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 Christopher House Of Worcester during CMS and state inspections, most recent first.
Dirty wheelchair not cleaned as required: A resident who used a manual wheelchair and had diagnoses including spinal stenosis and CVA was observed with a visibly soiled wheelchair that had dried brown/black spots, flaky debris on the wheels, and stained armrests. The facility’s cleaning logs did not show weekly cleaning or cleaning since June, and the resident stated staff had not cleaned the wheelchair in a long time. An RN observed the wheelchair was dirty and covered in food debris, and housekeeping staff said it needed to be cleaned.
MDS assessments were not accurately completed for two residents because the BIMS and PHQ-9 were not attempted even though both residents were documented as usually understood and able to be interviewed. One resident had BiPolar Disorder and Mood Disorder, and the other had Dementia and Delusional Disorder; nursing notes also described the second resident as alert, responsive, and able to make needs known. The MDS Nurse stated the assessments should have been attempted because the MDS is resident driven and the PHQ-9 is used to assess for depression.
A resident with neurogenic bladder and an indwelling Foley catheter was found with a 10 cc balloon in place even though the MD order specified a 30 cc balloon. Staff confirmed the resident should have had the larger balloon, and the UM stated the catheter had been incorrectly changed.
Failure to Assess and Care Plan for Trauma History: A resident admitted with paraplegia, MDD, anxiety, insomnia, and BKA history was not assessed for trauma on admission, and the baseline care plan trauma screening was left incomplete. Later, Psych Services documented that the resident felt traumatized by hospitalizations and described repeated negative experiences, but the care plan did not address these trauma-related triggers. The SW confirmed no trauma assessment was found at admission and that a care plan for trauma and hospitalization triggers should have been developed.
Unsecured medication cart and unattended inhaler: An LPN left a medication cart unlocked multiple times during a med pass while stepping away from it and out of sight, with residents and staff nearby. In a separate event, a resident with dementia and severe cognitive impairment had a Spiriva Handihaler left on the nightstand in a clear bag after the nurse exited the room, and the nurse acknowledged it should not have been left unattended.
Incomplete intake and output documentation for a resident with CHF, CKD, and a Foley catheter. The resident was on a 1.5 L fluid restriction and had orders and a care plan requiring shift-by-shift monitoring, but the MAR, EHR vitals section, and meal intake records showed inconsistent fluid totals and blank entries. The record also lacked documented urine output every shift, and staff interviews confirmed that intake and output documentation was required in mL for the resident.
Failure to Perform Hand Hygiene During Wound Care: An LPN and CNA provided wound care to a resident on EBP for a stage II back/spine pressure ulcer and repeatedly changed gloves without performing hand hygiene between glove changes. The LPN also used a pen from her pocket while wearing soiled gloves to date the dressing, and the DON confirmed hand hygiene and a sanitary writing implement should have been used.
The facility failed to administer Pneumococcal Vaccinations to two residents who had consented and were eligible for further doses. One resident with COPD and CKD had only received a PCV13 dose in 2015, while another resident with Diabetes Mellitus had received a PCV13 dose in 2019. The Infection Preventionist had not audited the residents' vaccination needs, leading to this oversight.
A resident with a Stage 4 pressure ulcer did not receive the hospital-recommended wound care regimen upon re-admission to the facility. The facility failed to implement the Santyl wet-to-dry dressings, leading to the deterioration of the wound. Observations showed significant necrotic tissue and undermining, and staff interviews revealed that the hospital's recommendations were not correctly entered into the resident's clinical record.
The facility failed to adhere to infection control standards for two residents. One resident's wound care involved improper hand hygiene by staff, increasing infection risk. Another resident on Contact Precautions for C-diff had staff not wearing PPE correctly, and improper urinary catheter maintenance was observed. These deficiencies could lead to infection spread.
A resident who required a Hoyer lift with two staff members for transfers was injured when a CNA transferred them alone, resulting in a fall and multiple injuries. The CNA admitted to not following the care plan, and the facility's investigation confirmed this failure.
A resident who required a Hoyer lift with two staff members for transfers was injured when CNA #1 attempted the transfer alone, resulting in a fall and multiple injuries. The facility's policy required two-person assistance, which was not followed, leading to significant harm.
