Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Odd Fellows Home Of Massachusetts during CMS and state inspections, most recent first.
The facility failed to implement safety measures for three residents, including not following safe swallow strategies for a resident with swallowing difficulties and not completing fall risk assessments for two residents after hospitalization. Staff were not adequately informed or trained, leading to increased risk of accidents and injuries.
A resident with dementia and dysphagia did not receive routine dental services despite signing a consent form in 2020. The facility failed to schedule dental appointments, resulting in dental deterioration. The resident was observed with missing and broken teeth, and a dentist later found poor dentition and gingivitis. The Unit Manager confirmed the oversight, and the Director of Nursing acknowledged the expectation for timely dental care.
A resident with dementia was found using a dusty and debris-laden wheelchair, which had not been cleaned since their admission. Despite requests from the resident and their family, the facility lacked a tracking system and policy for wheelchair cleaning, as acknowledged by the Housekeeping Manager and Administrator.
A facility failed to accurately complete a Level I PASRR for a resident with Schizophrenia, resulting in the resident not receiving a necessary Level II PASRR Evaluation. The resident had a court-appointed legal guardian and was on antipsychotic medication, but these factors were not properly documented, leading to a negative SMI screen and no referral for further evaluation.
Two residents in a facility experienced deficiencies in care. One resident's swallowing ability was not assessed in a timely manner, despite a decline in function and weight loss, leading to a delayed speech therapy evaluation. Another resident had an incorrect size urinary catheter in place, contrary to physician orders, which could lead to complications. These issues highlight lapses in communication and adherence to care plans.
A resident with dementia and muscle weakness was not properly assessed or treated for finger contractures, as required by facility policy. Despite a PA noting the contractures, no follow-up or monitoring was documented, and staff were unaware of the issue until a surveyor's observation. The DON acknowledged the need for a rehab screen and monitoring, which were not conducted, leading to unaddressed contractures.
The facility failed to maintain accurate medical records for three residents, including incomplete documentation of urinary output and missing speech therapy evaluations. A resident with a urinary catheter had vague and missing entries for urine output, while another resident's intake and output records were incomplete and unclear. Additionally, a resident's speech therapy documentation was not included in the electronic health record, leaving staff unaware of recommended safe swallowing strategies.
A facility failed to adhere to infection control standards for a resident with an indwelling urinary catheter. Staff transferred the resident without wearing protective gowns, contrary to the facility's Enhanced Barrier Precautions (EBP) policy, which requires gowns and gloves during high-contact care activities. Despite EBP signage indicating the need for such precautions, staff did not comply, as confirmed by interviews with the CNA and the SDC/IP.
A facility failed to inspect bed rails for entrapment risk for a resident with limited mobility using bilateral side rails. Despite policies requiring assessments to prevent entrapment, the Maintenance Director could not provide evidence of such assessments for the resident's bed and mattress. The resident, with conditions like Vascular Dementia and muscle weakness, was observed bed-bound with side rails in place, highlighting a lapse in following safety procedures.
The facility failed to issue SNF ABN notices to three residents when their Medicare Part A benefits ended, leaving them uninformed about potential financial liabilities. The residents, with various medical conditions, chose to remain in the facility without receiving the required notices. The Social Worker confirmed the oversight in issuing these notices.
The facility failed to ensure the Medical Director's attendance at two out of four required quarterly QAPI meetings. The facility's QAPI Plan mandates the Medical Director's presence at least quarterly. The Medical Director attended meetings in April and October but missed those in January and July, as confirmed by the Administrator.
Failure to Implement Safety Measures for Residents
Penalty
Summary
The facility failed to provide an environment as free of accident hazards as possible for three residents. For one resident with a history of swallowing difficulty and dementia, the facility did not implement safe swallow strategies. Despite being on a downgraded diet due to coughing concerns, the resident was observed alone with food in their mouth, indicating a lack of supervision and adherence to recommended swallowing precautions. Interviews revealed that staff were not adequately informed or educated about the resident's swallowing strategies, and there was a lack of communication between the speech-language pathologist and the care team. Two other residents, both with a history of falls and on anticoagulant medication, were not reassessed for fall risk upon readmission to the facility after hospitalization. One resident had been hospitalized due to a fall resulting in a fracture and surgery, while the other had a fall at home leading to a spinal fracture. Despite these incidents, the facility did not complete fall risk assessments upon their return, which was against the facility's policy. Interviews with staff confirmed the oversight, and there was no evidence of post-hospitalization fall risk assessments in the residents' medical records. The lack of proper assessments and communication regarding the residents' conditions and care needs led to an increased risk of accidents and injuries. The facility's failure to adhere to its policies and ensure staff were informed and trained on necessary precautions contributed to the deficiencies observed by the surveyors.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for a resident, resulting in complications related to dental deterioration. The resident, who was admitted in January 2020 with diagnoses including dementia and dysphagia, had signed a dental consent form in January 2020 indicating a desire to receive dental care. Despite this, the facility did not schedule any dental appointments for the resident, and there was no record of the resident receiving any dental services as requested. The resident was observed to have several missing and broken teeth, and a review of the medical record indicated a physician order for a dentist consult as needed, which was not acted upon. The deficiency was further highlighted during interviews with the Unit Manager (UM) and the Director of Nursing (DON). The UM confirmed that the resident had never been seen by the dentist since signing the consent and was not on the list to be seen. It was only after the surveyor's inquiry that the resident was seen by a dentist, who found very poor dentition, fractured teeth, multiple roots, poor oral hygiene, and moderate to severe gingivitis. The DON stated that the expectation was for residents to receive dental services as soon as possible after signing a consent form, which did not occur in this case.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident who was admitted with dementia. The resident, who was mildly cognitively impaired, was observed using a wheelchair that was dusty and had crumbs and debris on the frame and cushion. The resident expressed concern about the cleanliness of the wheelchair, stating it had not been cleaned since they began using it. A family member also reported having requested the wheelchair be cleaned multiple times without success. The Housekeeping Manager acknowledged the lack of a tracking log for wheelchair cleaning and admitted there was no evidence of when the resident's wheelchair was last cleaned. The manager observed the wheelchair's condition and deemed it unacceptable. The facility administrator confirmed the absence of a policy regarding wheelchair cleaning, indicating a gap in the facility's procedures for maintaining a clean environment.
