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 St Mary Health Care Center during CMS and state inspections, most recent first.
A resident with Type 2 Diabetes Mellitus and dementia did not receive routine diabetes monitoring, including overdue HgA1c testing and assessment for signs of hypo/hyperglycemia, despite care plan requirements. Nursing staff failed to recognize or act on the resident's diabetes diagnosis during a significant change in condition, resulting in critically high blood glucose and hospital admission for hyperosmolar hyperglycemic state.
A resident with severe dementia and an invoked Health Care Agent (HCA) developed new skin issues, including MASD and a fluid-filled blister, both requiring new physician-ordered treatments. Facility staff did not notify the HCA of these changes, and documentation of notification was missing or incomplete, despite facility policy and protocol requiring such notification.
Several alert residents reported that a nurse repeatedly treated them without dignity or respect, including yelling, using a curt or aggressive tone, withholding medications, and handling medications roughly. Staff interviews supported these accounts, describing the nurse as lacking compassion and speaking rudely or condescendingly to residents. These actions violated residents' rights to be treated with dignity and respect.
The facility failed to complete a Significant Change in Status Assessment (SCSA) within the required 14-day timeframe for two residents. One resident experienced a decline in bowel and bladder function and developed a Stage 3 pressure injury, while another was admitted to hospice services. The MDS Nurse acknowledged the delays, citing unawareness of the hospice admission as a reason for the oversight.
The facility failed to conduct required PASRR assessments for two residents after significant changes in their mental health conditions, including new diagnoses and medication adjustments. Despite these changes, the necessary screenings were not completed, as confirmed by the Social Worker.
A facility failed to remove hazardous items from a resident's room, who had a history of suicidal ideation and cognitive impairment. Surveyors found disposable razor blades on the resident's bedside table, despite the resident's known history of self-harm attempts. The facility's policy required hazardous items to be removed, and interventions were in place to ensure safety, but these were not followed.
A resident with a history of mental health issues expressed a plan to self-harm, but the facility failed to provide timely psychiatric assessment and continuous monitoring. Despite initial actions by the DON, the resident was not seen by psychiatric services until three days later, contrary to facility policy.
The facility failed to ensure timely re-ordering of Insulin E-Kits on the Fourth and Fifth Floor Units, as required by their policy. The E-Kits were opened and medications removed, but there was no evidence of re-ordering from the pharmacy, which should have occurred the same day. Nurses acknowledged the oversight, which deviated from the facility's procedures.
A facility failed to conduct regular laboratory tests for a resident as ordered by the physician. Despite an active order for blood tests, including FSBS, WBC, ANC, and BMP, only a WBC and BMP draw was completed on one occasion. The resident, with diagnoses including Schizophrenia and Major Depressive Disorder, was moderately cognitively impaired. Interviews confirmed the order was still active, but there was no evidence of the tests being performed as required.
A facility failed to perform EKG testing every six months for a resident with heart failure and on antipsychotic medication, as ordered by the physician. Despite an active order, no EKGs were documented since 2023. Interviews with the UM and DON confirmed the oversight and lack of evidence for completed tests.
A resident with a sacro-coccyx wound did not receive proper infection control during wound care. Nurse #1 failed to perform hand hygiene between glove changes, contrary to facility policy and CDC guidelines. This lapse was acknowledged by both the nurse and the DON, highlighting a risk of infection for the resident.
The facility did not post the required daily nurse staffing information, omitting total and actual hours worked by RNs, LPNs, LVNs, and CNAs. Additionally, the facility failed to maintain staffing records for 18 months as required. The Administrator was unaware of these requirements.
