Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Blaire House Of Worcester during CMS and state inspections, most recent first.
A facility failed to follow its infection prevention and control program for residents with Covid-19 and a resident with open wounds. A resident with respiratory symptoms was not tested before hospital transfer, a shared bathroom used by a Covid-positive resident was not disinfected before another resident entered, staff entered isolation rooms without PPE or hand hygiene, several Covid-positive residents were removed from precautions before they could maintain a mask, outdated signage was used, and staff provided wound care to a resident on EBP without gowns or proper hand hygiene.
Failure to complete annual CNA performance reviews: Five CNAs had no documented performance appraisal within the past 12 months, despite the facility policy requiring evaluations every 12 months. The employee records did not show the required reviews, and the Administrator confirmed the CNAs had not received a performance review in the past year or related in-service education based on those reviews.
A resident with dementia, weakness, abnormal gait, low back pain, and scoliosis was observed repeatedly leaning heavily to one side while seated in a scoot chair. Although lateral supports were ordered, included in the care plan, and documented on the TAR, staff reported using pillows or blankets instead and acknowledged the supports were not actually in place. The OT confirmed the supports were intended to improve positioning, while nursing and the UM noted the TAR was signed as if the supports were present when they were not.
Wound care for a resident with a Stage 3 pressure ulcer, a right hip wound, and a left elbow skin tear was not performed according to physician orders or infection control practices. An RN and CNA entered the room without gowns despite EBP signage, and the RN did not sanitize hands between glove changes while providing dressing changes. The RN also sprayed skin prep directly into wound beds and stated this was her routine practice, while the UM said this could interfere with Santyl and confirmed the gowning and hand hygiene were not followed.
Failure to ensure wound care and infection control competencies were completed for an LPN and a CNA. During wound care for a resident on EBP, staff did not wear gowns, the LPN did not sanitize hands after glove removal, did not disinfect scissors, and used skin prep without an order. The LPN stated she had never been educated on EBP, and the UM confirmed there was no evidence of competency evaluation for either staff member.
An unsecured bag of topical meds and treatment items was found stored under the desk at the nurses station and was easily accessible to residents or staff. An LPN said the meds should not have been kept there because residents could access the area, and the ADON said the desk was not a secure storage area.
Incomplete and inaccurate charting was found for two residents. One resident with a G-tube and hx of aspiration pneumonia had TAR entries for residual checks that were inaccurate or missing, with no documentation showing feedings were held, residuals were rechecked, or the NP/MD was notified as ordered. Another resident with dementia and mobility impairments was documented on the TAR as having lateral supports in a scoot chair, but surveyor observations repeatedly found the resident leaning without the supports in place, and staff confirmed the charting did not match what was observed.
A resident, who was alert but disoriented and dependent on staff for care, was found restrained in a wheelchair with a gait belt, contrary to the facility's policy on restraints. The incident was discovered by the Activity Director and Scheduler, but staff on duty denied applying the restraint. An internal investigation was conducted, but the responsible party was not identified.
The facility failed to conduct Nurse Aide registry checks for three staff members before they began working with residents, as required by their Abuse Prevention Policies and Procedures. The personnel records for these staff members, employed since early 2023 and 2024, lacked documentation of such checks. An HR staff member confirmed the oversight, acknowledging the absence of necessary documentation.
The facility failed to implement an effective infection prevention and control program, particularly in tracking and trending skin disorders among residents. Multiple residents were observed with symptoms of skin irritation, such as itchiness and rashes, which were not properly tracked or addressed. Interviews with staff revealed a lack of systematic tracking of resident rashes, and the facility did not maintain a line listing for infections other than COVID-19 and influenza. This deficiency hindered the facility's ability to identify trends and implement appropriate interventions, compromising the safety and sanitary environment for residents.
The facility failed to administer Pneumococcal Vaccinations to three residents as recommended, despite obtaining consent. Two residents with dementia and over the age of 65 did not receive the vaccinations until after a surveyor's inquiry, and another resident with multiple health issues had a delay in receiving the required vaccination. The deficiency was identified through record reviews and interviews with the DON.
