Gardner, MA

Wachusett Manor

2-star overall rating with 3-star inspections with $26,756 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

32 Hospital Hill Road, Gardner, MA

(978) 632-5477

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Ephram Lahasky

Operator or chain grouping

Approved since

1991-01-08

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

28 facilities

Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.42

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

0.95

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.05

Nurse aide staffing · state 2.26 · national 2.35

Total nurse hours

3.42

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.37

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.04

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.37

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.36

CMS adjusted RN staffing hours

Adjusted total hours

2.93

CMS adjusted total nurse staffing hours

Case-mix index

1.60

Higher values indicate more complex resident acuity

RN turnover

46%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

47%

Annual nurse turnover · state 40% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,919

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

14.71

Composite VBP score used to determine payment impact.

Payment multiplier

0.9814

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.26

Baseline 20.75% · Performance 20.85% · Measure score 1.26 · Achievement 1.26 · Improvement 0

Healthcare-associated infections

Baseline 5.89% · Performance 8.90% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

3.19

Baseline 53.26% · Performance 50.65% · Measure score 3.19 · Achievement 3.19 · Improvement 0.42

Adjusted total nurse staffing

1.43

Baseline 3.63 hours · Performance 3.49 hours · Measure score 1.43 · Achievement 1.43 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	14.13%	10.72% 3.4 pts worse	No Different than the National Rate · Eligible stays 131 · Observed rate 20.61% · Lower 95% interval 10.05%
Discharge to community	57.82%	50.57% 7.2 pts better	No Different than the National Rate · Eligible stays 121 · Observed rate 48.76% · Lower 95% interval 49.05%
Medicare spending per beneficiary	0.81	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 59 · Denominator 59
Falls with major injury	3.39%	0.77% 2.6 pts worse	Numerator 2 · Denominator 59
Discharge self-care score	50%	53.69% 3.7 pts worse	Numerator 17 · Denominator 34
Discharge mobility score	52.94%	50.94% 2 pts better	Numerator 18 · Denominator 34
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 59 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	8.9%	7.12% 1.8 pts worse	No Different than the National Rate · Eligible stays 64 · Observed rate 12.5% · Lower 95% interval 5%
Staff COVID-19 vaccination coverage	7.95%	8.2% 0.2 pts worse	Numerator 7 · Denominator 88
Staff flu vaccination coverage	24.8%	42% 17.2 pts worse	Numerator 31 · Denominator 125
Discharge function score	47.06%	56.45% 9.4 pts worse	Numerator 16 · Denominator 34
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 27 · Denominator 27
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	37.5%	25.2% 12.3 pts better	Numerator 9 · Denominator 24

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.4	1.9 0.5 pts better	1.9 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.8	1.5 0.3 pts worse	1.8 About the same	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	92.2% 7.8 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	94.8% 5.2 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.6%	3.5% 2.9 pts better	3.3% 2.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	85.5%	12.0% 73.5 pts worse	11.4% 74.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 74.6% · Q2 89.7% · Q3 91.3% · Q4 85.5% · 4Q avg 85.5%
Percentage of long-stay residents who lose too much weight	4.6%	5.2% 0.6 pts better	5.4% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.4% · Q3 2.8% · Q4 4.5% · 4Q avg 4.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	24.8%	19.2% 5.6 pts worse	19.6% 5.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 21.3% · Q3 26.0% · Q4 27.5% · 4Q avg 24.8%
Percentage of long-stay residents who received an antipsychotic medication	26.0%	22.5% 3.5 pts worse	16.7% 9.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 27.8% · Q3 16.7% · Q4 31.6% · 4Q avg 26.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	14.4%	17.7% 3.3 pts better	16.3% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 21.3% · Q3 15.9% · Q4 4.8% · 4Q avg 14.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	18.7%	17.6% 1.1 pts worse	14.9% 3.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 18.8% · Q3 23.2% · Q4 12.5% · 4Q avg 18.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.8%	1.0% 0.2 pts better	1.0% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.6%	2.0% 0.4 pts better	1.7% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.2% · Q3 1.3% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	14.4%	21.7% 7.3 pts better	19.8% 5.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 13.3% · Q3 16.6% · Q4 9.4% · 4Q avg 14.4%
Percentage of long-stay residents with pressure ulcers	4.6%	4.6% About the same	5.1% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.9% · Q3 4.0% · Q4 7.5% · 4Q avg 4.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.4%	77.1% 22.3 pts better	81.7% 17.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 100.0% · Q4 98.9% · 4Q avg 99.4%
Percentage of short-stay residents who had an outpatient emergency department visit	22.1%	11.8% 10.3 pts worse	12.0% 10.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 26.5% · Expected 13.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	98.9%	77.7% 21.2 pts better	79.7% 19.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 98.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	32.2%	25.8% 6.4 pts worse	23.9% 8.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 32.2% · Observed 32.7% · Expected 24.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-26 · Fire 2025-09-26

