Worcester Rehabilitation & Health Care Center
Inspection Findings
F-Tag F0580
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
fall during the overnight night shift, that he/she slipped on his/her own vomit and had a change in condition.
The NP said she gave orders to send him/her to the Hospital Emergency Department. The NP said there is
an On -Call Provider on overnight until 08:00 A.M., and that the nursing staff should have called the OnCall Provider. During an interview on 10/21/25 at 10:34 A.M., the Nursing Supervisor said she was notified by Nurse #1 at approximately 9:00 A.M. on 9/22/25 that Resident #1 had an episode of emesis with an unwitnessed fall during the night and had a decline in condition in the morning and said she (Nursing Supervisor) called the Provider and received an order to send him/her to the Hospital ED. During a telephone interview on 10/21/25 at 2:00 P.M., the Director of Nursing (DON) said there was no documentation to support that Nurse #1 notified the On-Call Provider during the overnight shift to report that Resident #1 had an unwitnessed fall, emesis and a decline in condition in a timely manner. The DON said that it is the facility's expectation that nursing staff assess for acute changes in the resident's condition, notify the resident's Provider, and the DON and in this case, it was not done. On 10/21/25, the Facility presented the Surveyor with a Plan of Correction with an effective date of 10/01/25, that addressed the areas of concern identified in this survey; the Plan of Correction provided is as follows: A. Resident #1 no longer resides at the facility. B. On 9/22/25, a Facility wide audit was initiated by the Nursing Administration
on residents with acute condition changes to ensure Facility policy was followed. C. Starting on 9/22/25, audits were conducted daily by the DON/designee with a 30 day lookback period on documentation to ensure that the provider had been notified of any residents with changes in condition, and will be reviewed at the daily morning report until substantial compliance is met and the results of the audits will be reviewed at the next monthly QAPI meeting. D. On 9/22/25, education of Nursing and Certified Nurse Aide (CNA) staff was initiated by the Director of Nurses on the Change in Condition Policy. E. On 9/27/25, a Quality Assurance Performance Improvement (QAPI) meeting was conducted, concern areas discussed included: immediate response and ongoing monitoring plan to sustain compliance with Facility Policy on Acute Condition Changes-Clinical Protocol, and results of the Audits. F. On 10/01/25, the Facility completed the Education of all nursing staff on the facility protocol and process (per policy) when a resident has a change
in condition. G. The Director of Nursing and/or Designee are responsible for overall compliance.
Event ID:
Facility ID:
If continuation sheet
WORCESTER REHABILITATION & HEALTH CARE CENTER in WORCESTER, MA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WORCESTER, MA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WORCESTER REHABILITATION & HEALTH CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.