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Deficiency Records for Wachusett Manor
A list of the most recent deficiencies for Wachusett Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Wachusett Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2024-08-29 | 2024-09-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-29 | 2024-09-27 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-08-13 | 2024-09-15 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-08-29 | 2024-09-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-08-29 | 2024-09-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-08-13 | 2024-09-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-13 | 2024-09-06 | N |
| Provide or obtain dental services for each resident. | Health | 2024-08-13 | 2024-09-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-13 | 2024-09-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-29 | 2024-09-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-08-13 | 2024-09-04 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-08-29 | 2024-09-04 | N |
| Develop a communication plan. | Fire Safety | 2024-08-29 | 2024-09-04 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-08-29 | 2024-09-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-08-29 | 2024-09-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-08-29 | 2024-08-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-08-13 | 2024-08-27 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-08-13 | 2024-08-21 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-08-13 | 2024-08-13 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-16 | 2023-05-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-16 | 2023-05-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-16 | 2023-05-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-16 | 2023-05-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-16 | 2023-05-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-16 | 2023-05-23 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-05-16 | 2023-05-23 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-05-16 | 2023-05-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-16 | 2023-05-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-16 | 2023-05-23 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-16 | 2023-05-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-16 | 2023-05-23 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-16 | 2023-05-23 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-05-16 | 2023-05-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-16 | 2023-05-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-16 | 2023-05-23 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-05-16 | 2023-05-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-16 | 2023-05-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-16 | 2023-05-23 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-05-16 | 2023-05-23 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-05-16 | 2023-05-23 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-05-16 | 2023-05-23 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-05-16 | 2023-05-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-16 | 2023-05-23 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-05-16 | 2023-05-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-16 | 2023-05-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-16 | 2023-05-23 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-05-16 | 2023-05-23 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-05-16 | 2023-05-23 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-05-16 | 2023-05-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-18 | 2021-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-18 | 2021-10-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-18 | 2021-09-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-18 | 2021-09-30 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-08-06 | 2021-09-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-06 | 2021-09-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-08-06 | 2021-09-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-06 | 2021-09-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-06 | 2021-09-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-08-06 | 2021-09-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-08-06 | 2021-09-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-06 | 2021-09-10 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-08-06 | 2021-09-10 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-08-06 | 2021-09-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-06 | 2021-08-27 | N |
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