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Health Inspection Summary

St Francis Rehabilitation & Nursing Center

101 Plantation Street

Worcester, MA 01604

(508) 755-8605

Deficiency Category	Inspection Date: 8/6/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 4/11/23 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 6/22/21 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	0	0	2
Quality of Life and Care Deficiencies	3	3	1
Infection Control Deficiencies	1	1	1
Resident Assessment and Care Planning Deficiencies	1	4	0
Nursing and Physician Services Deficiencies	0	0	0
Resident Rights Deficiencies	3	2	1
Nutrition and Dietary Deficiencies	0	0	2
Pharmacy Service Deficiencies	0	2	0
Environmental Deficiencies	0	0	0
Administration Deficiencies	0	0	0

Detailed result for inspection on 8/6/24

Date of last standard health inspection:	8/6/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	4/25/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	8
Average number of Health Deficiencies in Massachusetts:	10
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	4/25/24	4/10/24	3 - Actual harm	Few
Provide safe and appropriate respiratory care for a resident when needed.	8/6/24	8/24/24	2 - Minimal harm or potential for actual harm	Few
Provide care and assistance to perform activities of daily living for any resident who is unable.	8/6/24	8/24/24	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.	8/6/24	8/24/24	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	8/6/24	8/24/24	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	8/6/24	8/24/24	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	8/6/24	8/24/24	2 - Minimal harm or potential for actual harm	Few
Give residents a notice of rights, rules, services and charges.	8/6/24	8/24/24	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 4/11/23

Date of last standard health inspection:	4/11/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	9/12/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	12
Average number of Health Deficiencies in Massachusetts:	12
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	4/11/23	5/1/23	2 - Minimal harm or potential for actual harm	Some
Assist a resident in gaining access to vision and hearing services.	4/11/23	5/1/23	2 - Minimal harm or potential for actual harm	Few
Provide or obtain dental services for each resident.	4/11/23	5/1/23	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	4/11/23	5/1/23	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	9/12/23	9/25/23	3 - Actual harm	Few
Ensure services provided by the nursing facility meet professional standards of quality.	9/12/23	9/25/23	3 - Actual harm	Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	4/11/23	5/1/23	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	9/12/23	9/25/23	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	9/12/23	9/25/23	3 - Actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	4/11/23	5/1/23	2 - Minimal harm or potential for actual harm	Some

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that residents are free from significant medication errors.	4/11/23	5/1/23	2 - Minimal harm or potential for actual harm	Some
Ensure each resident’s drug regimen must be free from unnecessary drugs.	4/11/23	5/11/23	2 - Minimal harm or potential for actual harm	Some

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 6/22/21

Date of last standard health inspection:	6/22/21Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	5/31/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	1/3/23Read the full report (PDF)
Total number of Health Deficiencies for this nursing home:	7
Average number of Health Deficiencies in Massachusetts:	11
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.	5/31/22	5/31/22	2 - Minimal harm or potential for actual harm	Few
Develop and implement policies and procedures to prevent abuse, neglect, and theft.	5/31/22	5/31/22	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	6/22/21	7/9/21	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	1/3/23	1/31/23	2 - Minimal harm or potential for actual harm	Some

Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Keep residents' personal and medical records private and confidential.	5/31/22	7/8/22	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	6/22/21	7/9/21	2 - Minimal harm or potential for actual harm	Some
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.	6/22/21	7/9/21	2 - Minimal harm or potential for actual harm	Many

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	4/25/24	4/10/24	3 - Actual harm	Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	9/12/23	9/25/23	3 - Actual harm	Few
Ensure services provided by the nursing facility meet professional standards of quality.	9/12/23	9/25/23	3 - Actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	9/12/23	9/25/23	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	9/12/23	9/25/23	3 - Actual harm	Few
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.	5/31/22	5/31/22	2 - Minimal harm or potential for actual harm	Few
Develop and implement policies and procedures to prevent abuse, neglect, and theft.	5/31/22	5/31/22	2 - Minimal harm or potential for actual harm	Few
Keep residents' personal and medical records private and confidential.	5/31/22	7/8/22	2 - Minimal harm or potential for actual harm	Few

Infection control inspection deficiencies in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	1/3/23	1/31/23	2 - Minimal harm or potential for actual harm	Some

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