Infection Control Program Failures with Covid-19 Precautions and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and follow an infection prevention and control program for multiple residents with Covid-19 and for a resident with open wounds. Resident #55, who had diagnoses including Alzheimer's disease and unspecified dementia, developed fever, paleness, wheezes, cough, and low oxygen saturation on 8/14/25 and was sent to the hospital without being tested for Covid-19 in the facility, despite the DON stating the resident should have been tested when symptoms appeared. The resident later returned with discharge diagnoses including acute hypoxemic respiratory failure, Covid positive, and pneumonia. The DON stated the facility did not begin outbreak testing until 8/16/25, although it should have started on 8/14/25. Resident #21 tested positive for Covid-19 and was observed leaving the room without a mask and using a hallway bathroom. After the resident used the bathroom, it was not sanitized before another resident entered, touched the door and doorknob, and then continued moving through the hallway touching handrails and doorknobs. The Housekeeping Director stated nursing staff were supposed to alert housekeeping immediately after a Covid-positive resident used a bathroom, and the DON stated nursing staff did not notify housekeeping after Resident #21 used the shared bathroom. The facility also failed to follow infection control practices for staff entering rooms of residents on Droplet/Contact Precautions and for residents who could not maintain a mask outside their rooms. Housekeeping Staff #1 entered rooms of residents who had tested positive for Covid-19 without donning PPE or performing hand hygiene, and an Activity Aide entered a room with Droplet/Contact Precautions without PPE and left without hand hygiene. The DON and Housekeeping Director stated staff should have performed hand hygiene and worn PPE based on the precaution signage and because the residents were still on precautions and unable to maintain a mask. The facility also used outdated precaution signage that did not reflect the updated PPE requirements described by the DON. For Resident #5, who had severe cognitive impairment, an unhealed stage 3 pressure ulcer, impaired mobility, and an order for Enhanced Barrier Precautions, staff provided wound care without gowns and did not perform hand hygiene between glove removal and donning new gloves. The resident’s room had EBP signage posted, but the nurse and CNA stated they did not believe the resident was on precautions and were unaware of the need for EBP. The report also states that multiple Covid-positive residents were removed from isolation precautions before day 10 even though they were unable to maintain a mask outside their rooms, and the DON stated there had been confusion among staff about when precautions should end.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete a performance review of every Certified Nurse Aide (CNA) at least once every 12 months for five CNAs (#4, #5, #6, #7, and #8) out of five records reviewed. The Employee Policy Manual, revised 6/2025, stated that employees continuing employment would be evaluated at the end of each 12-month period, and that the performance appraisal would be reviewed by the administrator. The manual also stated that evaluations were an opportunity to discuss performance and set goals, and that performance appraisals were part of the permanent personnel record. Review of the CNA Active Employee Listing showed CNA #4 was hired 12/18/23, CNA #5 on 6/24/13, CNA #6 on 5/16/17, CNA #7 on 11/30/06, and CNA #8 on 2/1/24. Review of the employee records for these five CNAs failed to indicate that an annual performance review had been completed as required. During interview on 8/29/25 at 10:04 A.M., the Administrator stated that CNAs #4, #5, #6, #7, and #8 did not have a performance review in the past 12 months and that each CNA should have a performance review completed by the nursing department at least every 12 months, with education provided based on the outcome of those reviews.
