Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wachusett Manor during CMS and state inspections, most recent first.
Failure to notify the Ombudsman of resident hospital transfers. Several residents with conditions including UTI, ESRD, COPD, PVD, morbid obesity, and bilateral BKA were sent to the hospital after changes in condition such as vomiting, missed dialysis, lethargy, confusion, and unresponsiveness. The UM said transfer packets were completed by nursing, and the SW said she was responsible for Ombudsman notification, but no evidence was provided that the Ombudsman was notified for these transfers.
A resident with DM2, renal dialysis dependence, and dementia had a sliding-scale insulin order requiring provider notification when FSBS was 351 to 999 mg/dl. The MAR showed repeated elevated FSBS readings across multiple months, but the clinical record contained no evidence that the Physician was notified as ordered; the DON confirmed she could not find documentation of the required communication.
Grievance About Room Noise Not Adequately Resolved: A cognitively intact resident complained that a roommate’s TV was too loud at night and was preventing sleep. Staff offered a room change and a facility transfer, but the resident declined and the grievance was marked resolved even though the noise problem continued, the resident was unaware of the grievance, and no follow-up was completed.
Failure to Care Plan Self-Injurious Behavior: A resident with schizophrenia, depression, and agitation had documented SI and self-injurious episodes, including grabbing a cord and later cutting and scratching the wrists. The comprehensive care plan did not reflect the resident’s history of self-harm or SI, and the DON stated no incident report or investigation was completed after the wrist injury; the SW said a care plan and Kardex should have been in place to identify behaviors, triggers, and interventions.
Failure to Follow Hand Hygiene and Equipment Cleaning During EBP Care: An RN entered multiple rooms with EBP signage without performing hand hygiene before entry or after exit, and used the same blood pressure equipment for two residents without cleaning or sanitizing it between uses. The DON stated staff should clean BP equipment after each resident use and perform hand hygiene before entering and exiting EBP rooms.
A resident with recent diagnoses of aspiration pneumonia and pericardial effusion experienced a decline in condition, including pallor, lethargy, and the new need for oxygen. Nursing staff observed these changes and initiated oxygen therapy but did not notify the provider or document the change, as required by facility policy.
A resident with a complex cardiac history was found unresponsive and pulseless. Nursing staff initiated a Code Blue, began CPR, and called 911, but failed to retrieve and use the facility's AED as required by policy. Interviews confirmed that no staff member was directed to bring the AED, and it was not present when EMS arrived, resulting in a deficiency in meeting professional standards of care.
The facility failed to adhere to infection control practices, as a CNA did not follow Standard and Contact Precautions, increasing infection risk between two residents. Additionally, unsanitary ice distribution practices were observed, and the facility did not implement its Water Management Program effectively, failing to flush dead legs and low utilization sinks as required.
The facility failed to maintain an effective pest control program, resulting in small flies in the main kitchen, Unit Two kitchenette, Unit Four dining room, and resident rooms. Staff interviews revealed inconsistent pest control measures, with the Maintenance Director unsure of service frequency and lacking documentation. Residents observed flies but did not report them, and housekeeping staff noted flies without specific instructions for removal.
The facility failed to maintain a clean and homelike environment in the Unit #4 multi-purpose room, where the flooring was observed to have several gouges, holes, and a torn area. The Maintenance Director acknowledged the damage, attributing it to equipment use and cleaning, and stated there were no plans for repair.
A resident at high risk for skin breakdown did not receive a pressure redistribution cushion for their wheelchair, as required by their care plan and physician's orders. Despite multiple observations and staff interviews confirming the absence of the cushion, the facility failed to provide this necessary support, compromising the resident's comfort and care.
A resident with COPD and CRF did not receive the correct oxygen flow rate as prescribed, with the oxygen concentrator set incorrectly at times. The facility's staff failed to verify and maintain the prescribed 7 LPM, and there was no documentation or care planning for potential self-adjustment by the resident.
A resident with PTSD did not receive trauma-informed care due to the facility's failure to conduct a trauma history assessment upon admission. The resident, who was severely cognitively impaired, showed behaviors like self-isolation and care refusal. Staff interviews confirmed the oversight, which was only addressed after being pointed out by a surveyor.
A resident with Alzheimer's Disease did not receive dental services due to the facility's failure to obtain timely consent from the resident's Health Care Proxy (HCP). Despite the resident's expressed desire for dental care and visible dental issues, the facility did not secure the necessary consent after the HCP was invoked, resulting in a deficiency.
