Inspection Reports for Life Care Center of Leominster
370 West St, Leominster, MA 01453, United States, MA, 01453
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than Massachusetts average
Massachusetts average: 7.3 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards for nursing home care, including physical restraint use, nursing care quality, respiratory care, hospice coordination, immunization policies, and kitchen equipment safety.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints (pillows under sheets), failure to date and initial bandages, inadequate respiratory care equipment maintenance, lack of current hospice care plans, incomplete immunization education and documentation, and unsafe kitchen equipment conditions due to a malfunctioning walk-in freezer door.
Deficiencies (6)
Failed to ensure one resident was free from physical restraints in the form of pillows stuffed under fitted sheets without proper assessment or physician order.
Failed to follow professional nursing standards by not dating and initialing a bandage on a resident's left lower extremity.
Failed to provide respiratory care consistent with professional standards by not developing or maintaining a care plan for nebulizer equipment.
Failed to ensure a current hospice plan of care was present and coordinated with facility staff for a resident receiving hospice services.
Failed to implement policies ensuring residents and representatives were educated on pneumococcal immunization benefits and side effects, and failed to document consent or refusal in medical records for four out of five sampled residents.
Failed to maintain kitchen equipment safely by not repairing a broken walk-in freezer door, resulting in ice buildup and frost covering food products.
Report Facts
Residents sampled: 25
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Date survey completed: Aug 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager #1 | Unit Manager | Instructed removal of pillows considered restraints; commented on restraint assessments |
| Director of Nursing | Director of Nursing | Provided statements on restraint use, nursing standards, respiratory care, and immunization expectations |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Observed adjusting pillows used as restraint |
| Unit Manager #2 | Unit Manager | Commented on bandage dating and resident scratching behavior |
| Nurse #1 | Nurse | Stated requirement for dating and initialing bandages |
| Nurse #2 | Nurse | Described nebulizer mask and tubing care procedures |
| Social Worker #1 | Social Worker | Discussed hospice plan of care availability and coordination |
| Social Worker #2 | Social Worker | Responsible for hospice referrals and care coordination |
| Infection Preventionist | Infection Preventionist | Discussed immunization education and documentation practices |
| Food Service Director | Food Service Director | Reported on freezer door gasket issue and ice buildup |
| Maintenance Director | Maintenance Director | Discussed freezer door repair plans and timeline |
Inspection Report
Routine
Deficiencies: 5
Date: Jul 1, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to physical restraints, pressure ulcer care, medication regimen reviews, unnecessary medications, and COVID-19 vaccination protocols at the Life Care Center of Leominster.
Findings
The facility was found deficient in multiple areas including failure to properly assess and document the use of physical restraints for one resident, failure to provide appropriate pressure ulcer care for another resident, failure to act on consultant pharmacist medication recommendations for two residents, administration of an antibiotic eye ointment beyond the ordered duration for one resident, and failure to offer an updated COVID-19 vaccination to an eligible resident.
Deficiencies (5)
Failed to provide an environment free from physical restraints by positioning Resident #56's bed flush against the wall without proper assessment, physician order, or documentation.
Failed to ensure a wound dressing was in place as ordered for Resident #60's pressure ulcer, placing the resident at risk for infection and worsening of the ulcer.
Failed to act on Consultant Pharmacist recommendations for medication regimen changes for Residents #60 and #79.
Failed to discontinue antibiotic eye ointment for Resident #60 after the ordered 7-day duration, resulting in 10 days of administration.
Failed to offer an updated COVID-19 vaccination to Resident #24 despite eligibility and lack of medical contraindication.
Report Facts
Residents sampled: 23
Resident #56 sample size: 23
Resident #60 applicable residents: 4
Resident #60 medication administration duration: 10
Resident #60 antibiotic eye ointment order duration: 7
Resident #79 applicable residents: 5
Resident #60 applicable residents: 5
Resident #24 applicable residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Aide #1 | Certified Nurses Aide | Provided information about Resident #56's bed positioning |
| Unit Manager #1 | Unit Manager | Discussed assessment and restraint concerns for Resident #56 |
| Director of Nursing | Director of Nursing | Discussed restraint assessment, medication regimen review process, and wound care |
| Nurse #1 | Nurse | Observed wound care and medication administration issues for Resident #60 |
| Assistant Director of Nursing | Assistant Director of Nursing | Described wound team process and medication regimen review follow-up |
| Consultant Pharmacist | Consultant Pharmacist | Made medication regimen recommendations for Residents #60 and #79 |
| Infection Preventionist | Infection Preventionist | Discussed COVID-19 vaccination offering and documentation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an alleged verbal abuse incident involving a Certified Nurse Aide (CNA #1) and Resident #1 during a dinner meal on 04/04/23.