Failure to Provide Ordered Wheelchair Lateral Supports
Penalty
Summary
The facility failed to provide specialized rehabilitative services consistent with the comprehensive plan of care for a resident with dementia with behavioral disturbance, weakness, abnormal gait and mobility, low back pain, and scoliosis. The resident was admitted in October 2021 and was documented as severely cognitively impaired, rarely or never understood, dependent on staff for ADLs, and requiring substantial to maximum assistance with transfers and repositioning. The resident’s care card, physician orders, and care plan all included lateral supports while seated in the scoot chair, ordered to be used every shift and initiated on 4/10/25. Surveyors observed the resident multiple times seated in the scoot chair leaning heavily to the right, with the arm and upper body hanging over the right side of the wheelchair. On one observation, numerous staff were seen in the hallway walking by without assisting with the resident’s positioning. On another observation, a folded blanket was placed on the inside of the resident’s right side against the armrest, and on a later observation the resident was leaning heavily to the right with the head against the chair rail on the wall. At that time, there were no lateral supports in place on the scoot chair, nor a pillow or folded blanket on the resident’s right side. During interviews, CNA staff stated the resident leaned to the right in the scoot chair and that staff used a pillow or folded blanket to assist with positioning because the resident removed them. The OT stated the lateral supports were implemented to assist with the resident’s right-sided leaning and that the resident did not have the lateral supports in place; the OT also located only the back portion of the supports and was unsure where the side cushions were. Nursing staff stated they were not aware of other positioning devices and acknowledged the resident did not currently have lateral supports in place, while the TAR had been signed off as if the supports were in place. The UM reviewed the record and stated there was no indication the supports were refused, discontinued, or unavailable, and that nursing should not have signed off that they were in place if they were not.
Wound Care Not Performed per Orders and EBP
Penalty
Summary
The facility failed to provide wound care consistent with professional standards for one resident with a Stage 3 pressure ulcer, a right hip open area, and a left elbow skin tear. The resident was admitted with diagnoses including Stage 3 pressure ulcer and impaired mobility, and the MDS indicated severe cognitive impairment with a BIMS score of 0 and dependence on staff for bathing, grooming, and dressing. Physician orders directed cleansing and specific dressings for the right heel pressure wound, right hip wound, and left elbow skin tear, and also included Enhanced Barrier Precautions every shift. During observed wound care, Nurse #5 and CNA #3 entered the resident’s room without gowns despite EBP signage posted outside the room. Nurse #5 donned gloves, removed the old dressing from the right heel, patted the wound bed with moistened gauze, sprayed skin prep over the entire wound bed, applied Santyl to an Aquacel pad, and dressed the wound. She then changed gloves between wound sites but did not sanitize her hands between glove changes. The nurse repeated similar care for the right hip and left elbow, including wiping the wounds with wet gauze and spraying skin prep directly onto the wound beds before applying foam dressings. In interviews, CNA #3 stated the resident was not on precautions and there was no need to wear a gown. Nurse #5 stated she did not believe EBP applied to the resident, said the EBP sign was only a reminder to sanitize hands, and said there was no need to wash or sanitize hands between glove removal because the dressing changes were on the same resident. She also stated she routinely sprayed skin prep into wound beds to help dressings adhere and did not obtain a physician order for that practice. The Unit Manager stated the skin prep spray would prevent Santyl from debriding the wound and confirmed the nurse and CNA should have worn gowns and that the nurse should have changed gloves and sanitized hands before donning new gloves.
Failure to Ensure Wound Care and Infection Control Competencies
Penalty
Summary
The facility failed to ensure that appropriate competencies related to wound care services were completed for one licensed nurse and one CNA out of five staff records reviewed. The record review showed no documentation that the licensed nurse or the CNA had completed the required nursing competencies for wound care and infection control practices. Facility policies for clinical competency training for licensed nursing staff and clinical day for CNAs both required the DON to coordinate competency programs that included infection control, and the report also cited CDC guidance on Enhanced Barrier Precautions for residents with wounds or indwelling devices. During observation of wound care for a resident on Enhanced Barrier Precautions, the licensed nurse and CNA did not wear gowns when entering the room or during wound care and repositioning. The licensed nurse did not remove gloves after removing the old dressing, did not sanitize hands after doffing soiled gloves, sprayed skin prep on all wound areas, and did not disinfect scissors after use. During interviews, the CNA stated the resident was not on precautions and there was no need for a gown, and the licensed nurse stated there was no need to sanitize hands between glove removal because the dressing changes were on the same resident. The licensed nurse also stated she had never been educated on the use of EBP and was not aware it applied to the resident, and the unit manager confirmed there was no evidence that either staff member had received competency evaluation on infection control practices and wound care.