The facility failed to maintain clean and sanitary wheelchairs for two residents, leading to a deficiency. One resident's wheelchair had a peeling cover, a burn hole in the cushion, and dust on the frame, while another's had a ripped cushion with duct tape, an exposed metal connector, and a frame covered with debris. The facility's cleaning policy was not effectively implemented, as confirmed by the Unit Manager and Housekeeping Director, who could not provide logs to verify scheduled cleanings.
A facility failed to accurately code the MDS for a resident, omitting their Anxiety Disorder diagnosis and broken natural teeth. The resident had been diagnosed with Anxiety Disorder and was prescribed Olanzapine. Despite this, the MDS did not reflect these conditions, which was confirmed as an error by the MDS Nurse.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide notification of resident transfers and discharges to a representative of the State Office of the Long-Term Care Ombudsman for six residents who were sent to the hospital. Review of the facility policy titled Resident Transfer and Discharge Policy and Procedure indicated that transfer and discharge notices were to be properly documented, a copy of the notice was to be sent to the Ombudsman, and evidence of that notification was to be maintained. Resident #51, admitted with diagnoses including metabolic encephalopathy and GERD, was sent to the hospital after a nursing progress note documented cough and vomiting, and later returned to the facility after a hospital stay for UTI. Resident #43, admitted with ESRD and dependence on renal dialysis, was sent to the hospital after missing a morning dialysis treatment and was later documented as admitted to the hospital. Resident #53, admitted with rheumatoid arthritis and morbid obesity, was sent by ambulance to the hospital after labs were reviewed with the Nurse Practitioner, and the facility later received an update that the resident had been admitted. Resident #92, admitted with bilateral below-the-knee amputations, was sent to the emergency room after being found lethargic with a strong foul smell coming from a wound and later returned after hospitalization. Resident #7, admitted with UTI and adult failure to thrive, was sent to the emergency room after increased confusion, altered mental status, difficulty moving or walking, and increased incontinence, and was later documented as admitted to the hospital. Resident #89, admitted with COPD and PVD, was transferred to the hospital after becoming unresponsive to verbal or physical stimuli. The Unit Manager stated that transfer packets included bed hold and transfer notices, while the Social Worker stated she was responsible for Ombudsman notification but could not provide evidence that the Ombudsman had been notified for any of these residents.
Failure to Notify Physician of Elevated Blood Sugars
Penalty
Summary
The facility failed to notify the Physician of pertinent information for one resident out of a sample of 19. Resident #5, who was admitted with diagnoses including Type 2 DM with ketoacidosis without coma, dependence on renal dialysis, and unspecified dementia, had a MDS assessment showing moderate cognitive impairment with a BIMS score of 8 out of 15 and was receiving daily insulin injections. The resident’s physician order for sliding-scale Insulin Lispro required notification of the provider when FSBS was 351 to 999 mg/dl. Review of the resident’s July 2025, August 2025, and September 2025 MARs showed FSBS results between 351 and 999 mg/dl on 47 of 85 days reviewed, including multiple dates in each month. The clinical record did not contain evidence that the Physician was notified of any of these elevated FSBS results. During interview, the DON reviewed the MARs, confirmed the repeated elevated FSBS readings, and stated she could not find evidence that staff had notified the Physician as ordered, although that was the expectation.
Grievance About Room Noise Not Adequately Resolved
Penalty
Summary
The facility failed to adequately resolve a grievance filed on behalf of a cognitively intact resident who complained that noise in the room at night was preventing sleep. The resident, admitted in June 2025 with diagnoses including infection of amputation stump and acquired absence of the left leg below knee, had a BIMS score of 14 out of 15. A grievance/concern form received on 9/4/25 documented the complaint that the roommate’s television was too loud at night, and the assigned staff offered a room change and a facility change, both of which were declined. The form indicated the grievance was resolved on 9/5/25 after those offers were refused, and the resident was notified in a one-to-one discussion. During interviews, the resident stated he/she continued to have trouble sleeping because the roommate’s television was very loud all night, that ear plugs did not work well, and that several staff had been told about the issue but nothing had been done. The resident was unaware of any grievance filed on his/her behalf and said nobody followed up. The social worker later acknowledged that the grievance should not have been considered resolved because the problem persisted and follow-up had not occurred. The administrator stated a grievance is considered resolved when the resident is happy with the outcome and the outcome is discussed with the resident or responsible party.
