Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Jewish Healthcare Center during CMS and state inspections, most recent first.
A resident with anxiety disorder and Down Syndrome was admitted on clonazepam, which the NP ordered at 1 mg TID based on family report and recent hospital use. During medication reconciliation, a nurse compared the hospital discharge summary listing clonazepam 1 mg BID to the NP’s TID order in the EMR, assumed the TID order was an error, and independently changed the order to BID without consulting a practitioner. The MAR shows the resident then received clonazepam 1 mg BID for several days, and a family member later reported the resident was more angry and was told by staff the drug was being given only twice daily. The NP stated the resident should have continued on clonazepam 1 mg TID and expressed concern that nursing altered the order without provider involvement.
A resident with a history of small bowel resection and recent TPN for significant malnutrition had multiple meal intake percentages left undocumented on CNA flow sheets over several days. The facility could not produce CNA assignment records for the period in question. Staff interviews confirmed that CNAs are responsible for documenting meal intake percentages at each meal as part of routine documentation, and the DON acknowledged there was no formal policy on medical record accuracy, stating it was a standard of care while still expecting complete documentation.
A resident with anxiety, muscle weakness, and dementia was not invited to initial and quarterly care plan meetings, and the record did not document why the resident could not or did not participate. The resident said he/she had never been invited but would like to attend, while the SW stated the HCP had been invoked and the resident was not invited; the DON confirmed that attending care plan meetings is a resident right.
Dirty Oxygen Concentrator Filter: A resident with COPD was receiving humidified O2 via nasal cannula connected to an oxygen concentrator, but the concentrator’s filter was observed covered with thick grey dust. The record did not show documentation that staff cleaned the filter, despite the facility policy requiring weekly filter cleaning and weekly tubing changes. The UM said the filter should not have been dusty, and the DCS stated night shift staff were responsible for cleaning the filters every Wednesday.
A nurse made two medication errors during a med pass, resulting in a 7.69% error rate. The nurse gave an ARB despite an order to hold it when SBP was below 130 mmHg and administered Calcium/Vitamin D instead of the ordered Calcium 1200 mg for a resident with cardiomegaly, CKD, hypertensive heart and CKD with HF, MS, and osteoporosis. The MAR also showed prior administrations of the ARB when SBP was below the hold parameter, and both the nurse and DON acknowledged the errors.
Unlabeled pre-poured medications were found in a medication cart when an LPN was observed storing one cup in the top drawer and another in the bottom drawer. The LPN said the medications had been prepared for two residents who refused them, and the DON stated that refused medications should be destroyed immediately. Facility policy stated that medications are never pre-poured and must be stored and labeled properly.
Unpasteurized eggs were served over easy to residents despite facility policy stating fried eggs must be cooked over hard because pasteurized whole eggs were not used. A cook served residents eggs with runny yolks, and the FSD confirmed the eggs purchased and used were not pasteurized and should have been cooked through.
A facility did not complete a required Level I PASRR for a resident with PTSD before their admission, as mandated by policy. The PASRR, intended to assess for mental disorders or intellectual disabilities, was conducted after the resident's admission. The DON confirmed the delay in completing the PASRR.
The facility failed to follow infection control standards on the Fourth Floor Unit. A nurse did not disinfect a glucometer after use, risking cross-contamination, and a wound nurse improperly handled wound care supplies, placing them on a resident's bed and returning them to the treatment cart, contrary to policy.
Nursing Changed Clonazepam Order Without Practitioner Consultation
Penalty
Summary
The deficiency involves nursing staff failing to follow professional standards of practice and facility policy when they unilaterally changed a physician’s order for an anti-anxiety medication. A resident with anxiety disorder and Down Syndrome was admitted with a hospital discharge summary listing clonazepam 1 mg twice daily as a modified medication, but had actually been prescribed and administered clonazepam 1 mg three times daily during the hospitalization until the morning dose on a specified date when the frequency was modified. On admission, the NP, after being informed by nursing that the family reported the resident had been taking clonazepam 1 mg three times per day before and during the hospitalization, wrote an order for clonazepam 1 mg three times daily. The facility’s medication reconciliation policy required licensed nurses to compare discharge medication lists with admission orders, clarify discrepancies with a practitioner, and ensure accurate reconciliation. Review of the MAR showed that the resident had a physician’s order for clonazepam 1 mg three times daily, but the order was changed by nursing the day after admission to clonazepam 1 mg twice daily without consulting a practitioner. The MAR indicated the resident received clonazepam 1 mg twice daily for several days following this change. During interviews, a family member reported the resident appeared more angry during visits and was told by staff that the resident was only receiving clonazepam twice daily. A nurse stated that, while performing the second-check reconciliation, she saw the hospital discharge summary listed clonazepam twice daily and assumed the three-times-daily order in the EMR was an error, so she changed the order back to twice daily without contacting a practitioner. The NP later stated she was upset that nursing had changed the frequency without consulting her or the physician and affirmed the resident should have received clonazepam three times daily per her order. The DON acknowledged that there had been a breakdown in communication regarding the clonazepam order, resulting in the medication error.
