Worcester Rehabilitation & Health Care Center

In the surveyor’s words

From the most serious findings on record at Worcester Rehabilitation & Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 7, 2022

  Based on records reviewed, review of facility surveillance camera footage, and interviews, for one of three sampled residents (Resident #1) who had a history of being homeless, required hospitalization after sustaining a Traumatic Brain Injury (TBI) due to a fall, and had a Temporary Guardianship in place, the Facility failed to ensure he/she was assessed for risk of elopement and that he/she was provided with adequate supervision to maintain his/her safety to prevent an incident of elopement, when he/she was able to walk out of and away the facility past multiple staff members who were assigned to monitor visitors and residents entering and leaving through the front entrance of the facility. […]

• Immediate jeopardy, isolatedF689Jun 21, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a permanent Guardianship in place and therefore was not his/her own responsible person, the Facility failed to ensure their policy for residents requiring accompaniment to appointments was implemented and followed, so that Resident #1 was provided with adequate supervision during an appointment outside of the Facility. On [DATE], Resident #1 left the Facility transported to a medical appointment by a chair van service, without an escort to accompany and stay with him//her while he/she was at an outside appointment. […]

• Immediate jeopardy, isolatedF842Jun 21, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record, when on [DATE], his/her temporary Guardianship expired and became a permanent Guardianship, the Director of Social Services, who was made aware of the change, failed to update Resident #1's medical record with the new Guardianship paperwork. As a result, on [DATE], Resident #1, who was not his/her own responsible person, left the Facility without an escort, was transported to a medical appointment by a chair van service, and while at the appointment, Resident #1 eloped and has not been located since. […]

• Immediate jeopardy, isolatedF689Oct 27, 2021

  Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who were assessed to be at risk for elopement, were severely cognitively impaired, and resided on a secure unit, the Facility failed to maintain Resident #1's and Resident #2's safety and ensure adequate supervision was provided during scheduled resident smoke breaks in the Facility's designated smoking area, which is an open, unsecured patio in the front of the Facility with direct access to the street via a set of stairs, as a result both residents eloped from the smoking area, and one resident remains missing. […]

• Actual harm, isolatedF689Sep 27, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had limited mobility, and preferred to stay in bed, the Facility failed to ensure he/she was provided with adequate preventative measures to maintain his/her safety in an effort to prevent incidents/accidents resulting in serious injury, when he/she sustained burns from food that had been reheated in the microwave by staff. On 09/01/23, Resident #1 asked a staff member to reheat his/her soup, after the staff member reheated the soup in the microwave, she did not check the temperature of the soup, per facility guidelines, before bringing it back to Resident #1. […]