Failure to Care Plan Self-Injurious Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #8 that addressed a history of self-injurious behaviors and suicidal ideation. Resident #8 was admitted with diagnoses including schizophrenia, restlessness and agitation, and major depressive disorder, and the quarterly MDS showed moderate cognitive impairment with a BIMS score of 11 out of 15 and mood indicators of feeling down, depressed, or hopeless nearly every day. The record also included a hospital discharge summary stating the resident had grabbed a cord and stated he/she would strangle himself/herself, and a psychosocial evaluation noting the resident was at risk for decompensation and that increased monitoring for safety, including risk for falls or self-harm, should be considered. The resident later had additional self-injurious events documented in nursing and social work notes, including being found with blood on the sheets and long cuts/scratches to both wrists and being sent to the ER for suicidal ideations. Another hospital discharge summary stated the resident had reportedly cut himself/herself with a knife and then scratched the cuts with fingernails, with discharge diagnosis of status-post self-injurious behavior by superficially scratching himself/herself. Review of the comprehensive care plan showed no indication of a history of self-injurious behaviors or SI. During interviews, the DON stated the facility did not complete an investigation or incident report after the wrist injury, and both the DON and SW stated a care plan and Kardex should have been implemented to identify behaviors, triggers, and interventions, including after the hospital paperwork and return from the hospital stay related to self-injurious behavior.
Failure to Follow Hand Hygiene and Equipment Cleaning During EBP Care
Penalty
Summary
The facility failed to follow infection prevention and control practices on the second-floor short hall unit when Nurse #1 completed vital signs for residents in rooms with Enhanced Barrier Precautions (EBP) signage posted. During observation, Nurse #1 entered resident rooms without performing hand hygiene before entry, exited rooms without performing hand hygiene, and moved between rooms while using the same blood pressure equipment. The equipment was not cleaned or sanitized after use on the first resident before being used on another resident in a different room. The observed sequence showed Nurse #1 entering the first resident room carrying blood pressure equipment, obtaining blood pressure, and leaving the room without hand hygiene or sanitizing the equipment. He then went to the medication cart, handled the cart and computer, and later entered a second resident room with EBP signage without performing hand hygiene. After exiting that room, he again failed to perform hand hygiene and picked up the same blood pressure equipment before entering a third resident room. The report also notes that the third resident room had EBP signage visible, yet Nurse #1 entered without hand hygiene and used the same blood pressure equipment that had not been sanitized after the earlier resident encounter. During interview, Nurse #1 stated he believed equipment should be cleaned after each resident use and acknowledged that he did not clean it. The DON stated that nursing staff should use Sani-cloth germicidal wipes to clean blood pressure equipment after each resident use and should perform hand hygiene before entering and exiting EBP resident rooms.
Failure to Notify Provider of Resident's Acute Condition Change
Penalty
Summary
Nursing staff failed to notify the provider of a significant change in condition for a resident who had recently been readmitted with new diagnoses of aspiration pneumonia and pericardial effusion. The resident, who had a complex cardiac history including atrial fibrillation, cardiac pacemaker, hypertension, coronary artery disease, and unstable angina, reported feeling unwell, appeared extremely pale, and was more lethargic than usual. A nurse observed these changes, noted a bluish tint to the resident's lips, and applied oxygen at 3 liters via nasal cannula, which was a new intervention for this resident. Despite these acute changes and the initiation of oxygen therapy, the nurse did not notify the provider or obtain new orders, and there was no documentation of provider notification in the medical record. Interviews with facility staff, including the nurse practitioner and the director of nursing, confirmed that the provider was not informed of the resident's decline or the need for oxygen. The facility's policy required nursing staff to notify the attending physician or on-call physician when there is a significant change in a resident's condition, such as decreased food intake or changes in skin color or condition. In this case, the required notification and documentation did not occur, constituting a failure to follow established protocols for managing acute changes in resident condition.
Failure to Retrieve and Use AED During Code Blue Response
Penalty
Summary
A deficiency occurred when a resident, who was a full code and had a significant cardiac history including atrial fibrillation, cardiac pacemaker, hypertension, coronary artery disease, unstable angina, and recent cardiac effusion, was found unresponsive and pulseless during the evening shift. The certified nurse aide discovered the resident and immediately notified the nurse, who assessed the resident, called a Code Blue, obtained the crash cart, and began CPR. Another nurse called 911 and assisted with CPR until EMS arrived. Despite the facility's policy requiring immediate retrieval and use of the Automated External Defibrillator (AED) during a Code Blue, the nursing staff did not obtain or apply the AED at any point during the resuscitation efforts. Interviews with the involved staff confirmed that no one was directed to retrieve the AED, and the device was not present in the room when EMS arrived. The Director of Nursing and the Nurse Practitioner both stated that the AED should have been used according to facility policy and professional standards of nursing practice. Documentation and interviews further indicated that the staff were current on CPR certification and followed other aspects of the emergency response, such as calling 911 and performing CPR. However, the failure to obtain and use the AED during the Code Blue was a direct violation of the facility's emergency procedures and professional standards, as outlined in the facility's own policy.
