Worcester Rehabilitation & Health Care Center
WORCESTER REHABILITATION & HEALTH CARE CENTER in WORCESTER, MA — inspection on October 21, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
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