Failure to Accurately Document Meal Intake Percentages
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident by not documenting meal intake percentages for multiple meals. The resident, admitted in January 2026 with a diagnosis including status post small bowel resection, had a hospital discharge summary indicating they had received total parenteral nutrition (TPN) during hospitalization due to significant malnutrition, with TPN discontinued on 01/20/26. Review of the resident’s CNA flow sheets for January 2026 showed that the meal intake percentage boxes were left blank for five applicable meals: dinner on 01/25/26; breakfast and lunch on 01/26/26; and breakfast and lunch on 01/27/26. The facility was unable to provide CNA assignment records for the resident’s stay. In interviews, a CNA and the Unit Manager stated that CNAs are responsible for documenting residents’ meal intake percentages at each meal as part of their routine documentation, and the DON stated there was no written policy on medical record accuracy and documentation because it was considered a standard of care, but that CNAs were expected to document all of the resident’s meal intake percentages.
Failure to Invite Resident to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that one resident was given the opportunity to participate in the care plan process and failed to document why the resident could not or did not participate in two care plan meetings. The resident was admitted in September 2025 with diagnoses including anxiety, muscle weakness, and dementia. The MDS showed cognitive impairment with a BIMS score of 4 out of 15, while also indicating the resident was English speaking and usually able to make himself/herself understood and understand others. During interviews, the resident stated being unaware of what a care plan meeting was and said he/she had never been invited to one, but would definitely like to attend. Review of the clinical record showed no evidence that the resident participated in the interdisciplinary care planning process during the initial and quarterly care plan reviews held on 10/30/25 and 1/2/26. The record also lacked documentation explaining why the resident did not or could not participate, or any refusals to attend those meetings. The SW stated that all residents should be invited to care plan meetings, but said the resident was not invited because the HCP had been invoked and acknowledged there was no documented evidence in the record supporting why the resident had not been invited. The UM stated residents are invited unless it is determined that doing so would be detrimental, and the DON stated that being invited to care plan meetings is a resident's right.
Dirty Oxygen Concentrator Filter
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for one resident who had COPD and was receiving humidified oxygen via nasal cannula connected to an oxygen concentrator. The resident was cognitively intact, and the most recent physician’s order directed humidified oxygen at 1 to 4 LPM, titrated to keep oxygen saturation greater than 90% for shortness of breath. During observation, the oxygen concentrator was running at 1.5 LPM, and the filter on the left side of the concentrator was observed to be covered entirely with thick grey dust. Review of the resident’s medical record did not show any documentation that staff cleaned the oxygen concentrator filter. The facility’s Oxygen Maintenance policy stated that oxygen concentrators must be maintained in a clean, safe, and functional condition and that weekly cleaning of concentrator filters and weekly oxygen tubing changes were mandatory. On a later observation, the filter remained covered with thick grey dust. The Unit Manager stated the filter was dirty and should not have been covered in dust, and the Director of Clinical Services stated night shift staff were responsible for cleaning the filters and that they should be cleaned every Wednesday.
Medication Administration Errors With Blood Pressure Hold Parameter and Wrong Calcium Dose
Penalty
Summary
Medication administration errors occurred when Nurse #1 made two errors in 26 total opportunities, resulting in a medication error rate of 7.69%. During observation, record review, and interview, the facility failed to ensure that the nurse followed the physician order to hold Losartan Potassium when Resident #119’s systolic blood pressure was less than 130 mmHg. On 1/16/26, the nurse obtained a blood pressure of 113/65 mmHg and administered Losartan Potassium 100 mg despite the hold parameter. Resident #119 had diagnoses including cardiomegaly, chronic kidney disease stage 2, hypertensive heart and chronic kidney disease with heart failure, multiple sclerosis, and age-related osteoporosis. The facility also failed to ensure the correct calcium medication was administered. The physician order called for Calcium 1200 mg daily, but Nurse #1 administered Calcium/Vitamin D 600 mg/10 mcg, two tablets by mouth. Review of the MAR showed Losartan Potassium was also documented as administered on other dates when systolic blood pressure readings were below 130 mmHg, including 128 mmHg, 123 mmHg, 125 mmHg, and 122 mmHg. During interview, Nurse #1 stated he did not see the order to hold Losartan Potassium when blood pressure was below 130 mmHg and acknowledged he should not have administered either the Losartan Potassium or the Calcium/Vitamin D medication. The DON stated the nurse should not have administered those medications and should have followed the physician order to hold the blood pressure medication.