Infection Control and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by the actions of a Certified Nurse Aide (CNA) who did not adhere to Standard and Contact Precautions. The CNA provided personal care to a resident requiring Contact Precautions due to a multi-drug resistant organism (MDRO) and then handled another resident's wheelchair without changing gloves or performing hand hygiene. This lapse in protocol increased the risk of infection transmission between residents. Additionally, the facility did not maintain sanitary practices in the distribution of ice used to keep residents' drinks cool. The ice machine was broken, and staff resorted to purchasing large bags of ice, which were then dropped on the floor to break them up before being placed in bins with drink containers. This practice was unsanitary and increased the risk of contamination. The facility also failed to implement its Water Management Program effectively. The Maintenance Director could not provide evidence that dead legs were flushed quarterly or that low utilization sinks and faucets were flushed monthly, as required by the program. This oversight could potentially lead to the growth of harmful bacteria, such as Legionella, in the facility's water system.
Ineffective Pest Control Program Leads to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of small flies in various areas, including the main kitchen, Unit Two kitchenette, Unit Four dining room, and the rooms of three residents. The presence of these flies increased the risk of contamination and transmission of infectious pathogens. Observations by the surveyor revealed small flies in the food preparation area, cold storage room, and dry food storage room of the main kitchen, as well as in the rooms of the residents. Interviews with facility staff indicated a lack of consistent pest control measures. The Maintenance Director was unsure of the frequency of pest control services and had not received any paperwork from the pest control company. The Food Service Director acknowledged the presence of drain flies in the kitchen for about two years, despite monthly pest control services. The Administrator was unaware of the fly presence in resident units, believing the issue was confined to the lower level of the facility. Residents reported observing small flies in their rooms but had not informed facility staff. Housekeeping staff also noted the presence of flies but had not received specific instructions on addressing the issue. The Maintenance Director only contacted the pest control company for service records after the surveyor's request, indicating a lack of proactive management in addressing the pest issue.
Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the multi-purpose room on Unit #4. Observations by the surveyor revealed several gouges and holes in the flooring throughout the room, as well as a torn and lifted area at the transition from the hallway into the room. These conditions were noted during a time when several residents were present in the room for breakfast, along with three staff members assisting them. During an interview, the Maintenance Director acknowledged the poor condition of the flooring, attributing the damage to the use of equipment such as mechanical lifts and cleaning activities. The Maintenance Director admitted that the floor had been in this state for some time and that he was aware of the issue. However, he also stated that there were no known plans to repair or improve the flooring to make it more homelike for the residents.
Failure to Provide Pressure Redistribution Cushion
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice by not supplying a pressure redistribution cushion to a resident's wheelchair, despite the resident being at high risk for skin breakdown. The resident, who was admitted with conditions such as spinal stenosis, abnormal posture, osteoarthritis, difficulty in walking, and muscle weakness, was assessed as moderately cognitively impaired. The resident's care plan and physician's orders both indicated the need for a pressure redistribution cushion, which was not provided. Observations by the surveyor on multiple occasions confirmed the absence of the cushion, and interviews with staff, including a CNA and a nurse, revealed that they were unaware of the cushion's necessity or existence. The unit manager also confirmed the lack of a cushion in the resident's room, and the resident expressed a desire for the cushion for comfort. This deficiency highlights a failure to adhere to the facility's policy and the resident's care plan, resulting in a lack of necessary pressure relief for the resident.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for a resident with Chronic Obstructive Pulmonary Disease (COPD) and Chronic Respiratory Failure (CRF). The deficiency involved the improper administration of supplemental oxygen via nasal cannula, where the oxygen flow rate was not consistently set according to the physician's order of 7 liters per minute (LPM). Observations revealed that the oxygen concentrator was set at 8 LPM during one instance and 6 LPM during another, contrary to the prescribed 7 LPM. The facility's policy on oxygen administration requires verification of physician orders and adjustment of oxygen delivery to ensure the proper flow is administered. However, the staff did not adhere to these guidelines, as evidenced by the discrepancies in the oxygen flow rate settings. The resident, who was usually able to make themselves understood, reported that they did not adjust the oxygen concentrator settings, indicating that the nursing staff was responsible for the adjustments. Interviews with the nursing staff revealed that it was their responsibility to ensure the correct oxygen flow rate, yet there was no documentation in the resident's clinical record indicating that the resident had adjusted the settings themselves. Additionally, there was no care planning for the possibility of the resident self-adjusting the oxygen concentrator, nor was there verification of the appropriate oxygen liter flow for the resident's specific medical conditions.