Complaint Details
The complaint investigation was substantiated. CNA #1 engaged in verbally abusive behavior toward Resident #1 on 04/04/23, witnessed by staff and a visitor. The facility's internal investigation confirmed the verbal abuse, and CNA #1 was terminated.
Findings
The investigation substantiated that CNA #1 verbally abused Resident #1 by yelling, using profanity, and forcing the resident to eat, which caused Resident #1 to become agitated and distressed. The facility failed to ensure staff consistently followed Resident #1's care plans related to dementia and communication, resulting in escalation of behaviors and refusal of care. CNA #1 was terminated following the substantiated abuse.
Deficiencies (2)
Failure to protect Resident #1 from verbal abuse by staff, including yelling, profanity, and intimidation during care.
Failure to consistently implement and follow Resident #1's care plan interventions related to dementia, cognition, communication, and activities of daily living, leading to escalation of behaviors and distress.
Report Facts
Residents sampled: 3
Resident cognitive score: 2
Date of incident: Apr 4, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Named in verbal abuse finding and terminated following substantiation |
| Certified Nurse Aide #2 | Certified Nurse Aide | Witnessed and intervened in the verbal altercation |
| Nurse Aide #1 | Nurse Aide | Witnessed verbal altercation and reported observations |
| Director of Nurses | Director of Nurses (DON) | Conducted investigation and confirmed substantiation of verbal abuse |
| Administrator | Administrator | Conducted investigation and confirmed substantiation of verbal abuse |
Inspection Report
Routine
Deficiencies: 8
Date: Feb 2, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, and facility operations at Life Care Center of Leominster.
Findings
The facility was found deficient in multiple areas including accurate completion of Minimum Data Set (MDS) assessments, implementation of care plans for pressure injury prevention, fall management interventions, provision of therapeutic diets, dialysis care communication, maintenance of accurate medical records, infection control practices during wound care, and COVID-19 outbreak testing protocols.
Deficiencies (8)
Failed to ensure accurate coding of MDS assessments for pressure ulcers, insulin injections, and dialysis treatments for three residents.
Failed to implement care plan interventions for repositioning and pressure injury prevention for two residents.
Failed to develop interventions following a fall with major injury for one resident.
Failed to offer a therapeutic diet as required for one resident at risk for dehydration and malnutrition.
Failed to provide safe and appropriate dialysis care by not communicating pertinent clinical information to the dialysis provider for one resident.
Failed to maintain accurate medical records reflecting changes in artificial hydration and non-invasive ventilation orders for two residents.
Failed to implement appropriate infection control practices including hand hygiene and PPE use during wound care for one resident.
Failed to conduct required COVID-19 outbreak testing for staff as soon as possible and every 48 hours thereafter.
Report Facts
Residents sampled: 18
Deficiencies cited: 8
Fall Risk Assessment score: 16
Dialysis Communication Forms: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Nurse #2 | Interviewed regarding inaccurate MDS assessments for Residents #43 and #77 | |
| MDS Nurse #1 | Interviewed regarding inaccurate MDS assessment for Resident #252 | |
| Certified Nurse Aide (CNA) #5 | Certified Nurse Aide | Interviewed about repositioning interventions for Resident #43 |
| Unit Manager (UM) #2 | Unit Manager | Interviewed about care plan implementation for Residents #43 and #49 |
| CNA #3 | Certified Nurse Aide | Interviewed about therapeutic diet provision for Resident #43 |
| Nurse #2 | Nurse | Observed assisting Resident #43 with breakfast and interviewed about meal provision |
| CNA #4 | Certified Nurse Aide | Interviewed about Resident #43's eating habits |
| Unit Manager (UM) #1 | Unit Manager | Interviewed about fall management interventions and wound care infection control practices |
| Nurse #1 | Nurse | Observed and interviewed regarding wound care infection control practices |
| Unit Manager (UM) #1 | Unit Manager | Interviewed about dialysis communication and wound care infection control practices |
| Unit Manager (UM) #2 | Unit Manager | Interviewed about medical record maintenance and CPAP use for Resident #77 |
| Director of Nursing (DON) | Director of Nursing | Interviewed about dialysis communication form completion |
| Infection Preventionist (IP) | Infection Preventionist | Interviewed about COVID-19 outbreak testing practices |
| Administrator | Administrator | Interviewed about COVID-19 testing policies |
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