Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Notre Dame Long Term Care Center during CMS and state inspections, most recent first.
Loose Unlabeled Pills Found in Medication Carts: Staff failed to ensure drugs were stored and labeled properly in two medication carts. Observers found loose pills, paper remnants, elastics, and powder in the drawers holding resident-specific medication cards on both the High Side and Low Side carts. The UM said loose meds could have been dropped by the nurse, and the DON stated the assigned nurse was responsible for cleaning the cart at the end of the shift.
A resident with dysphagia, severe cognitive impairment, and significant weight loss was care planned for supervised meals, setup assistance, mouth checks, and assistance as needed, with orders for a pureed diet and supervised dining at all meals. Surveyors observed staff set up breakfast in the resident’s room and leave, after which the resident ate without staff present, spilled food and liquids on clothing, and left part of the meal untouched. Staff interviews confirmed the resident required a staff member to be present during meals for supervision and encouragement.
Medication Administration Outside BP Parameters: Staff administered antihypertensive and diuretic medications to two residents without following ordered BP checks and hold parameters. One resident received Amlodipine without a documented SBP assessment, and another resident received Amlodipine, Torsemide, and Valsartan multiple times when DBP readings were below the physician-ordered limits. Nursing staff and the DON confirmed the medications should have been held when BP values were outside the ordered parameters.
A nurse in an LTC facility failed to follow proper infection control practices during wound care for a resident with an unstageable pressure ulcer and MRSA. The nurse did not wash or sanitize hands between glove changes and used non-disinfected scissors, compromising infection control. The facility's Infection Preventionist acknowledged that nursing competency assessments for infection control had not been conducted.
A resident with dementia and muscle weakness was not provided with necessary adaptive eating utensils, despite care plans indicating their need. Observations showed the resident struggling to eat with standard silverware, leading to food spillage. Staff interviews confirmed the oversight, as the required utensils were highlighted on the diet slip but not provided.
The facility failed to adhere to infection control standards for two residents, increasing the risk of contamination and infection spread. One resident with a urinary catheter did not receive care with proper Enhanced Barrier Precautions, as a hospice staff member did not wear a gown. Another resident with a pressure ulcer and MRSA infection experienced improper hand hygiene during wound care, as a nurse repeatedly failed to sanitize hands between glove changes.
A resident with poly-osteoarthritis and dementia, requiring two-person assistance for bed mobility, was repositioned by a single staff member multiple times, contrary to their care plan. This failure was discovered after the resident sustained a fractured tibia, confirmed by an x-ray. Interviews revealed that CNAs were unaware of the two-person requirement for bed mobility, although they knew it was needed for mechanical lift transfers. The DON expected staff to follow care plans.
Loose Unlabeled Pills Found in Medication Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled in accordance with accepted professional standards of practice. During observation, loose, unlabeled pills were found in the Cuvilly Unit High Side medication cart, along with paper remnants, elastics, and powder in the corners of the drawer that held resident-specific medication cards. The Unit Manager stated that the loose medications could have been dropped by the nurse, which could lead to an omission of prescribed medications, and said she expected the medication carts to be clean and free of loose medications and debris. A similar observation was made in the Cuvilly Unit Low Side medication cart, where loose pills, paper remnants, elastics, and powder were found in the drawer that held resident-specific medication cards. The nurse present said she was unsure who was responsible for ensuring the cart was clean and free of debris and would need to ask the Unit Manager. The DON stated that medication carts were expected to be clean and that the nurse assigned to the cart was responsible for cleaning it at the end of the shift.
Failure to Provide Ordered Meal Supervision and Assistance
Penalty
Summary
The facility failed to implement the resident’s person-centered care plan for eating assistance and supervision for a resident with moderate protein calorie malnutrition, dysphagia, hypothyroidism, and hypo-osmolality/hyponatremia. The resident had a significant weight loss, declining from 106.1 pounds on 11/12/25 to 88.8 pounds on 5/5/26, and was care planned for supervised meals, setup assistance, mouth checks after meals, and assistance as needed. The resident’s records also reflected severe cognitive impairment, holding food in the mouth or cheeks after meals, and the need for a mechanically altered diet with set-up and assistance with eating. The resident’s speech care plan stated the resident was to eat only with supervision and that the mouth should be checked after each meal for pocketed food and debris. The nutritional risk assessment documented swallowing disorder data including holding food in the mouth after meals and coughing or choking during meals or when swallowing medications, along with physical and functional data indicating setup assistance and supervision. The physician’s orders included a pureed diet, thin liquids, no straws, supervised dining at all meals, and a protein shake supplement with meals. The dietician’s progress note documented ongoing significant weight loss and low weight, and the alteration in nutrition care plan included ongoing supervision at meals, encouragement, and assistance when able. On 5/6/26 and 5/7/26, surveyor observations showed staff entering the resident’s room, placing the meal on a bedside table, elevating the head of the bed, setting up the meal, and leaving the room. The resident was then observed eating without staff present. During these observations, the resident spilled oatmeal and milk on clothing, used the adaptive nosey cup independently, and left portions of the meal untouched. Staff interviews confirmed that supervision meant a staff member must be present during meals, that the resident required supervision during meals, and that a staff member should have been in the room supervising the resident during breakfast. The speech therapist and registered dietician both stated the resident needed supervision and encouragement with meals, and the dietician said she was not aware the resident was eating in the bedroom rather than the dining room.
