Inspection Reports for Sudbury Pines Extended Care
642 Boston Post Rd, Sudbury, MA 01776, MA, 01776
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
74% worse than Massachusetts average
Massachusetts average: 7.3 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 10, 2025
Visit Reason
The inspection was conducted following allegations of abuse involving a Certified Nurse Aide (CNA) slapping a resident (Resident #1) on the arm, reported by staff members after delays in reporting the incidents.
Complaint Details
The complaint investigation involved allegations that CNA #1 slapped Resident #1 on the arm on 05/07/25 and approximately one month prior. CNA #2 and CNA #3 witnessed the abuse but delayed reporting by 12 days and about one month respectively. The facility's internal investigation confirmed these delays and failures to report immediately.
Findings
The facility failed to ensure staff implemented and followed their Abuse Policy by not immediately reporting witnessed abuse incidents involving Resident #1. Multiple CNAs witnessed CNA #1 slap Resident #1 on different occasions but delayed reporting, placing the resident and others at risk.
Deficiencies (1)
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft, specifically failure to ensure immediate reporting of witnessed abuse incidents.
Report Facts
Residents sampled: 3
Days delay in reporting by CNA #2: 12
Approximate days delay in reporting by CNA #3: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Alleged perpetrator who slapped Resident #1 |
| CNA #2 | Certified Nurse Aide | Witnessed abuse on 05/07/25, delayed reporting by 12 days |
| CNA #3 | Certified Nurse Aide | Witnessed abuse during week of 04/14/25, delayed reporting by about one month |
| Unit Manager #1 | Unit Manager | Received abuse report from CNA #2 and reported to Clinical Manager and Directors |
| Clinical Manager | Clinical Manager | Led internal investigation into abuse allegations |
Inspection Report
Routine
Deficiencies: 23
Date: Mar 6, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements for Sudbury Pines Extended Care.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining experiences, failure to notify physicians of resident care issues, inaccurate resident assessments, failure to implement care plans, inadequate assistance with activities of daily living, improper medication storage and labeling, failure to provide appropriate respiratory and wound care, and failure to maintain accurate medical records.
Deficiencies (23)
Failed to ensure staff treated residents in a dignified manner during dining and catheter care.
Failed to notify physician when Resident #28 was not utilizing Bipap machine as ordered.
Failed to provide accurate estimated cost of services to residents or representatives.
Failed to provide a homelike environment during dining; residents served meals on trays not removed.
Failed to accurately assess use of alarmed velcro seat belt as a restraint for Resident #18.
Failed to timely report suspected abuse related to a bruise of unknown origin for Resident #24.
Failed to thoroughly investigate a bruise of unknown origin for Resident #24.
Failed to accurately complete Minimum Data Set assessments for Residents #41 and #60.
Failed to implement complete care plans for Residents #50, #58, and #60 including oxygen use and transfer assistance.
Failed to provide assistance with activities of daily living including meals and grooming for seven residents.
Failed to revise comprehensive care plans after assessments for Residents #28 and #70.
Failed to provide appropriate pressure ulcer care and prevent new ulcers for Residents #61, #60, #69, and #78.
Failed to provide two-person assistance with mechanical lift for Resident #60.
Failed to ensure Resident #17 was consistently provided a smoking apron while smoking.
Failed to provide bed and chair alarms as ordered for Resident #41.
Failed to provide appropriate catheter care for Resident #60 including correct balloon size and timely drainage bag changes.
Failed to provide safe and appropriate dialysis care for Resident #35 by obtaining blood pressures from arm with AV fistula.
Failed to provide safe and appropriate respiratory care for Residents #34, #50, and #69 including timely tubing changes and oxygen administration.
Failed to provide food that accommodates resident preferences for Resident #3 by not providing a banana with all meals as ordered.
Failed to conduct and document a comprehensive facility-wide assessment to determine resources necessary to care for residents competently.
Failed to maintain accurate medical records for Residents #24 and #50 including documentation of bruises and nebulizer tubing changes.
Failed to provide appropriate treatment and services for Resident #24 with a bruise under his/her left eye.
Failed to provide dignified dining experience for Residents #61, #39, and #62 by pushing meals away so they could not reach them.
