Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
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 St Francis Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
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.
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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Nursing homes near Worcester
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 | — | 12 | 0 |
| Blaire House Of Worcester | 0.6 mi | — | 0 | 0 |
| Worcester Rehabilitation & Health Care Center | 0.8 mi | — | 1 | 0 |
| Christopher House Of Worcester | 1.2 mi | — | 1 | 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 August 2026) and official state health department websites.