Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 St Francis Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
Staff failed to follow infection control and PPE requirements during wound care, an EBP transfer, and care for a resident on Droplet Precautions. A nurse changed gloves during wound care without hand hygiene and handled a pen with soiled gloves; two CNAs transferred a resident on EBP without gowns; and a CNA entered and exited a droplet-precaution room without proper hand hygiene, gown use, or mask change.
A resident receiving weekday hemodialysis with a CVC had a physician order for a non-toothed clamp at the bedside at all times when the catheter was in use, but surveyors did not find the clamp or any other emergency supplies in the room. The resident was cognitively intact and unsure what the clamp was, while the UM and DON stated the clamp and emergency supplies should have been available at the bedside/headboard.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A facility failed to provide a dignified dining experience for a resident during breakfast. A CNA was observed standing while assisting the resident, contrary to the facility's policy that requires staff to be seated to maintain eye contact and engage in conversation. The CNA admitted to standing due to personal preference, and the DON confirmed that staff should be seated for dignity purposes.
The facility did not conduct ongoing reviews of residents' rights and services for six residents attending Resident Council meetings. Despite policy requirements, no evidence was found in meeting minutes or through resident interviews that rights were discussed. The Administrator admitted to the oversight, with no written postings observed on relevant units.
A resident's wheelchair was found in disrepair and unclean, with exposed padding and food debris. The facility lacked a maintenance policy and no work order was reported, leaving staff unaware of the issue.
The facility failed to develop comprehensive care plans for two residents prescribed anticoagulant and antiplatelet medications. Despite the administration of Clopidogrel Bisulfate and Apixaban as ordered, there were no care plans addressing the risks, potential complications, and monitoring associated with these medications. The Director of Nurses acknowledged the absence of required care plans, contrary to the facility's anticoagulation use policy.
A resident with dementia and Alzheimer's disease was not provided necessary grooming assistance, despite requiring substantial help with personal care. Observations showed the resident with long facial hair, and staff interviews confirmed that shaving should be part of daily ADL care. The facility's records did not indicate any refusals of care by the resident.
A resident's oxygen concentrator was not maintained in a clean and sanitary manner, with thick dust and dried liquid stains observed on the device. Despite the resident's need for continuous oxygen therapy due to COPD, Asthma, and CHF, the concentrator was not cleaned as required, and an error in the physician's orders regarding filter cleaning was identified.
The facility failed to offer and administer the updated COVID-19 vaccine to two residents. One resident, with a history of dementia, was not offered the vaccine due to a lack of contact with their legal guardian for consent. Another resident, with a stroke diagnosis, had consent from their Health Care Proxy but did not receive the vaccine. These failures highlight a lapse in the facility's vaccination process.
A resident with Parkinsonism and diabetes mellitus with polyneuropathy sustained a second-degree burn after being served hot coffee in a Styrofoam cup instead of the required double handled mug. The incident occurred due to the nursing staff's failure to check meal trays for accuracy, including the presence of necessary adaptive equipment, prior to distribution.
Infection Control and PPE Noncompliance During Resident Care
Penalty
Summary
The facility failed to follow infection control practices during wound care for a resident with malignant neoplasm of bone and physician orders for wound treatment and Enhanced Barrier Precautions (EBP) due to ESBL in urine. While Nurse #1 was changing the resident’s coccyx dressing, she washed her hands and donned a gown and gloves, but then removed and replaced gloves multiple times without performing hand hygiene between glove changes. During the dressing change, she also reached into her pocket while still wearing soiled gloves, removed a pen, and dated the wound dressing. Nurse #1 later stated she had performed hand hygiene before starting the dressing change but did not perform hand hygiene between doffing and donning new gloves, and acknowledged she should have done so. The facility also failed to ensure that appropriate PPE was worn for a resident on EBP for ESBL in urine during a Hoyer lift transfer from bed to chair. Two CNAs transferred the resident while neither was wearing a gown, even though the resident had an EBP sign posted at the door. One CNA stated she had removed her gown to look for the lift and did not put on a new gown before the transfer, and the other CNA stated she should have worn a gown but did not. The nurse caring for the resident confirmed that both CNAs should have had gowns on during the transfer. The facility further failed to follow droplet precaution signage for a resident with MRSA of the nares who was ordered to remain on Droplet Precautions. A CNA entered the room wearing a mask but did not perform hand hygiene, did not don a gown, and did not change her mask after exiting the room. The CNA stood at the bedside, removed the resident’s breakfast tray, and left without performing hand hygiene on exit. The CNA stated she should have performed hand hygiene and donned PPE before entering, and should have performed hand hygiene when leaving. The unit manager and infection preventionist both stated the CNA should have followed the posted precautions, including hand hygiene and changing the mask when leaving the room.