A resident fell during a transfer with a Hoyer lift, resulting in significant injuries. The CNA transferred the resident to bed before notifying nursing staff, contrary to the Facility's policy requiring immediate nurse assessment after a fall. The CNA admitted to not seeking assistance and cleaning the blood before informing the nurse.
Dirty wheelchair not cleaned as required
Penalty
Summary
The facility failed to maintain a clean and homelike environment for Resident #123 by not keeping the resident’s wheelchair clean and sanitary. The resident was admitted in September 2023 with diagnoses including spinal stenosis and cerebral infarction due to embolism of the left middle artery. The resident’s 6/8/25 MDS indicated cognitive intactness with a BIMS score of 12 out of 15, supervision needed to walk 10 feet due to medical condition or safety concern, and use of a manual wheelchair. The facility’s Wheelchair Cleaning Policy required wheelchairs to be cleaned at least weekly, with additional cleaning for visible soiling, and assigned housekeeping/maintenance responsibility for weekly cleaning. Weekly wheelchair cleaning schedules dated 7/8/25, 7/17/25, 7/24/25, 7/31/25, 8/7/25, 8/18/25, and 8/25/25 did not show that Resident #123’s wheelchair had been cleaned weekly or since June 2025. During observations, the wheelchair was seen with dried dark brown spots on the frame, flaky white debris on the spokes and wheels, and stained armrests with a dark brown/black substance. The resident stated staff had not cleaned the wheelchair, and later said staff had not cleaned it in a long time. A nurse observed the wheelchair was dirty and covered in food debris and should have been cleaned. Housekeeping staff acknowledged the wheelchair needed cleaning.
MDS Assessments Not Completed for Two Residents
Penalty
Summary
Ensure each resident receives an accurate assessment. Based on record reviews and interviews, the facility failed to complete MDS assessments that accurately reflected the status of 2 residents out of a sample of 28. For Resident #15, who was admitted in July 2025 with diagnoses including BiPolar Disorder and Mood Disorder, the MDS dated [DATE] indicated the resident was usually understood and usually understood others, but the BIMS and PHQ-9 were not attempted. During an interview on 8/26/25, Resident #15 appropriately understood and answered the surveyor's questions about the stay in the facility. The medical record did not show that either assessment had been conducted or attempted during the assessment period for the 7/15/25 MDS. For Resident #142, who was admitted in March 2024 with diagnoses including Dementia and Delusional Disorder, the MDS dated [DATE] also indicated the resident was usually understood and usually understood others, but the BIMS and PHQ-9 were not attempted. Nursing progress notes documented that the resident was alert and responsive and denied pain or discomfort on 5/12/25, and later noted the resident was alert and able to make needs known on 5/27/25. The medical record did not indicate that either assessment had been conducted or attempted during the assessment period for the 5/27/25 MDS. In interviews, the MDS Nurse stated both residents should have participated in the assessments because they were able to be interviewed, and that the MDS is resident driven and would not accurately reflect the resident if the resident was not involved.
Incorrect Foley Balloon Size
Penalty
Summary
Resident #3, who was admitted with diagnoses including neurogenic bladder and obstructive uropathy and was severely cognitively impaired with a BIMS score of 3, had an indwelling Foley catheter ordered for care every shift and to be changed as needed for leakage, blockage, or wear. The physician’s order specified a size 16 Fr catheter with a 30 cc balloon. The record showed the catheter was changed on 7/31/25 due to leakage and again on 8/9/25 due to blockage, but the August TAR did not indicate that the urinary catheter had been changed. On 8/27/25, the surveyor and Nurse #2 observed that Resident #3 had a 16 Fr catheter in place with a 10 cc balloon instead of the ordered 30 cc balloon. Nurse #2 stated she had checked the physician’s orders earlier that morning and the resident should have had a 30 cc balloon, and she notified the Unit Manager. The Unit Manager stated the resident should have had a 30 cc balloon inserted and said the urinary catheter must have been incorrectly changed; the Unit Manager also said the physician’s order had just been changed to a 10 cc balloon after the surveyor requested to observe the catheter.