Failure to Monitor and Manage Diabetes Leading to Hospitalization
Penalty
Summary
A resident with a history of Type 2 Diabetes Mellitus and vascular dementia was not provided with care that met professional standards, as routine laboratory testing to monitor diabetes control was not performed. The resident's last documented Hemoglobin A1c (HgA1c) test was over a year prior, despite facility policy and American Diabetes Association guidelines recommending regular testing. The resident's diabetes was diet-controlled, and the care plan required monitoring for signs and symptoms of hypo/hyperglycemia, but there was no documentation that such monitoring occurred. On a specific day, the resident experienced a significant change in condition, presenting as lethargic, refusing meals, and being unresponsive. Nursing staff, including two nurses assigned to the resident, did not recognize or act upon the resident's diabetes diagnosis during their assessments. One nurse stated she was unaware of the diabetes diagnosis, despite signing off on diabetic foot care in the treatment administration record. Another nurse, who was aware of the diagnosis, could not recall if a finger stick blood sugar was checked, and there was no documentation that this assessment was performed. The resident was eventually found to have a critically high blood glucose level (611 mg/dl) and elevated sodium, leading to transfer to the hospital and admission for hyperosmolar hyperglycemic state and hypernatremia. Interviews with facility staff, including the nurse practitioner and director of nursing, revealed a lack of awareness regarding the overdue HgA1c testing and uncertainty about whether staff were monitoring for diabetes-related complications as required by the care plan.
Failure to Notify Health Care Agent of Resident's Skin Condition Changes
Penalty
Summary
The facility failed to notify a resident's Health Care Agent (HCA) of significant changes in the resident's skin condition, despite the HCA's authority being permanently invoked due to the resident's severe dementia. The resident, who had diagnoses including Type II Diabetes Mellitus and vascular dementia, developed a new area of Moisture Associated Skin Damage (MASD) on the buttocks and a fluid-filled blister on the left foot, both of which required new physician-ordered treatments. Documentation showed that the HCA was not informed of these changes, even though facility policy required notification of the resident's representative when new treatments or significant changes occurred. Interviews with nursing staff revealed that notification to the HCA was either not attempted, not completed, or not documented. One nurse stated that if she had notified the HCA, she would have documented it, but the relevant form was left blank. Another nurse attempted to call the HCA but did not retry when the call did not go through. The Director of Nursing confirmed that it was facility protocol to notify the HCA at the same time as the provider, but there was no evidence in the medical record that this occurred for either the new MASD or the foot blister.
Failure to Treat Residents with Dignity and Respect by Nursing Staff
Penalty
Summary
Multiple residents who were alert and able to communicate their needs reported being treated without dignity and respect by a nurse during the overnight shift. The facility's own policy requires that residents be treated with dignity and respect, recognizing their individuality and accommodating their needs and preferences. However, five residents described consistent patterns of yelling, rudeness, and disrespectful behavior from the nurse, including the use of a curt or aggressive tone, withholding medications, and physically throwing or banging medications onto tables rather than handing them to residents. Specific incidents included residents feeling afraid to ask for assistance due to the nurse's behavior, being spoken to in a sharp, dismissive, or angry tone, and being reprimanded loudly in front of others. One resident recounted being yelled at for requesting medication, while another described the nurse interrupting care and speaking angrily about the use of a bedpan. Staff interviews corroborated these accounts, with other nurses and a CNA noting that the nurse in question was perceived as lacking compassion, being annoyed by resident requests, and speaking in a rude or condescending manner. Additional staff, including a nurse supervisor, observed the nurse moving a resident abruptly and speaking in a loud, reprimanding tone. The consistent and corroborated reports from both residents and staff indicate that the nurse's actions failed to honor the residents' rights to be treated with dignity and respect, as required by facility policy and regulatory standards.
Failure to Complete Timely SCSA for Residents
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for two residents within the required 14-day timeframe following significant changes in their conditions. For one resident, there was a decline in bowel and bladder functioning, along with the development of a Stage 3 pressure injury. Despite these changes, the SCSA was not completed during the most recent assessment period, as confirmed by the MDS Nurse during an interview. Another resident was admitted to hospice services, which also necessitated a SCSA within 14 days. However, the assessment was not completed in the required timeframe because the MDS Nurse was unaware of the hospice admission. The delay in completing the SCSA was acknowledged by the MDS Nurse, who noted that the assessment was initiated much later to capture the resident's current status.