Missing Emergency Clamp for Dialysis CVC
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required hemodialysis and had a central venous catheter (CVC). The resident was admitted with diagnoses including dependence on renal dialysis, ESRD, and anemia, and was cognitively intact with a BIMS score of 13. Physician orders directed dialysis Monday through Friday and required a non-toothed clamp at the bedside at all times when the dialysis catheter was in use. The resident’s MAR showed dialysis was received every Monday through Friday. During observation, the resident was seen in a wheelchair in the room with a dressing on the right chest wall CVC, but no emergency non-toothed clamp or other emergency supplies were observed in the bedroom. The resident said dialysis was received on weekdays and was unsure what a non-toothed clamp was. On a later observation, the clamp still was not present. The UM stated the clamp should have been mounted on the back of the headboard, but the surveyor and UM could not locate it anywhere in the room. The UM also stated the emergency supplies should have been available in the bedroom and unit, but there were none. The DON stated that emergency supplies including a non-toothed clamp should be mounted on the back of the headboard for any resident with dialysis access ports.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident, identified as Resident #97, during a breakfast meal. The deficiency was observed when a Certified Nurses Aide (CNA) assisted the resident while standing, rather than being seated, which is contrary to the facility's Dining Guideline policy. This policy, last revised in November 2017, emphasizes enhancing the individual's quality of life through person-centered dining and care, which includes staff being seated to maintain eye contact and engage in conversation with residents. The incident was observed by a surveyor and a nurse, who confirmed that the CNA should have been seated while assisting the resident. During interviews, the CNA admitted to standing because she did not like to sit down, acknowledging that she was supposed to be seated to ensure a dignified dining experience. The Director of Nursing also confirmed that staff should be seated while assisting residents with meals for dignity purposes, indicating a clear deviation from the established policy in this instance.
Failure to Review Residents' Rights During Council Meetings
Penalty
Summary
The facility failed to provide ongoing review of residents' rights and services to six residents who attended Resident Council meetings. The facility's policy, revised on 5/25/22, mandates that residents be informed both orally and in writing about their rights and the rules governing their conduct during their stay. However, a review of the Resident Council Meeting minutes for 2023 - 2024 showed no evidence that residents' rights were discussed during these meetings. During a group meeting with six residents, they confirmed that although monthly Resident Council meetings were held, their rights were not reviewed by facility staff. Observations on the third floor units, where most of these residents reside, revealed no written postings of Resident Rights and Services. The Administrator acknowledged that staff had not been reviewing residents' rights during these meetings and could not provide evidence of any such reviews being conducted.
Failure to Maintain Resident's Wheelchair in Safe Condition
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for a resident, specifically regarding the condition of the resident's wheelchair. The resident, who was admitted in June 2012 and has diagnoses including dementia and cerebral infarction, was observed on two separate occasions sitting in a wheelchair that was in disrepair and unclean. The wheelchair had food debris, a worn left arm pad with exposed padding, a torn right-side pad exposing blue foam, and a ripped footrest extender with exposed white padding. The facility did not have a preventative maintenance or cleaning policy for wheelchairs, nor a routine maintenance schedule. Interviews with staff revealed that concerns about wheelchairs should be reported through an electronic work order system called Tels, but no such report was made for this resident's wheelchair. The Unit Manager and Director of Nursing indicated that staff are trained to report issues, but the maintenance and rehabilitation staff were unaware of the wheelchair's condition due to the lack of a reported work order.
Failure to Develop Care Plans for Anticoagulant and Antiplatelet Medications
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents who were prescribed anticoagulant and antiplatelet medications. Resident #8, who was admitted with diagnoses including Peripheral Vascular Disease and Cerebral Vascular Accident, was prescribed Clopidogrel Bisulfate. Despite the administration of this medication as ordered, there was no evidence of a care plan addressing the risks, potential complications, and necessary monitoring associated with its use. Similarly, Resident #78, admitted with a diagnosis of Cerebral Infarction, was prescribed Apixaban. The medication was administered as ordered, but again, there was no care plan in place to address the associated risks and monitoring requirements. The facility's policy on anticoagulation use requires staff and physicians to monitor for complications and manage related problems, including holding or discontinuing medication if necessary. However, during an interview, the Director of Nurses acknowledged that care plans for monitoring complications and side effects were not developed for these residents, despite the policy's requirements. This oversight indicates a failure to adhere to the facility's guidelines for managing residents on anticoagulant therapy.
