Christopher House of Worcester

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain a clean and homelike environment for one Resident (#123), out of a total sample size of 28 residents. Specifically, for Resident #123, the facility staff failed to maintain the Resident's wheelchair in a clean and sanitary manner when the Resident was dependent on the wheelchair use for mobility and the wheelchair was visibly soiled.

Inspectors wroteBased on record reviews, and interviews, the facility failed to complete Minimum Data Set (MDS) Assessments that accurately reflected the status of two Residents (#15 and #142) out of a total sample of 28 Residents. Specifically, for Resident #15, and Resident #142, the facility failed to ensure that the Brief Interview for Mental Status (BIMS) and Patient Health Questionnaire-9 (PHQ-9: questionnaire used to assess for Depression) were completed, placing the Resident's at risk for care that is not Resident driven and unidentified Depression.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services as required for an indwelling urinary/Foley catheter for one Resident (#3) out of a total sample of 28 residents. Specifically, for Resident #3, the facility failed to ensure that a blocked indwelling urinary catheter was replaced with the correct sized catheter balloon as ordered by the Physician.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide trauma-informed care according to professional standards of practice and accounting for the Resident's experiences for one Resident (#6) out of a total sample of 28 residents. Specifically, for Resident #6, the facility failed to:-assess the Resident for a history of trauma when the Resident was newly admitted to the facility.-recognize the Resident's experiences of traumatization when, during the Resident's stay at the facility, contracted Psychological Services identified that the Resident had a history of trauma, putting the Resident at risk for re-traumatization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored and secured in accordance with State and Federal requirements on one unit (Brookside unit) medication carts, out of total of four units and that medications were stored in a safe and secure manner for one Resident (#3) out of a total sample of 28 residents. Specifically, the facility failed to:1. ensure that one medication cart on the Brookside Unit was locked while the Nurse walked away from the medication cart multiple times and the unlocked medication cart was out of her sight, providing ready access of medications in the medication cart to unauthorized personnel and residents.2. For Resident #3, ensure that a prescribed inhaler was secured and not left on the Resident's nightstand table that was readily accessible to other residents and/or unauthorized individuals.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain complete and accurately documented medical records relative to fluid intake and urinary output for one Resident (#5) out of a total sample of 28 residents. Specifically, the facility failed to maintain complete and accurate documentation of:1. Resident #5's fluid intake when the Resident was identified to have Congestive Heart Failure (CHF), required the use of diuretic medication, and was placed on fluid restriction.2. Resident #5's urine output when the Resident was identified to have CHF, was placed on fluid restriction, and the Resident had an indwelling urinary catheter, putting the Resident at risk for inadequate monitoring of his/her medical condition and fluid-related complications.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain an effective infection control and prevention program to stop the spread of organisms and infections for one Resident (#52) out of a total sample of 28 residents. Specifically, for Resident #52, the facility failed to ensure that staff performed appropriate hand hygiene during glove changes while providing wound care for Resident #52 who was on Enhanced Barrier Precautions (EBP: infection prevention practice of wearing gown and gloves to reduce transmission of multi-drug-resistant organisms [MDRO's - bacteria that are resistant to three or more types of antimicrobial drugs]) during high contact resident care), placing the Resident at risk for contracting healthcare-associated infections.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that one Resident (#130) of four applicable residents reviewed, out of a total sample of 29 residents, received care and services for his/her pressure ulcer (a wound, usually over a bony prominence, that is caused by unrelieved pressure to the area) in accordance with professional standards. Specifically, the facility failed to ensure a wound care recommendation from the hospital, that was approved by the facility Nurse Practitioner (NP) was implemented placing the Resident at risk for worsening of his/her pressure ulcer.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to adhere to infection control standards in order to prevent the potential transmission of communicable diseases and infections within the facility for two Residents (#130 and #241), out of a total sample of 29 residents. Specially, the facility failed to: 1) For Resident #130, ensure that staff performed hand hygiene after the removal of gloves during a dressing change procedure placing the Resident at risk for infection in his/her wound. 2) For Resident #241, ensure that staff: [...]

Inspectors wroteBased 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. Resident #1 was transferred to the Hospital Emergency Department (ED) and diagnosed with a laceration, head injuries and fractures.

Inspectors wroteBased 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. Resident #1 was transferred to the Hospital Emergency Department (ED) and diagnosed with a head laceration, head injuries and multiple facial fractures.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who on 03/12/24, experienced a fall to the floor during a transfer with the Hoyer lift (mechanical mobility aid that supports a person's body weight to allow movement from one surface to another), the Facility failed to ensure he/she was provided with quality of care that met acceptable standards of practice, when after the fall despite noting that while Resident #1 was on the floor he/she was bleeding from his/her nose, Certified Nurse Aide (CNA) #1 transferred Resident #1 off the floor and put him/her in bed, before notifying nursing so Resident #1 could be assessed for injuries. Resident #1 was transferred that evening to the Hospital Emergency Department (ED) for an evaluation and was diagnosed with a laceration, head injuries and fractures.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure its staff maintained a complete and/or accurate medical record for four Residents (#60, #85, #95 and #112), out of a total sample of 26 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff conducted the required COVID-19 outbreak testing for residents on one out of four units, when the facility was experiencing an outbreak of COVID-19. Specifically, the facility failed to ensure its staff tested all residents on the Brookside Unit for 1) initial requisite outbreak testing when all residents with potential exposure could not be determined, and 2) every 48 hours following initial requisite outbreak testing until the Unit went seven days with no new positive cases after one Employee (#1) had worked on the Unit, became symptomatic, and tested positive, for COVID-19.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff developed a baseline care plan within 48 hours of admission to the facility for one Resident (#1), out of 26 total sampled residents. Specifically, the facility failed to ensure its staff developed a baseline care plan, or completed a comprehensive care plan in its place for Resident #1, within 48 hours of the Resident's admission to the facility to include the following: the Resident's a) risk for falls when the Resident had a history of repeated falls and sustained a fracture of the seventh thoracic (upper and middle part of the back) vertebra and b) provide communication for Resident's needs when a language barrier was present.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that its staff implemented the plan of care for two Residents (#95 and #60), out of a total of 26 sampled residents. Specifically, the facility staff failed to follow the plan of care for: 1) the application of TED Stockings (compression stockings used to gently squeeze the lower extremities to improve blood flow in the veins of the legs) for Resident #95, and 2) implementation of a perimeter mattress for Resident #60.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure its staff provided care consistent with professional standards of practice to prevent pressure ulcers (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) from developing and promote healing of a pressure ulcer that had developed for one Resident (#20), out of three applicable residents who had pressure ulcers, out of a total sample of 26 residents. Specifically, the facility staff failed to: 1) perform weekly skin assessments when the Resident was identified as being at risk for developing pressure ulcers, and 2) provide treatment to a pressure ulcer that included adequate infection control practices.

Inspectors wroteBased on observations and interview, the facility failed to ensure its staff secured and locked one medication cart on one of four units. Specifically, Nurse #2 left an unlocked and unattended medication cart on the Hillside Unit and also provided instruction for an unauthorized Employee to access the cart to retrieve medication.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure its staff assessed and obtained informed consent for the use of bed rails for two Residents (#185 and #1), out of a total sample of 26 residents.