Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
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 Wachusett Manor during CMS and state inspections, most recent first.
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 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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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.