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 | 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 |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-21 | 2019-07-03 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-05-21 | 2019-07-03 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-21 | 2019-07-03 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-02 | 2019-06-14 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-02 | 2019-06-14 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-02 | 2019-06-14 | N |