Medication Administration Outside Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for two residents, resulting in two significant medication errors. The deficiency involved blood pressure parameters tied to antihypertensive and diuretic medications, with staff administering medications when required blood pressure checks were not documented or when the documented blood pressure values were outside the ordered hold parameters. For one resident, admitted with diagnoses including essential hypertension, chronic kidney disease stage 3A, hypertensive chronic kidney disease, and sequelae of cerebral infarction, the physician ordered Amlodipine Besylate 2.5 mg in the morning and to hold the medication if SBP was less than 110 mmHg. Review of the MARs for March, April, and May 2026 showed the medication was administered daily with no blood pressure assessment documented in the clinical record relative to the administration. During interview, nursing staff stated the medication should not have been given without a documented SBP assessment and that the resident’s blood pressure should have been assessed daily before administration, rather than weekly as it had been. For the second resident, admitted with chronic diastolic congestive heart failure, atrial fibrillation, chronic kidney disease stage 3B, essential hypertension, and a pacemaker, the active orders included Amlodipine Besylate, Torsemide, and Valsartan with instructions to hold for SBP less than or equal to 105 mmHg and/or DBP less than or equal to 60 mmHg. Review of the February, March, and May 2026 MARs showed multiple administrations of these medications when the documented DBP was below 60 mmHg, including several readings in the 50s. Nursing staff and the DON confirmed the medications should have been held and the physician notified when the DBP was below the ordered parameters, and the NP stated she expected staff to monitor blood pressure as ordered and notify her when the DBP was low.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to ensure that a Licensed Nurse had the necessary competencies and skills to provide proper wound care for a resident with an unstageable pressure ulcer and a Methicillin Resistant Staphylococcus Aureus (MRSA) infection. During a wound care observation, the nurse did not adhere to infection control practices as outlined in the facility's policies. Specifically, the nurse did not wash or sanitize her hands between glove changes multiple times throughout the procedure, which is a critical step in preventing the transmission of healthcare-associated infections. The nurse also failed to disinfect scissors before using them to cut a piece of Calcium Alginate, which was then placed on the overbed table. Additionally, the nurse handled personal items, such as a pen, without sanitizing her hands, further compromising infection control. The Infection Preventionist/Staff Development Coordinator admitted that nursing competency relative to infection control during wound care had not been performed, which contributed to the deficiency observed.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment for a resident, specifically built-up handled utensils, which were necessary to maintain the resident's current level of function during meals. The resident, who was admitted with diagnoses including unspecified dementia and generalized muscle weakness, had care plans and assessments indicating the need for black handled utensils to aid in eating. Despite these documented needs, observations on two separate occasions revealed that the resident was provided with standard silverware instead of the required adaptive utensils, leading to difficulties in self-feeding. During the observations, the resident struggled to use the standard utensils, resulting in food spillage and the need to use hands to eat. Interviews with staff, including a nurse and a CNA, confirmed that the resident required the black handled utensils for easier grasping, as indicated on the diet slip. The staff acknowledged that the adaptive equipment was highlighted on the diet slip and should have been checked before meal delivery, but this was not done, leading to the deficiency.
Infection Control Lapses in PPE and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection control standards for two residents, increasing the risk of contamination and the spread of infection. For one resident, the staff did not follow Enhanced Barrier Precautions (EBPs) while providing high-contact care. The resident had an indwelling urinary catheter and was on hospice care. Despite the presence of an EBP sign and PPE supplies, a hospice staff member did not wear a gown while adjusting the resident's urinary catheter and providing morning care. The hospice staff member admitted to not noticing the EBP sign and not understanding the requirements for wearing a gown during care. For another resident, the facility failed to ensure proper hand hygiene practices during wound care. The resident had an unstageable pressure ulcer and a MRSA infection. During a wound care procedure, a nurse did not wash or sanitize her hands between glove changes multiple times. The nurse also used scissors from her pocket without disinfecting them and handled a pen without sanitizing her hands. The nurse acknowledged that she should have cleaned her hands between glove changes but did not. These deficiencies highlight lapses in infection control practices, specifically in the use of PPE and hand hygiene during resident care. The failure to adhere to these standards poses a risk of spreading infections within the facility, particularly among residents with compromised health conditions.
Failure to Implement Care Plan for Resident Requiring Two-Person Assistance
Penalty
Summary
The facility failed to ensure that staff consistently implemented the care plan interventions for a resident who required assistance from two staff members for bed mobility. The resident, who had a history of poly-osteoarthritis and frontotemporal neurocognitive disorder, was non-ambulatory and dependent on staff for bed mobility and transfers. Despite the care plan indicating the need for two staff members for assistance, the resident was repositioned by a single staff member on multiple occasions, as documented in the CNA flow sheets for the evening and night shifts. The deficiency was identified after the resident sustained a fractured left tibia of unknown origin. The fracture was discovered when the resident moaned in pain during morning personal care, and an x-ray confirmed the injury. Interviews with CNAs revealed that they were not aware of the requirement for two-person assistance for bed mobility, although they knew it was necessary for mechanical lift transfers. The Director of Nurses stated that the expectation was for staff to always follow each resident's plan of care.
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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) |
|---|---|---|---|---|
| Regalcare At Worcester | 0.6 mi | ★★★★★ | 0 | 0 |
| Christopher House Of Worcester | 1.3 mi | ★★★★★ | 0 | 0 |
| Holy Trinity Eastern Orthodox N & R Center | 1.9 mi | ★★★★★ | 2 | 0 |
| Odd Fellows Home Of Massachusetts | 2 mi | ★★★★★ | 10 | 0 |
| Knollwood Nursing Center | 2.1 mi | ★★★★★ | 9 | 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 August 2026) and official state health department websites.