Christopher House of Worcester

In the surveyor’s words

From the most serious findings on record at Christopher House of Worcester, in the surveyor’s own words.

• Actual harm, isolatedF656Mar 28, 2024

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose comprehensive plan of care indicated he/she required the use of a Hoyer lift (mechanical mobility aid that supports a person's body weight to allow movement from one surface to another) with assistance of two staff members for all transfers, the Facility failed to ensure staff implemented and followed interventions in his/her care plan, when on 03/12/24, Certified Nurse Aide (CNA) #1 transferred Resident #1 from his/her wheelchair into bed with a Hoyer lift, without another staff member present to assist him. Resident #1 fell to the floor onto his/her knees then fell forward landing on his/her face. […]

• Actual harm, isolatedF689Mar 28, 2024

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the use of a Hoyer lift (mechanical mobility aid that supports a person's body weight to allow movement from one surface to another) with assistance of two staff members for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety and prevent an incident/accident resulting in an injury, when on 03/12/24, while Certified Nurse Aide (CNA) #1 transferred Resident #1 from his/her wheelchair into bed without another staff member present to assist him. Resident #1 fell to the floor onto his/her knees then fell forward landing on his/her face. […]

• No harm, potential for more than minimal, widespreadF880Feb 17, 2023

  Based on observations, interviews, record and policy reviews, the facility failed to ensure that its staff implemented an infection prevention and control program in order to provide a sanitary environment and help prevent the development and transmission of communicable diseases. Specifically, the facility failed to ensure its staff: 1) implemented a surveillance plan to identify the potential presence of Legionella (a bacteria that can grow and multiply in moist areas of a building water system and cause lung infections) within the facility, 2) implemented contact precautions for one Resident (#3), with a diagnosis of Extended Spectrum Beta-Lactamase (ESBL- enzyme found in bacteria that cause infections that are resistant to many types of antibiotics), 3) adhered to the Centers of… […]

• No harm, potential for more than minimal, widespreadF909Feb 17, 2023

  Based on interviews and documentation review, the facility failed to ensure its staff completed annual inspections of all bed frames, mattresses and bed rails as part of the regular maintenance program to identify areas of possible entrapment on four of four units. Findings include: During an interview and review of the annual bed inspections forms for all units on 2/17/23 at 8:00 A.M., the Director of Maintenance said that bed assessments and entrapment evaluations are conducted annually for all resident beds as part of the preventative maintenance program. The Director of Maintenance was able to provide the bed assessments from 2019 through 2021 but was unable to provide documented evidence that the annual inspections of the resident beds were completed in 2022. […]

• No harm, potential for more than minimal, patternF883Jun 14, 2024

  Based on interview, record and policy review, the facility failed to ensure that the Pneumococcal (bacterial infection caused by streptococcus pneumoniae/ pneumococci, that can range from ear and sinus infections to Pneumonia and blood stream infections) Vaccination was administered to two Residents (#35, and #81) for five applicable residents, out of a total sample of 29 residents. Specifically, the facility staff failed to: 1. identify whether Resident #35 was up to date with Pneumococcal Vaccinations, administer the Pneumococcal Vaccine when the Resident was not up to date, and determine whether he/she was eligible to receive the Pneumococcal Vaccine when the Resident/Representative consented to receive the vaccination. 2. […]