Failure to Assess and Care Plan for Trauma History
Penalty
Summary
The facility failed to provide trauma-informed care for one resident out of a sample of 28. The resident was admitted in August 2024 with diagnoses including complete paraplegia, major depressive disorder, anxiety disorder, insomnia, family history of psychoactive substance abuse and dependence, and a history of bilateral below-the-knee amputations. The facility’s policy required all new admissions to be assessed for a history of traumatic events through interviews, record review, and observations, but the resident’s 48-hour baseline care plan section related to trauma screening was not completed and there was no evidence that a trauma assessment had been done when the resident was newly admitted. The resident’s record later showed that Psychological Services evaluated the resident on 3/4/25 for medication review and concerns about increased depression and medical decision-making capacity. During that evaluation, the resident stated feeling traumatized every time he/she went to the hospital and said that something always went wrong or that more problems were found during hospitalizations. The resident also stated knowing that refusing treatment could result in death, but did not feel the psychological effects of being in the hospital were worth it. The resident’s care plan from 8/1/24 through 8/28/25 did not show any person-centered plan addressing the resident’s reported traumatic experiences related to hospitalizations. During interview, the Social Worker confirmed there was no evidence of a trauma assessment at admission and stated the facility should have developed a care plan for trauma and triggers related to hospitalizations.
Unsecured Medication Cart and Unattended Inhaler
Penalty
Summary
Drugs and biologicals were not stored and secured in accordance with facility policy and State and Federal requirements on the Brookside unit medication cart. During a medication pass, Nurse #2 removed supplies from the cart, walked away multiple times without locking it, and left the unlocked cart out of sight while residents and staff were nearby and passing by. The cart remained unlocked while the nurse entered a supply room, the dining room, and a resident room to complete a blood glucose finger stick, and the nurse later acknowledged that the cart should have been locked each time she stepped away. The report also identified that Resident #3, who was admitted with dementia, major depressive disorder, and COPD, had severe cognitive impairment with a BIMS score of 3. During a blood glucose assessment, a Spiriva Handihaler capsule and inhalation device labeled with the resident’s name was observed in a clear plastic bag on the resident’s nightstand table. The nurse left the room and the Spiriva remained unattended on the nightstand while the resident was unable to self-administer the medication. Nurse #2 stated that the Spiriva inhaler should not have been left on the nightstand without the nurse present and that she should have removed it when exiting the room to prevent access by others. The DON stated that it was standard practice for nursing staff to ensure that no medication was left unattended on a resident nightstand table for other residents’ safety.
Incomplete Intake and Output Documentation for Resident on Fluid Restriction with Foley Catheter
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for a resident with CHF, stage four CKD, neurogenic bladder, and an indwelling urinary catheter. The resident was admitted with diagnoses including CHF and was later assessed as moderately cognitively impaired, dependent on staff for toilet hygiene, and having an indwelling urinary catheter. The facility’s policy required nursing staff to document intake and output in the EHR, and the resident’s care plan directed staff to monitor fluid intake with meals and document urinary output every shift, including amount, type, color, and odor. The resident’s NP progress note indicated altered mental status, urinary retention, pulmonary vascular congestion, acute on chronic systolic CHF, an extra dose of Bumex, continuation of Bumex daily, and a fluid restriction. Physician orders placed the resident on a 1.5 L fluid restriction with monitoring every shift. However, the clinical record showed inconsistent and incomplete documentation of fluid intake between the MAR, EHR vitals section, and paper meal intake records on multiple dates, with differing totals and blank meal entries. On one date, the paper meal record showed 960 mL total intake while the MAR and EHR documented lower amounts; on other dates, meal intake entries were blank or totals did not match across records. The clinical record also failed to show any documented urine output every shift from 8/15/25 through 8/26/25, despite the resident having an indwelling urinary catheter and a care plan requiring output documentation. During observation, surveyors saw catheter tubing and a urinary catheter collection bag, while the resident stated he/she no longer had a catheter in place. Staff interviews confirmed the resident was on fluid restriction and had an indwelling urinary catheter, that intake and output monitoring was required, and that urine output should have been documented in milliliters each shift.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control and prevention program for Resident #52 during wound care while the resident was on Enhanced Barrier Precautions for a stage II pressure ulcer to the mid back/spine. The resident was admitted in March 2025 with diagnoses including vascular dementia, pressure ulcer of unspecified part of the back, and unspecified severe protein calorie malnutrition. Physician orders included measuring the wound every Monday, maintaining enhanced barrier precautions every shift, and cleansing the stage II wound with soap and water before applying calcium alginate and a superabsorbent pad. During observation on 8/27/25, Nurse #3 performed wound care while CNA #1 assisted with positioning the resident in bed. Multiple times during the procedure, Nurse #3 and CNA #1 removed gloves and put on new gloves without performing hand hygiene before continuing care. Nurse #3 also removed a pen from her pant pocket while wearing soiled gloves and used it to write the date on tape for the dressing. In interview, Nurse #3 stated she should have performed handwashing after removing her gloves and should have used a clean pen. The DON stated Nurse #3 should have sanitized her hands after glove removal and used a sanitary writing implement to date the wound dressing.