Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as Massachusetts average
Massachusetts average: 7.3 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 7
Date: Aug 29, 2025
Visit Reason
Routine inspection to assess compliance with regulatory requirements related to resident care, safety, infection control, medication management, and documentation at Christopher House of Worcester nursing home.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean environment, incomplete resident assessments, improper catheter care, lack of trauma-informed care, unsecured medications, incomplete fluid intake and output documentation, and inadequate infection control practices during wound care.
Deficiencies (7)
F 0584: The facility failed to maintain Resident #123's wheelchair in a clean and sanitary manner, with visible soiling and lack of weekly cleaning as per policy.
F 0641: The facility failed to complete accurate Minimum Data Set (MDS) assessments for Residents #15 and #142, omitting required BIMS and PHQ-9 evaluations.
F 0690: The facility failed to ensure Resident #3's indwelling urinary catheter was replaced with the correct 30 cc balloon as ordered, instead a 10 cc balloon was in place.
F 0699: The facility failed to provide trauma-informed care for Resident #6 by not assessing trauma history on admission or developing a care plan addressing trauma triggers.
F 0761: The facility failed to ensure medication carts were locked when unattended and left Resident #3's prescribed inhaler unsecured on the nightstand.
F 0842: The facility failed to maintain complete and accurate documentation of fluid intake and urinary output for Resident #5, who was on fluid restriction and had an indwelling catheter.
F 0880: The facility failed to maintain effective infection control during wound care for Resident #52, with repeated failure to perform hand hygiene between glove changes.
Report Facts
Residents sampled: 28
Wheelchair cleaning schedule dates missing: 7
BIMS score: 12
BIMS score: 3
BIMS score: 15
Fluid intake measurements: 420
Fluid intake measurements: 660
Fluid intake measurements: 280
Fluid intake measurements: 300
Fluid intake measurements: 440
Balloons size: 10
Balloons size: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Observed and acknowledged wheelchair was dirty for Resident #123 | |
| Housekeeping Staff #1 | Acknowledged wheelchair needed cleaning and committed to cleaning it | |
| MDS Nurse | Acknowledged failure to complete BIMS and PHQ-9 assessments for Residents #15 and #142 | |
| Nurse #2 | Observed with unlocked medication cart and unsecured inhaler for Resident #3 | |
| Unit Manager #1 | Acknowledged incorrect catheter balloon size for Resident #3 and changed physician order | |
| Social Worker #1 | Acknowledged failure to complete trauma assessment for Resident #6 | |
| Nurse #3 | Failed to perform hand hygiene during wound care for Resident #52 | |
| Director of Nursing | DON | Confirmed standard practices for medication cart security and hand hygiene during wound care |
| Certified Nurse Aide #2 | CNA | Unaware of fluid restriction for Resident #5 and responsible for urine output documentation |
| Nurse #4 | Responsible for documenting fluid intake and urine output for Resident #5 | |
| Nurse #5 | Responsible for staff education and documentation oversight for Resident #5 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 14, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding pressure ulcer care, infection prevention and control practices, and vaccination policies at the facility.
Complaint Details
The investigation was complaint-driven, focusing on wound care deficiencies, infection control breaches, and vaccination administration failures. The complaints were substantiated with findings of minimal harm and affected residents.
Findings
The facility failed to implement hospital wound care recommendations for a resident with a pressure ulcer, failed to adhere to infection control standards for two residents including improper catheter care and PPE use, and failed to ensure pneumococcal vaccinations were administered to eligible residents.
Deficiencies (3)
F 0686: The facility failed to implement hospital wound care recommendations for Resident #130 with a Stage 4 pressure ulcer, risking worsening of the wound.
F 0880: The facility failed to adhere to infection control standards for Residents #130 and #241, including improper hand hygiene, PPE use, and catheter drainage bag management.
F 0883: The facility failed to ensure pneumococcal vaccinations were administered to Residents #35 and #81 despite consent and eligibility, increasing risk of infection.