Unsecured Medications Stored at Nurses Station
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional standards of practice on one out of one nurses station. During observation, the surveyor and Nurse #5 found an unsecured bag of medications stored under the desk at the nurses station. The bag contained Skin prep swabs, Antifungal cream, Santyl Cream, Zinc Oxide, Bacitracin ointment, and [NAME] Cream, and it was located in an area that was easily accessible to residents or staff. The facility policy titled Storage and Expiration Dating of Medications and Biologicals stated that medications and biologicals, including treatment items, should be securely stored in a locked cabinet/cart or locked medication room inaccessible to residents and visitors. During interview, Nurse #5 stated the medications should not have been kept under the desk because residents could access the area and potentially consume the medications. The ADON later stated she was unsure how long the bag had been stored there and confirmed the desk area was not considered a secure area.
Incomplete and inaccurate documentation of G-tube residuals and wheelchair lateral supports
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. One resident was admitted with dysphagia, a history of aspiration pneumonia, reduced mobility, muscle weakness, and a G-tube, and was NPO. Physician orders required residual checks every shift, with feeding to be held for one hour if residuals were above 100 ml, then rechecked, and the NP/MD notified if the residual remained above 100 ml. The August 2025 TAR showed residuals of 350 ml, 120 ml, and 240 ml on three occasions, but the record did not show that feedings were held, residuals were rechecked, or the NP/MD was notified as ordered. The same resident’s TAR also did not document residual amounts on multiple shifts, and the medical record did not explain why residuals were not recorded on those dates. During interviews, two nurses stated that the residual amounts they had documented were inaccurate, and one nurse said the resident never had residuals over 100 ml while another said the resident never had residuals over 10 ml. The DON reviewed the record and stated that the documentation on the TAR was inaccurate and incomplete, and that there was no way to monitor for residual amounts outside the set parameter or for missing residual documentation. For a second resident with dementia with behavioral disturbance, weakness, abnormal gait and mobility, low back pain, and scoliosis, the physician ordered lateral supports while in the scoot chair every shift. The August 2025 TAR was signed off by nursing staff indicating the lateral supports were in place, but surveyor observations on multiple occasions showed the resident seated in the scoot chair leaning heavily to the right over the armrest with no lateral supports in place. A nurse stated that if the supports were not in place, staff should enter a code on the TAR and document that they were not in place, and the UM confirmed there was no indication the supports were refused, discontinued, or unavailable, and that staff should not have signed off that they were in place if they were not.
Resident Found Restrained with Gait Belt in Wheelchair
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as observed on a specific date when the resident was found seated in a wheelchair with a gait belt wrapped around them and the wheelchair, effectively restraining their movement. The resident, who was alert but disoriented and unable to make their needs known, was dependent on staff for transfers, dressing, and hygiene. The facility's policy clearly states that residents have the right to be free from physical restraints unless required for medical treatment, which was not the case here. The incident was discovered by the Activity Director and the Scheduler, who observed the resident in the dayroom with the gait belt latched behind the wheelchair, making it impossible for the resident to remove it themselves. Interviews with staff members who were on duty during the relevant shifts revealed that none of them admitted to applying the gait belt, and they all denied seeing it on the resident. The resident's care plan included interventions to minimize fall risks, but there was no indication that the use of a gait belt as a restraint was part of the plan. The Director of Nursing conducted an internal investigation, which included obtaining written witness statements from staff members on duty during the shifts in question. Despite the investigation, it remained unclear who applied the gait belt, as all staff members involved denied responsibility. The resident was dependent on staff for care and was physically incapable of applying the restraint themselves, indicating a failure in staff adherence to the facility's restraint policy.