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that the Pneumococcal Vaccination was administered to two residents, despite having consent from the residents or their representatives. Resident #35, who was over the age of 65 and had a history of Chronic Obstructive Pulmonary Disease and Hypertensive Heart and Chronic Kidney Disease, consented to receive the Pneumococcal Vaccine in March 2023. However, the facility's records showed that the resident had only received one dose of PCV13 in 2015, with no evidence of any subsequent doses, despite being eligible for further vaccination according to CDC guidelines. Similarly, Resident #81, who was also over the age of 65 and had a diagnosis of Diabetes Mellitus, had consented through a representative to receive the Pneumococcal Vaccine if indicated. The facility's records indicated that this resident had received one dose of PCV13 in 2019, but no further doses were administered, even though the resident was eligible for additional vaccination. The Infection Preventionist, who started in June 2024, acknowledged that she had not audited the residents for Pneumococcal Vaccine needs and confirmed that both residents were eligible for further vaccination.
Failure to Implement Hospital Wound Care Recommendations
Penalty
Summary
The facility failed to provide appropriate care for a resident with a Stage 4 pressure ulcer, as per the hospital's wound care recommendations. The resident, who was admitted with a Stage 4 pressure ulcer and quadriplegia, was supposed to receive a specific wound care regimen upon re-admission to the facility. This regimen included washing the wound with soap and water, applying Santyl, using saline-moistened kerlix, and covering the wound with Mepilex. However, the facility did not implement the recommended Santyl wet-to-dry dressings, which were crucial for the resident's wound care. The deficiency was identified through a review of the resident's clinical records and observations made by the surveyor. The records showed that the hospital's wound care recommendations were not followed, and the resident's wound deteriorated over time. Initially documented as a Stage 2 wound with light exudate, it progressed to an unstageable wound with heavy exudate and a foul odor. During an observation, the surveyor noted a significant portion of the wound with necrotic tissue and undermining, indicating a decline in the wound's condition. Interviews with facility staff revealed that the hospital's recommendations were not correctly entered into the resident's clinical record. The Admission Nurse and Nursing Supervisor acknowledged the oversight, with the Nursing Supervisor admitting to failing to include the wet-to-dry portion of the Santyl dressing order. The Director of Nursing confirmed that it was the responsibility of the nurse taking the order to ensure it was entered correctly and that any deviations from hospital recommendations should have been documented.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to adhere to infection control standards, leading to potential transmission of communicable diseases and infections for two residents. For Resident #130, the deficiency involved improper hand hygiene during a wound care procedure. The Unit Manager did not perform hand hygiene after removing gloves and before donning new ones while changing the dressing on a Stage 4 Pressure Ulcer, which could increase the risk of infection in the resident's wound. For Resident #241, the facility did not ensure proper use of Personal Protective Equipment (PPE) and urinary catheter care. A Certified Nurses Aide entered the resident's room without wearing a gown or gloves, despite the resident being on Contact Precautions for Clostridium Difficile. The aide also failed to wash hands after leaving the room. Additionally, a Rehabilitation Services Staff member wore a gown with untied waist ties, which could lead to contamination. These actions did not comply with the facility's infection control policies. Furthermore, the facility did not follow proper procedures for urinary catheter maintenance for Resident #241. After the resident's catheter drainage bag became disconnected, Nurse #2 reconnected it without replacing it with a new sterile bag, contrary to guidelines. The resident was also observed with the catheter drainage bag on the floor, which is against infection control protocols. These lapses in infection control practices could contribute to the spread of infections within the facility.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to ensure staff implemented and followed interventions in a resident's care plan, resulting in a serious injury. The resident, who required the use of a Hoyer lift with the assistance of two staff members for all transfers, was transferred by a CNA without the required assistance. During the transfer, the mechanical sling became loose, causing the resident to fall to the floor, landing on their knees and face. The resident sustained multiple injuries, including a subdural hematoma, subarachnoid hemorrhage, and bilateral nasal fractures, and was subsequently transferred to the hospital for treatment. The incident occurred despite the resident's care plan and Kardex clearly indicating the need for two staff members to assist with transfers using the Hoyer lift. The CNA admitted to transferring the resident alone, both before and after the fall, and acknowledged awareness of the requirement for assistance. The CNA's failure to follow the care plan and obtain the necessary help directly led to the resident's fall and subsequent injuries. The facility's investigation confirmed that the CNA did not follow the care plan and did not seek assistance from another staff member during the transfer. The Director of Nurses acknowledged that the CNA should have adhered to the care plan and obtained the required assistance for the transfer. The incident highlights a significant lapse in following established care protocols, resulting in severe harm to the resident.