Report Facts
Residents reviewed: 29
Residents affected by pressure ulcer care deficiency: 1
Residents affected by infection control deficiency: 2
Residents affected by vaccination deficiency: 2
Wound observation dates: 3
Physician's wound care order dates: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP #1 | Nurse Practitioner | Reviewed and approved hospital wound care recommendations for Resident #130 |
| UM #1 | Unit Manager | Observed providing wound care to Resident #130 without proper hand hygiene |
| Nurse #2 | Reconnected urinary catheter drainage bag for Resident #241 without changing the bag | |
| Nurse #3 | Interviewed about catheter care procedures for Resident #241 | |
| CNA #1 | Certified Nurses Aide | Observed not wearing required PPE and failing hand hygiene in Resident #241's room |
| Rehab Staff #1 | Rehabilitation Services Staff | Observed wearing untied gown while providing care to Resident #241 |
| Staff Development Coordinator | SDC | Interviewed regarding hand hygiene and PPE standards |
| Nursing Supervisor | Acknowledged failure to enter wet-to-dry dressing order for Resident #130 | |
| Director of Nursing | DON | Discussed responsibility for order entry and review for Resident #130 |
| Infection Preventionist | IP | Interviewed about vaccination audits and policies |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 28, 2024
Visit Reason
The investigation was conducted following a complaint related to a fall incident involving Resident #1 during a transfer with a Hoyer lift, which resulted in injuries.
Complaint Details
The investigation was triggered by a complaint regarding Resident #1's fall during a transfer with a Hoyer lift on 03/12/24. The complaint was substantiated with findings that staff failed to follow the care plan and proper post-fall procedures.
Findings
The facility failed to ensure staff followed the care plan requiring two-person assistance for transfers using a Hoyer lift. Resident #1 fell during a transfer by a single CNA, sustained serious injuries, and was transferred to the hospital. The CNA also transferred the resident off the floor without nurse assessment, contrary to policy.
Deficiencies (3)
F 0656: The facility failed to develop and implement a complete care plan ensuring two-person assistance for Resident #1's transfers with a Hoyer lift, resulting in a fall and serious injuries.
F 0684: The facility failed to provide appropriate treatment and care after Resident #1's fall, as the resident was transferred off the floor by a CNA without nurse assessment, delaying injury evaluation.
F 0689: The facility failed to ensure adequate supervision and staff assistance during mechanical lift transfers, resulting in Resident #1 falling and sustaining multiple facial fractures and head injuries.
Report Facts
Date of fall incident: Mar 12, 2024
Date of report completion: Mar 28, 2024
Laceration size: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in findings for transferring Resident #1 alone during mechanical lift transfer and transferring resident off floor without nurse assessment |
| Nurse #1 | Nurse | Observed Resident #1 after fall and called supervisor and 911 |
| Director of Nurses | Director of Nurses (DON) | Conducted investigation and telephone interviews regarding the incident |
| Nursing Supervisor | Nursing Supervisor | Responded to incident, observed injuries, and interviewed staff |
Inspection Report
Routine
Census: 26
Deficiencies: 9
Date: Feb 17, 2023
Visit Reason
Routine inspection to assess compliance with regulatory requirements including care planning, implementation of care plans, infection control, medication management, and safety.
Findings
The facility failed to develop baseline care plans within 48 hours for some residents, implement ordered interventions such as fall prevention and TED stockings, maintain accurate medical records, adhere to infection control protocols including COVID-19 outbreak testing and PPE use, and complete annual bed inspections.
Deficiencies (9)
F0655: The facility failed to develop a baseline care plan within 48 hours of admission for Resident #1, omitting risk for falls and communication needs.
F0656: The facility failed to implement fall interventions for Resident #60 and TED stocking application for Resident #95 as ordered.
F0686: The facility failed to perform weekly skin assessments and provide proper infection control wound care for Resident #20 with pressure ulcers.
F0689: The facility failed to secure medication carts, allowing unauthorized access to medications.
F0700: The facility failed to assess and obtain informed consent for bed rail use for Residents #185 and #1 prior to use.
F0842: The facility failed to maintain accurate medical records for Residents #60, #85, #95, and #112, including inaccurate documentation of treatments and conflicting physician orders.
F0880: The facility failed to implement infection prevention and control measures including Legionella water management, ESBL precautions, COVID-19 PPE use, and employee exclusion protocols.
F0886: The facility failed to conduct required COVID-19 outbreak testing for all residents on the Brookside Unit every 48 hours following initial testing.
F0909: The facility failed to complete annual inspections of all bed frames, mattresses, and bed rails to identify entrapment hazards.
Report Facts
Residents sampled: 26
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 14
Employee return to work days: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Named in TED stocking application and ESBL precaution documentation deficiencies | |
| Nurse #2 | Named in medication cart security and COVID-19 PPE deficiencies | |
| Unit Manager #3 | Interviewed regarding baseline care plan and bed rail consent deficiencies | |
| Assistant Director of Nurses | Interviewed regarding multiple deficiencies including infection control and medical record issues | |
| Director of Nursing | Interviewed regarding infection control, COVID-19 testing, and employee return to work policies | |
| Director of Maintenance | Interviewed regarding annual bed inspections | |
| Administrator | Interviewed regarding Legionella water management and annual bed inspections |
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