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), as they did not complete a trauma history assessment. This oversight was identified during a survey, where it was noted that the resident, who was admitted in August 2022, exhibited behaviors such as self-isolation and refusal of care. Despite having an active diagnosis of PTSD and being severely cognitively impaired, as indicated by a Brief Interview of Mental Status (BIMS) score of 5 out of 15, the facility did not conduct the necessary trauma assessment to identify triggers and provide appropriate care. Interviews with staff, including the Director of Nursing and a Social Worker, confirmed that a trauma assessment had not been completed for the resident. The Social Worker acknowledged that such an assessment should have been conducted upon admission to address the resident's PTSD and manage their behaviors effectively. The lack of a trauma assessment was only addressed after the surveyor highlighted the deficiency, indicating a lapse in following the facility's policy on trauma-informed and culturally competent care.
Failure to Obtain Consent for Dental Services
Penalty
Summary
The facility failed to provide dental services for a resident due to a lack of timely consent from the resident's Health Care Proxy (HCP). The resident, who was admitted in May 2022 with Alzheimer's Disease and lack of coordination, initially declined dental services shortly after admission. However, the resident's HCP was invoked by a physician in August 2022, indicating the resident lacked the capacity to make informed decisions. Despite this, the facility did not obtain consent from the HCP for dental services, as required by their policy. The resident expressed a desire to receive dental services and had not been seen by a dentist during their stay. Observations revealed the resident had missing, broken, and stained teeth. Interviews with facility staff confirmed that consent for dental services had not been obtained from the HCP, and the resident had not received necessary dental care. The facility's failure to act promptly in obtaining consent from the HCP led to the deficiency in providing dental services.
Deficiency in Wheelchair Maintenance and Sanitation
Penalty
Summary
The facility failed to maintain resident wheelchairs in a clean and sanitary manner for two residents, leading to a deficiency. Resident #291, admitted for rehabilitation services with diagnoses of muscle wasting and hemiplegia, was observed with a wheelchair that had a peeling protective cover, a burn hole in the cushion, and dust and debris on the frame and wheel spokes. Similarly, Resident #293, admitted with congestive heart failure and chronic obstructive pulmonary disease, had a wheelchair with a ripped cushion patched with duct tape, an exposed metal connector, and a frame covered with a dried brown substance, dust, and debris. The facility's policy on cleaning wheelchairs was not effectively implemented, as evidenced by the observations and interviews conducted. The Unit Manager acknowledged that the wheelchairs were dirty and had not been cleaned since the residents' admission. The Housekeeping Director, new to the position, provided a cleaning schedule but could not produce logs to confirm that the scheduled cleaning had been completed. The lack of evidence and adherence to the cleaning schedule contributed to the deficiency observed by the surveyor.
Inaccurate MDS Coding for Resident's Anxiety Disorder and Dental Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for a resident, leading to a deficiency. The resident, admitted in May 2022, had diagnoses including Anxiety Disorder and lack of coordination. The care plans, last revised in May 2024, indicated the resident was diagnosed with Anxiety Disorder and was at risk for altered dentition due to missing and broken teeth. Physician's orders for August 2024 included monitoring for anxiety symptoms and prescribed Olanzapine for anxiety management. However, the most recent MDS assessment did not reflect the resident's Anxiety Disorder diagnosis or the presence of broken natural teeth. During an interview, the MDS Nurse acknowledged the assessment was inaccurately coded.
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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 Gardner
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gardner Rehabilitation And Nursing Center | 0.3 mi | ★★★★★ | 13 | 0 |
| Alliance Health At Baldwinville | 5.1 mi | ★★★★★ | 10 | 0 |
| Highlands, The | 8.7 mi | ★★★★★ | 9 | 0 |
| Fitchburg Healthcare | 9.5 mi | ★★★★★ | 17 | 0 |
| Fitchburg Rehabilitation And Nursing Center | 9.7 mi | ★★★★★ | 0 | 0 |
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