Failure to Conduct PASRR Assessments After Significant Changes
Penalty
Summary
The facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program for two residents, leading to deficiencies in their care. Resident #13 experienced significant changes in status, including new diagnoses of Major Depressive Disorder and Delusional Disorders, which required adjustments to psychotropic medications and the care plan. Despite these changes, the facility did not complete a new Level I PASRR assessment as required. The Social Worker acknowledged that a new PASRR screening should have been submitted when these diagnoses were added to the resident's profile, but it was not done. Similarly, Resident #84 was admitted with diagnoses including Unspecified Dementia and later had a new diagnosis of Psychotic Disorder with delusions added to their clinical record. This change also necessitated adjustments to antipsychotic medications and the care plan. However, the facility again failed to conduct a new Level I PASRR screening. The Social Worker confirmed that a new PASRR screening should have been submitted when the new diagnosis was added, but it was not completed. These oversights indicate a failure to adhere to federal requirements for PASRR assessments following significant changes in residents' mental health conditions.
Failure to Remove Hazardous Items for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to ensure a safe environment for a resident with a history of suicidal ideation and cognitive impairment. During an observation, surveyors found three disposable razor blades on the resident's bedside table, which were easily accessible. This oversight occurred despite the resident's known history of self-harm attempts, including breaking a fork to create a weapon. The facility's policy required that such hazardous items be removed from the resident's room, and interventions were in place to provide plastic utensils and ensure razors were only given by nurses. The resident, who had been admitted with diagnoses of anxiety, major depressive disorder, and cognitive communication deficit, was under the guardianship due to their inability to make personal decisions. The resident's care plan included monitoring for suicidal thoughts and ensuring safety by removing potential hazards. However, the presence of razor blades in the resident's room indicated a lapse in following these safety protocols. Interviews with the Unit Manager and the Director of Nursing confirmed that the razors should not have been accessible to the resident.
Failure to Provide Timely Mental Health Services
Penalty
Summary
The facility failed to provide timely mental health services to a resident with a documented history of mental health concerns, including anxiety, major depressive disorder, and cognitive communication deficit. The resident expressed a plan to self-harm by making a weapon out of a fork, which was documented on 2/12/24. Despite the facility's policy requiring immediate action and psychiatric consultation, the resident was not assessed by a physician or psychiatric services until three days later, on 2/15/24. During this period, there was no documentation of continuous monitoring for the resident's safety. Interviews with facility staff revealed that the Director of Nursing (DON) was aware of the resident's suicidal ideation and had taken some initial steps, such as removing potential weapons from the resident's room and making a verbal safety contract. However, the facility did not provide one-on-one supervision or send the resident for an emergency psychiatric evaluation, as expected by the social worker. The physician confirmed being notified of the situation but was not present at the facility when the resident expressed suicidal thoughts. The lack of timely assessment and continuous monitoring constituted a failure to adhere to the facility's policies for addressing suicide threats and providing necessary behavioral health services.
Failure to Re-Order Insulin Emergency Kits
Penalty
Summary
The facility failed to ensure that pharmaceutical services were adequately provided to meet the needs of each resident, specifically in the management of Insulin emergency medication kits (E-Kits) on the Fourth and Fifth Floor Units. The facility's policy required that E-Kits be re-ordered and replaced by the pharmacy promptly after being opened. However, observations and interviews revealed that the Insulin E-Kits were not re-ordered in a timely manner after being opened, which is a deviation from the facility's policy. On the Fifth Floor, the Insulin E-Kit was opened on 7/22/24, with medications removed on 7/22/24 and 12/15/24, but there was no evidence that the kit was re-ordered from the pharmacy. Similarly, on the Fourth Floor, the E-Kit was opened on 12/10/24, and medication was removed, but again, there was no evidence of re-ordering. Nurses on both floors acknowledged the failure to re-order the kits as per the policy, which required re-ordering on the same day the kit was opened and expected delivery by the next business day.