Unlabeled Pre-Poured Medications Stored in Medication Cart
Penalty
Summary
Medication storage was not maintained in a safe and sanitary manner on the Fifth-Floor North medication cart. The facility policy stated that medications are never pre-poured and that medications must be stored, labeled, secured, and monitored in a manner that maintains drug integrity and potency. During observation, Nurse #2 was seen with a medication cup in the bottom drawer of the cart that had no name or label and contained applesauce mixed with white tablets and a blue and white capsule. Nurse #2 then opened the top drawer, where another unlabeled plastic medication cup was observed containing three white tablets and one white capsule. During interview, Nurse #2 stated that the medications in applesauce had been prepared for a resident who refused them and said she should have immediately destroyed them. Nurse #2 also stated that the second medication cup had been placed in the bottom drawer for another resident who had refused medications earlier. The DON later stated that the standard practice was to destroy medications immediately when residents refused them and confirmed that the medications should have been destroyed by Nurse #2.
Unpasteurized Eggs Served Over Easy
Penalty
Summary
The facility failed to follow professional standards of practice for food safety in the preparation and service of eggs. The facility policy titled Enhanced Dining stated that fried eggs prepared to order must be cooked over hard because pasteurized whole eggs were not used, and that no eggs over easy or sunny side up were to be served. Review of vendor invoices showed the whole eggs purchased for use in the facility were unpasteurized. On 1/16/26, a surveyor observed a staff member serve a resident breakfast that included an over easy egg, and the resident ate the egg with a runny yolk. On 1/20/26, the surveyor observed two residents eating over easy eggs with running yolks in the third-floor dining room. During interviews, Dietary Staff #1 stated she had prepared and served over easy eggs with runny yolks on both dates and confirmed the eggs were not pasteurized. The FSD also stated the whole eggs purchased were not pasteurized and that the eggs should not have runny yolks and should have been cooked through.
Failure to Complete PASRR Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review Level I (PASRR) was completed prior to the admission of a resident. The facility's policy requires a Level I PASRR to be conducted before admitting a resident to evaluate for the presence of a mental disorder or intellectual disability. However, for one resident with a diagnosis of Post Traumatic Stress Disorder (PTSD), the Level I PASRR was not completed until after their admission. The resident was admitted in July 2024, but the PASRR was only completed on August 15, 2024. During an interview, the Director of Nursing acknowledged that the PASRR was completed late and should have been done before the resident's admission.
Infection Control Deficiencies in Glucometer and Wound Care Practices
Penalty
Summary
The facility failed to adhere to infection control standards on the Fourth Floor Unit, as observed during a survey. Specifically, a nurse did not clean and disinfect a glucometer after using it on a resident, which is against the facility's policy. The nurse placed the glucometer back into a storage bag without disinfecting it, and the bag was used for all residents on her assignment. This action was confirmed by the nurse and the Infection Control Preventionist, who acknowledged that the glucometer should have been disinfected with PDI wipes before being stored to prevent cross-contamination. Additionally, during a wound care observation, the Staff Development Coordinator/Wound Nurse used a bottle of wound cleanser and placed it on a resident's bed. After completing the wound care, the nurse returned the bottle to the treatment cart, contrary to the facility's policy, which requires that any supplies brought into a resident's room should be labeled and left in the room. The Infection Control Preventionist confirmed that the shared wound care supply should not have been placed on the resident's bed and should have been left in the resident's room to prevent cross-contamination.
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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) |
|---|---|---|---|---|
| Holy Trinity Eastern Orthodox N & R Center | 2 mi | ★★★★★ | 2 | 0 |
| Odd Fellows Home Of Massachusetts | 2.1 mi | ★★★★★ | 10 | 0 |
| West Side House Ltc Facility | 2.3 mi | ★★★★★ | 17 | 0 |
| Hermitage Healthcare (the) | 2.4 mi | ★★★★★ | 18 | 0 |
| Lutheran Rehabilitation And Skilled Care Center | 2.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.