Failure to Provide Grooming Assistance to Resident
Penalty
Summary
The facility failed to provide necessary grooming assistance to a resident who required substantial help with personal care. The resident, diagnosed with dementia and Alzheimer's disease, was observed on multiple occasions with long facial hair and hair above the upper lip, indicating a lack of grooming care. Despite the resident's expressed need for assistance with shaving, no staff offered help, and the facility's records did not show any refusals of care by the resident. Interviews with staff, including a nurse and a CNA, confirmed that residents should be offered shaving as part of their daily ADL care. The Director of Nursing also emphasized the importance of daily shaving as part of routine care. However, the facility's failure to provide this care was evident through observations and interviews, highlighting a deficiency in meeting the resident's grooming needs.
Failure to Maintain Oxygen Concentrator Cleanliness
Penalty
Summary
The facility failed to maintain Resident #48's oxygen concentrator in a clean and sanitary manner, which is inconsistent with professional standards of practice. The oxygen concentrator, a device used to deliver supplemental oxygen, was observed with a thick layer of grey dust and dried liquid spill stains with hair stuck to the spills on the top rear intake vent. This lack of maintenance was noted on multiple occasions, indicating that the device was not being cleaned as required. The facility's policy and the manufacturer's guidelines both emphasize the importance of keeping the air intake vents unblocked to prevent device malfunction and ensure proper function. Resident #48, who was admitted with diagnoses including COPD, Asthma, and Congestive Heart Failure, was dependent on staff for activities of daily living and required continuous oxygen therapy. Despite the physician's orders indicating that the concentrator filter should be cleaned regularly, it was found that the concentrator did not require a filter, and an error had been made in the orders. The Director of Nursing confirmed that the concentrator should be cleaned weekly, but it had not been cleaned recently, as evidenced by the observations and interviews conducted during the survey.
Failure to Administer COVID-19 Vaccines to Residents
Penalty
Summary
The facility failed to ensure that COVID-19 vaccinations were offered and administered according to professional standards for two residents. Resident #101, who was admitted with a history of dementia and previous COVID-19 vaccinations, was not offered the updated 2023-2024 COVID-19 vaccine. The Staff Development Coordinator admitted that she did not contact the resident's legal guardian to obtain consent for the updated vaccine, despite the resident being due for it upon admission. Resident #100, admitted with a diagnosis of cerebral infarction, had an invoked Health Care Proxy who had signed consent for the updated COVID-19 vaccine. However, there was no evidence that the resident received the updated 2023-2024 vaccine. The Assistant Director of Nurses acknowledged that the resident should have received the vaccine but had not. These oversights indicate a failure in the facility's process to ensure residents are kept up to date with their COVID-19 vaccinations.
Inadequate Supervision and Missing Adaptive Equipment Lead to Resident Injury
Penalty
Summary
The deficiency identified in the report pertains to the failure of the facility to ensure adequate supervision and assistance for a resident (Resident #1) who required adaptive equipment due to hand tremors. On March 30, 2024, during dinner service, Resident #1's meal tray was not checked for accuracy by nursing staff as required. Consequently, the tray did not include the resident's required double handled mug, leading to Resident #1 being served hot coffee in a Styrofoam cup. This resulted in Resident #1 sustaining a second-degree burn on the left thigh. Resident #1, admitted to the facility in July 2023, had diagnoses of Parkinsonism and diabetes mellitus with polyneuropathy, indicating specific care needs due to these conditions. Despite the resident's documented requirement for a double handled mug for beverages, the necessary adaptive equipment was not provided during the dinner meal on the day of the incident. The failure extended to the lack of supervision by nursing staff, as the nurse on duty did not check meal trays for accuracy, including the presence of adaptive equipment, prior to distribution to residents.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vantage At Worcester Llc | 0.5 mi | ★★★★★ | 14 | 0 |
| Blaire House Of Worcester | 0.6 mi | ★★★★★ | 11 | 0 |
| Worcester Rehabilitation & Health Care Center | 0.8 mi | ★★★★★ | 1 | 0 |
| Christopher House Of Worcester | 1.2 mi | ★★★★★ | 9 | 0 |
| Lutheran Rehabilitation And Skilled Care Center | 1.4 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.