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-05-20 | 2021-06-30 | N |
| Keep all essential equipment working safely. | Health | 2021-05-20 | 2021-06-30 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-05-20 | 2021-06-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-20 | 2021-06-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-05-27 | 2021-06-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-03 | 2020-02-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-03 | 2020-02-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-03 | 2020-02-17 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-12-11 | 2020-02-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-12-11 | 2020-02-03 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-12-11 | 2020-02-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-12-11 | 2020-02-03 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-12-11 | 2020-02-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-11 | 2020-02-03 | N |
| Respond appropriately to all alleged violations. | Health | 2019-12-11 | 2020-02-03 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-12-11 | 2020-02-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-11 | 2020-02-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-12-11 | 2020-02-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-11 | 2020-02-03 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-12-11 | 2020-02-03 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-12-11 | 2020-02-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-11 | 2020-02-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-11 | 2020-02-03 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-12-11 | 2020-02-03 | N |
| Provide appropriate foot care. | Health | 2019-12-11 | 2020-02-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-11 | 2020-02-03 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-12-11 | 2020-02-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-11 | 2020-02-03 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-12-11 | 2020-02-03 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-12-11 | 2020-02-03 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-12-11 | 2020-02-03 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-12-11 | 2020-02-03 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-12-11 | 2020-02-03 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-12-11 | 2020-02-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-11 | 2020-02-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-11 | 2020-02-03 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-12-11 | 2020-02-03 | N |