Failure to Complete Accurate PASRR for Resident with Schizophrenia
Penalty
Summary
The facility failed to accurately complete a Level I PASRR for a resident, which resulted in the resident not receiving a necessary Level II PASRR Evaluation. The resident was admitted with a diagnosis of Schizophrenia, and the hospital records indicated a history of worsening dementia, hallucinations, and violent behavior. Despite this, the Level I PASRR did not document the resident's mental illness or disorder, leading to a negative SMI screen and no referral for a Level II evaluation. Additionally, the resident had a court-appointed legal guardian within two years prior to admission, which was not accurately reflected in the PASRR documentation. The social worker acknowledged that the presence of a legal guardian should have indicated legal involvement, necessitating a positive SMI screen and a referral for further evaluation. The oversight in the PASRR process meant that the resident's need for specialized services for serious mental illness was not assessed as required.
Failure to Timely Assess Swallowing and Incorrect Catheter Use
Penalty
Summary
The facility failed to provide services that met professional standards of quality for two residents. For Resident #83, the facility did not assess the resident's swallowing ability in a timely manner, as ordered by the Nurse Practitioner (NP). The resident, who was admitted with diagnoses including dementia and muscle weakness, experienced a decline in swallowing function and weight loss, necessitating a diet texture downgrade. Despite the NP's order for a speech therapy evaluation on 10/25/24, the referral was not completed until 11/21/24, resulting in a delayed assessment by the Speech Language Pathologist (SLP) on 11/27/24. This delay in evaluation and treatment potentially impacted the resident's nutritional status and overall health. Resident #37 was found to have an incorrect size indwelling urinary catheter in place, contrary to the physician's orders. The resident, admitted with unspecified neuromuscular dysfunction of the bladder, had a physician's order for a 16 French/10 ml balloon Foley catheter. However, during an observation, it was noted that an 18 French/30 ml balloon Foley catheter was in use. This discrepancy was acknowledged by the nursing staff, who confirmed that the correct size catheter was available in the central supply room but had not been utilized. The use of an incorrect catheter size could lead to complications, as noted by the facility's staff educator and Director of Nursing (DON). The deficiencies highlight lapses in communication and adherence to physician orders within the facility. In the case of Resident #83, the delay in referral for speech therapy evaluation was attributed to a lack of awareness by the Director of Rehabilitation (DOR) and the interdisciplinary team (IDT) until several weeks after the initial order. For Resident #37, the failure to use the correct catheter size was a result of not following established physician orders, despite the availability of the correct supplies. These issues underscore the importance of timely and accurate execution of care plans to ensure resident safety and well-being.
Failure to Address Resident's Finger Contractures
Penalty
Summary
The facility failed to provide appropriate care for a resident with contractures, specifically neglecting to assess, monitor, and treat the resident's right third and fourth finger mild contractures. The resident, admitted in January 2020 with diagnoses including dementia and generalized muscle weakness, was observed by a surveyor with contracted fingers and no positioning device or splint in place. The resident reported no pain and stated that staff did not provide any range of motion (ROM) exercises, and was unable to open their hand upon request. The facility's policy required residents with limited ROM to receive treatment and services to prevent further decline, but the resident's medical record showed no follow-up or reference to the contractures after a Physician Assistant (PA) noted them in September 2024. The PA had expected nursing staff to monitor for pain, skin integrity issues, and decreased function or ROM, but there was no evidence of such monitoring or intervention in the resident's medical record. The Unit Manager and Director of Rehabilitation were unaware of the contractures until pointed out by the surveyor. The Director of Nursing acknowledged that a rehab screen should have been performed when the contractures were identified, and nursing staff should have monitored and assessed the resident's condition. The lack of timely assessment and intervention led to the resident's contractures being unaddressed, potentially worsening over time without appropriate therapeutic measures in place.