Failure to Conduct Regular Laboratory Tests for Resident
Penalty
Summary
The facility failed to provide necessary laboratory services for a resident, identified as Resident #33, who was part of a sample of 21 residents. The deficiency was identified through a review of records and interviews, revealing that the facility did not conduct required blood tests every three months as ordered by the resident's physician. The resident, who was admitted in November 2017, had diagnoses including Schizophrenia, Major Depressive Disorder, and Benign Prostatic Hyperplasia. The resident's most recent Minimum Data Set assessment indicated moderate cognitive impairment. Despite an active physician's order from December 6, 2021, for specific blood tests, including fingerstick blood sugar (FSBS), white blood cell count (WBC), absolute neutrophil count (ANC), and Basic Metabolic Panel (BMP), the facility only completed a WBC and BMP blood draw on September 20, 2024. The clinical record showed no evidence that the ANC and FSBS tests had been completed since the order was issued, nor that the WBC and BMP tests were conducted at any other time besides the September 2024 draw. Interviews with the Unit Manager and the Director of Nursing confirmed that the order for these blood tests was still active as of December 16, 2024, yet they were unable to provide evidence that the tests were performed as ordered. This failure to adhere to the physician's orders for regular laboratory testing constitutes a deficiency in the facility's provision of care.
Failure to Provide Required EKG Testing for Resident
Penalty
Summary
The facility failed to provide or obtain necessary diagnostic services for a resident, specifically neglecting to perform electrocardiogram (EKG) testing every six months as ordered by the resident's physician. The resident, who was admitted in January 2022, had diagnoses including Unspecified Systolic Congestive Heart Failure, Major Depressive Disorder, and Borderline Personality Disorder, and was on antipsychotic medication. Despite an active order dated July 10, 2022, for EKGs every six months, there was no evidence in the clinical record that any EKGs had been completed since 2023. Interviews with the Unit Manager and the Director of Nursing revealed that the orders for the EKGs were not followed, and there was a lack of documentation to confirm that the tests had been performed. The Unit Manager acknowledged the oversight and mentioned that the order should have been completed or clarified with the physician. The Director of Nursing confirmed the active order for EKGs and was unable to provide evidence of any completed tests in the past year, indicating a lapse in the facility's adherence to the physician's orders for monitoring the resident's condition.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to adhere to infection control standards during wound care for a resident with a sacro-coccyx wound. The resident, who was admitted in October 2020, had a history of Alzheimer's Disease, Atrial Fibrillation, Congestive Heart Failure, and a Stage 4 pressure injury. The facility's policy required hand hygiene before and after glove use, and the resident's care plan included Enhanced Barrier Precautions to prevent infection. However, during an observation, Nurse #1 did not perform hand hygiene between glove changes multiple times while providing wound care, which was against the facility's policy and CDC guidelines. During the procedure, Nurse #1 and a CNA initially performed hand hygiene and donned protective equipment. However, Nurse #1 repeatedly changed gloves without using hand sanitizer or washing hands, even after handling soiled dressings and touching the wound. This lapse in protocol was acknowledged by Nurse #1, who admitted to not performing hand hygiene appropriately, and by the Director of Nursing, who confirmed that the nurse should have followed the recommended guidelines. This failure to perform proper hand hygiene put the resident at risk for infection.
Failure to Post and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the total number and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs), and Certified Nurses Aides (CNAs) per shift. During a survey, it was observed that the nurse staffing postings in the front lobby on specific days in December 2024 did not include the necessary details. Additionally, the facility did not maintain a copy of the staffing records for the required 18 months. The Administrator admitted to being unaware of the requirement to include actual and total hours worked in the postings and acknowledged the failure to maintain the records for the specified duration.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 244 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Worcester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Side House Ltc Facility | 0.7 mi | — | 17 | 0 |
| Lutheran Rehabilitation And Skilled Care Center | 1.1 mi | — | 0 | 0 |
| Worcester Rehabilitation & Health Care Center | 1.3 mi | — | 1 | 0 |
| Vantage At Worcester Llc | 1.5 mi | — | 12 | 0 |
| St Francis Rehabilitation & Nursing Center | 1.6 mi | — | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for St Mary Health Care Center.
100% money-back within 48 hours.
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.