Failure to Provide Adequate Staff Assistance During Transfer
Penalty
Summary
The Facility failed to ensure that Resident #1, who required the use of a Hoyer lift with the assistance of two staff members for all transfers, was provided with the necessary level of staff assistance to maintain safety. On 03/12/24, CNA #1 transferred Resident #1 from his/her wheelchair into bed without another staff member present to assist. During the transfer, the mechanical sling came loose, causing Resident #1 to fall to the floor onto his/her knees and then forward onto his/her face. This incident resulted in Resident #1 sustaining a head laceration, head injuries, and multiple facial fractures, necessitating transfer to the Hospital Emergency Department (ED). The injuries included a small acute subdural hematoma, small acute subarachnoid hemorrhage, and bilateral [NAME] II fractures, among others. The Facility's policy on Mechanical Lifts, revised on 1/25/22, clearly indicated that two staff members were required to assist with the use of a Hoyer lift for safe transfers. Despite this, CNA #1 proceeded with the transfer alone, which directly led to the incident. The Facility's investigation and staff interviews revealed that CNA #1 was aware of the requirement for two-person assistance but chose to perform the transfer alone. After the fall, CNA #1 further failed to follow protocol by not immediately seeking assistance from a nurse and instead moved Resident #1 from the floor to the bed by himself, cleaned the blood from the floor, and then notified Nurse #1 of the incident. Resident #1 had been admitted to the Facility in December 2018 with diagnoses including Alzheimer's Disease and unspecified osteoarthritis. The Quarterly Minimum Data Set (MDS) Assessment dated 03/06/24 indicated that Resident #1 had significant memory impairments and was dependent on two or more staff members for chair/bed-to-chair transfers. The Falls Care Plan and care Kardex also specified the need for a Hoyer lift with two staff members for all transfers. The failure to adhere to these documented care requirements directly contributed to the incident and subsequent injuries sustained by Resident #1.
Failure to Follow Fall Protocol and Immediate Assessment
Penalty
Summary
The Facility failed to ensure quality care for a resident who experienced a fall during a transfer with a Hoyer lift. Despite the resident bleeding from the nose and having visible injuries, the CNA transferred the resident off the floor and into bed before notifying nursing staff for an assessment. This action was against the Facility's policy, which requires a licensed nurse to conduct a physical assessment immediately after a fall. The incident occurred when the mechanical lift sling became loose, causing the resident to fall face forward onto the floor. The resident sustained significant injuries, including a small subdural hematoma, a small subarachnoid hemorrhage, and bilateral nasal fractures. The CNA admitted to transferring the resident by himself and cleaning the blood off the floor before notifying the nurse, despite knowing that a nurse should assess the resident immediately after a fall. The Facility's investigation revealed that the CNA did not seek assistance from another staff member during the transfer and failed to follow the proper protocol for post-fall assessment. The Director of Nurses confirmed that the CNA should have requested help and that staff are not supposed to move a resident who has fallen until a nurse has assessed them for injuries.
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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) |
|---|---|---|---|---|
| Lutheran Rehabilitation And Skilled Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
| St Francis Rehabilitation & Nursing Center | 1.2 mi | ★★★★★ | 5 | 0 |
| Notre Dame Long Term Care Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Regalcare At Worcester | 1.6 mi | ★★★★★ | 0 | 0 |
| West Side House Ltc Facility | 1.7 mi | ★★★★★ | 17 | 0 |
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