Inaccurate Documentation of Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documenting urinary output and speech therapy evaluations. Resident #46, who had a urinary catheter, did not have accurate measurements of urinary output documented as ordered. Instead, urine output was recorded in vague terms such as 'medium' or 'large' on several dates, and there were instances where no output was recorded at all. The Director of Nursing (DON) acknowledged the confusion surrounding the physician's order for intake and output monitoring and expressed a need to revise the process. Resident #69, who also had an indwelling urinary catheter, had incomplete and inaccurate documentation of 24-hour fluid intake and urinary output. The Treatment Administration Record (TAR) showed missing entries and unclear notations, such as the use of a '+' sign, which the DON could not interpret. The DON confirmed that the intake and output monitoring was not recorded accurately in the resident's clinical record. Resident #83's clinical record lacked documentation of speech therapy evaluations, treatment notes, and discharge summaries. Although the resident had been evaluated and treated by a Speech Language Pathologist (SLP), the documentation was not included in the electronic health record (EHR) accessible to facility staff. The Director of Rehabilitation (DOR) admitted that the electronic submissions were supposed to transfer automatically into the EHR but did not, leaving the staff unaware of the safe swallowing strategies recommended for the resident.
Failure to Follow Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to adhere to infection control standards for a resident with an indwelling urinary catheter, identified as Resident #69. The deficiency was observed when two staff members transferred the resident from bed to a wheelchair without wearing protective gowns, as required by the facility's Enhanced Barrier Precautions (EBP) policy. The policy mandates the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices to prevent the transmission of multi-drug-resistant organisms. Despite the presence of EBP signage outside the resident's room, indicating the need for gowns and gloves during such activities, the staff did not comply with these precautions. Resident #69, who was admitted to the facility with diagnoses including obstructive and reflux uropathy, urinary tract infection, and urethral fistula, was severely cognitively impaired and had an indwelling urinary catheter. The staff's failure to follow EBP was confirmed through interviews with the Certified Nurses Aide (CNA) involved and the Staff Development Coordinator/Infection Preventionist (SDC/IP). The CNA believed that only hand sanitization and glove use were necessary when handling the resident's Foley catheter, while the SDC/IP confirmed that EBP should be followed for any high-contact care involving residents with indwelling medical devices, such as transferring and handling bed linens.
Failure to Assess Bed Rails for Entrapment Risk
Penalty
Summary
The facility failed to complete an inspection of the bed rails to identify areas of possible entrapment for a resident with limited mobility who utilized bilateral side rails. The facility's policy required assessments to determine the risk of entrapment and to ensure the safe use of side rails and mattresses. However, the Maintenance Director was unable to provide evidence of any past assessments for the resident's current bed and mattress, indicating a lapse in following the facility's procedures. The resident, admitted in July 2020, had diagnoses including Vascular Dementia, Polyneuropathy, and muscle weakness, and was dependent on staff for various activities of daily living. Observations by the surveyor noted the resident lying in bed with bilateral side rails in place, and the resident confirmed being bed-bound. Despite the facility's policy requiring specific measurements to rule out entrapment risks, no documentation was available to confirm that these assessments had been conducted for the resident's bed setup.
Failure to Issue SNF ABN Notices
Penalty
Summary
The facility failed to issue Skilled Nursing Facility Advanced Beneficiary Notices of Non-coverage (SNF ABN) to three residents when they no longer qualified for Medicare Part A skilled services. This deficiency was identified for three residents who chose to remain in the facility after their Medicare benefits ended. The facility did not provide the necessary SNF ABN notices, which are required to inform residents of their potential financial liability for services that may not be covered by Medicare. Resident #17, admitted with diagnoses including hypertension, depression, and hyperlipidemia, had their Medicare Part A benefits end without receiving an SNF ABN. Similarly, Resident #35, diagnosed with diabetes mellitus, and Resident #38, with anemia, coronary artery disease, and heart failure, also did not receive the required notices when their Medicare benefits ended. The Social Worker acknowledged that the SNF ABN forms were not issued for these residents, indicating a lapse in the facility's process for notifying residents of their financial responsibilities.
Medical Director's Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure that the required members were included in the Quality Assessment and Performance Improvement (QAPI) committee quarterly meetings. Specifically, the Medical Director did not attend two out of the four required quarterly QAPI meetings. According to the facility's QAPI Plan dated January 16, 2019, the Medical Director is required to attend these meetings at least quarterly, with a preference for monthly attendance. During a review of the QAPI meeting schedule and attendance sheets, it was found that the Medical Director attended the meetings in April and October 2024 but did not attend or sign the attendance sheets for the meetings in January and July 2024. The Administrator confirmed that the Medical Director should have attended these meetings as required.
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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) |
|---|---|---|---|---|
| Holy Trinity Eastern Orthodox N & R Center | 0.1 mi | — | 2 | 0 |
| Regalcare At Worcester | 1.5 mi | — | 0 | 0 |
| Knollwood Nursing Center | 1.8 mi | — | 9 | 0 |
| Lutheran Rehabilitation And Skilled Care Center | 1.9 mi | — | 0 | 0 |
| Christopher House Of Worcester | 1.9 mi | — | 1 | 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.