Failure to Conduct Nurse Aide Registry Checks for New Staff
Penalty
Summary
The facility failed to ensure that Nurse Aide registry checks were completed for three staff members before they began working with residents. This deficiency was identified during a review of personnel files for five staff members, where it was found that documentation was missing for Staff Members #1, #2, and #3. The facility's policy on Abuse Prevention Policies and Procedures, revised in April 2017, mandates that all applicants undergo professional reference checks and further screenings, including Nurse Aide registry checks. However, the personnel records for these three staff members, who had been employed since February 2024, June 2024, and June 2023 respectively, lacked evidence of such checks. During an interview, the Human Resources (HR) staff member confirmed that Nurse Aide registry checks should be performed on all staff members prior to their employment at the facility. The HR staff member admitted to being unable to provide documentation proving that the checks were conducted for Staff Members #1, #2, and #3. This oversight indicates a failure to adhere to the facility's established procedures for screening new employees, which is crucial for ensuring the safety and well-being of the residents.
Failure in Infection Control and Surveillance for Skin Disorders
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically in tracking and trending skin disorders among residents. The deficiency was identified through observations, interviews, and record reviews, revealing that the facility did not adequately monitor or document skin infections requiring medical intervention for eight residents. The facility's policy on infection surveillance, revised in 2017, mandates ongoing surveillance for healthcare-associated infections and other significant infections, but this was not effectively executed. During the survey, multiple residents were observed with symptoms of skin irritation, such as itchiness and rashes, which were not properly tracked or addressed. For instance, one resident was seen scratching various parts of their body and was later assessed by a nurse practitioner who noted irritated and red areas from scratching. Another resident had a rash that was initially treated but persisted, indicating a lack of effective follow-up and monitoring. The Director of Nursing acknowledged the lack of documentation and tracking of these skin conditions, which hindered the facility's ability to identify trends and implement appropriate interventions. Interviews with staff, including CNAs and the Director of Nursing, revealed that there was no systematic approach to tracking resident rashes, and the facility did not maintain a line listing for infections other than COVID-19 and influenza. This lack of tracking and trending of skin conditions led to a failure in identifying potential outbreaks or transmission risks within the facility. The facility's infection prevention and control program did not meet the required standards, as it failed to prevent, identify, and control infections effectively, resulting in a deficiency in providing a safe and sanitary environment for residents.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer Pneumococcal Vaccinations as recommended for three residents, putting them at risk for developing facility-acquired pneumonia. The deficiency was identified during a review of records and interviews, revealing that the facility did not ensure that the vaccinations were offered, received, or declined by the residents as per physician's orders and after obtaining consent from the residents or their representatives. Resident #42, admitted with a diagnosis of dementia and over the age of 65, had consented to receive the Pneumococcal Vaccine. However, there was no evidence in the resident's medical record or the Massachusetts Immunization Information System (MIIS) that the resident received any Pneumococcal Vaccinations. Similarly, Resident #56, also diagnosed with dementia and over 65, had consented to receive the vaccine, but there was no record of administration in the facility's electronic health record or MIIS. The Director of Nursing (DON) confirmed that these residents did not receive the vaccinations until the surveyor's inquiry. Resident #14, with multiple diagnoses including dementia, COPD, and heart failure, had a history of receiving PCV 13 but was due for further vaccination. Despite consent being obtained, there was no documented evidence of the resident receiving the required Pneumococcal Vaccination. The DON/Infection Control Preventionist acknowledged that the vaccination was administered only after the surveyor's inquiry, indicating a delay in providing the necessary immunization.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Worcester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vantage At Worcester Llc | 0.1 mi | ★★★★★ | 14 | 0 |
| Worcester Rehabilitation & Health Care Center | 0.4 mi | ★★★★★ | 1 | 0 |
| St Francis Rehabilitation & Nursing Center | 0.6 mi | ★★★★★ | 5 | 0 |
| St Mary Health Care Center | 1.6 mi | ★★★★★ | 10 | 0 |
| Lutheran Rehabilitation And Skilled Care Center | 1.8 mi | ★★★★★ | 0 | 0 |
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