7 health deficiencies

Top issue: Resident Rights (4 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2024-08-13 · Fire 2024-08-13

9 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

10 fire-safety deficiencies

Top issue: Emergency Preparedness (5 deficiencies)

Cycle 3 Health 2023-05-16 · Fire 2023-05-16

26 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

4 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-09-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2026-01-18

F · Potential for more than minimal harm 2025-09-26

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2026-01-18

F · Potential for more than minimal harm 2025-09-26

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2026-01-18

E · Potential for more than minimal harm 2024-08-13

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-08-29

D · Potential for more than minimal harm 2024-08-13

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2024-09-04

D · Potential for more than minimal harm 2024-08-13

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2024-09-04

D · Potential for more than minimal harm 2024-08-13

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2024-09-04

D · Potential for more than minimal harm 2024-08-13

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-08-13

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-09-10

D · Potential for more than minimal harm 2024-08-13

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-09-06

D · Potential for more than minimal harm 2024-08-13

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-09-03

D · Potential for more than minimal harm 2024-08-13

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2024-09-12

D · Potential for more than minimal harm 2024-08-13

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-09-27

F · Potential for more than minimal harm 2023-05-16

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-05-25

F · Potential for more than minimal harm 2023-05-16

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-05-25

F · Potential for more than minimal harm 2023-05-16

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-05-25

D · Potential for more than minimal harm 2023-05-16

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-05-25

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-09-26

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-10-07

D · Potential for more than minimal harm 2025-09-26

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-10-07

D · Potential for more than minimal harm 2025-09-26

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2025-10-07

D · Potential for more than minimal harm 2025-09-26

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-10-07

D · Potential for more than minimal harm 2025-09-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-10-07

D · Potential for more than minimal harm 2025-06-24

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-06-19

D · Potential for more than minimal harm 2025-06-24

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-06-19

E · Potential for more than minimal harm 2024-08-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-06

E · Potential for more than minimal harm 2024-08-13

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2024-09-15

D · Potential for more than minimal harm 2024-08-13

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-09-04

D · Potential for more than minimal harm 2024-08-13

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-09-06

D · Potential for more than minimal harm 2024-08-13

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-09-06

D · Potential for more than minimal harm 2024-08-13

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2024-08-21

D · Potential for more than minimal harm 2024-08-13

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2024-09-06

D · Potential for more than minimal harm 2024-08-13

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2024-08-13

C · Minimal harm 2024-08-13

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-08-27

J · Immediate jeopardy 2023-05-16

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-05-23

J · Immediate jeopardy 2023-05-16

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-05-23

J · Immediate jeopardy 2023-05-16

F726 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2023-05-23

F · Potential for more than minimal harm 2023-05-16

F838 · Administration Deficiencies

Health

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected 2023-05-23

F · Potential for more than minimal harm 2023-05-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-05-23

F · Potential for more than minimal harm 2023-05-16

F888 · Infection Control Deficiencies

Health

Ensure staff are vaccinated for COVID-19

Corrected 2023-05-23

E · Potential for more than minimal harm 2023-05-16

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-05-23

E · Potential for more than minimal harm 2023-05-16

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2023-05-23

E · Potential for more than minimal harm 2023-05-16

F887 · Infection Control Deficiencies

Health

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.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F700 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F712 · Nursing and Physician Services Deficiencies

Health

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2023-05-23

D · Potential for more than minimal harm 2023-05-16

F909 · Environmental Deficiencies

Health

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.

Corrected 2023-05-23

Penalties and ownership