Report Facts
Deficiencies cited: 23
Resident sample size: 26
BIMS score: 15
BIMS score: 0
BIMS score: 9
BIMS score: 13
BIMS score: 5
Weight: 172.3
Weight: 169.4
Weight: 111.2
Pressure ulcer size: 1.5
Pressure ulcer size: 1
Pressure ulcer size: 0.1
Bruise size: 3
Bruise size: 1
Fall duration: 144
Fall duration: 86
Blood pressure attempts: 36
Blood pressure attempts left arm: 21
Blood pressure attempts right arm: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nurse Aide | Mentioned in relation to dignified dining and feeding assistance deficiencies |
| Unit Manager #2 | Mentioned in relation to dignified dining, feeding assistance, bruise reporting, and smoking apron | |
| Director of Nursing | Director of Nursing | Mentioned in relation to multiple deficiencies including dignified care, bruise reporting, catheter care, medication storage, respiratory care, and wound care |
| Nurse #4 | Nurse | Mentioned in relation to bruise observation and medication storage |
| CNA #6 | Certified Nurse Aide | Mentioned in relation to fall incident with Sara lift |
| CNA #5 | Certified Nurse Aide | Mentioned in relation to Sara lift use without second staff |
| Unit Manager #1 | Mentioned in relation to catheter care, air mattress settings, wound care, and medication storage | |
| Nurse #3 | Nurse | Mentioned in relation to oxygen tubing and blood pressure measurement |
| Social Worker #1 | Social Worker | Mentioned in relation to MDS assessment coding |
| Social Worker #2 | Social Worker | Mentioned in relation to PTSD care plan development |
| CNA #7 | Certified Nurse Aide | Mentioned in relation to feeding assistance and fall care |
| Nurse #2 | Nurse | Mentioned in relation to feeding assistance and Resident #26 supervision |
| Nurse #6 | Nurse | Mentioned in relation to catheter care and air mattress settings |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, coordination with pre-admission screening and resident review programs, and provision of respiratory care.
Findings
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three residents, failed to coordinate assessments with the PASRR program for one resident, and failed to provide safe and appropriate respiratory care for one resident, including lack of physician orders for oxygen administration and improper handling of oxygen equipment.
Deficiencies (3)
Failed to accurately complete MDS assessments for Residents #36, #3, and #86.
Failed to coordinate assessment with the PASRR program for Resident #3.
Failed to provide safe and appropriate respiratory care for Resident #58, including lack of physician order for oxygen and improper handling of oxygen tubing.
Report Facts
Residents reviewed: 18
Discharged residents reviewed: 1
Oxygen flow rate: 3
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Nurse | Observed handling oxygen tubing improperly and acknowledged no physician order for oxygen administration for Resident #58 |
| Nurse #2 | Infection Preventionist (former) | Provided information on oxygen tubing replacement and importance of physician orders for oxygen administration |
| MDS Coordinator | Interviewed regarding inaccurate MDS assessments for Residents #3 and #36 | |
| Director of Nurses | Director of Nurses (DON) | Interviewed regarding discharge plans and MDS assessment coding for Resident #86 |
| Social Worker | Social Worker (SW) | Interviewed regarding PASRR referral requirements for Resident #3 |
Inspection Report
Routine
Deficiencies: 11
Date: Sep 13, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care, improper medication self-administration assessment and storage, failure to notify physicians of changes in condition, late transmission of MDS assessments, inaccurate resident assessments, failure to provide ordered treatments, improper food storage, and inadequate infection control related to urinary catheter care.
Deficiencies (11)
Failure to provide residents #3 and #76 with dignified care, including use of a wheelchair with torn armrests and staff standing over resident while feeding.
Failure to ensure clinical appropriateness of self-administration of topical medications for Resident #71 and improper storage of medications.
Failure to notify physician or health care proxy of injury of unknown origin for Resident #63.
Failure to provide timely transfer notices to Resident #55 or representative.
Failure to transmit complete MDS assessments to CMS within required timeframe for eight residents.
Failure to accurately assess Resident #63's speech and cognitive status on MDS assessment.
Failure to provide appropriate treatment and care for Residents #63 and #85, including timely investigation of injury and application of ordered ace wraps.
Failure to provide diabetic foot care for Resident #33 as ordered and documented.
Failure to ensure medications were stored securely and locked for Resident #71.
Failure to properly store food, including unsealed, undated, expired items and food stored on the floor.
Failure to maintain infection control by keeping urinary catheter drainage bag and tubing off the floor for Resident #67.
Report Facts
Residents sampled: 18
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 8
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #4 | Named in failure to notify physician and timely investigate injury of unknown origin for Resident #63 | |
| Nurse #3 | Named in dignified care deficiency for Resident #3 and #76 | |
| Certified Nurse Aide (CNA) #2 | Certified Nurse Aide | Observed wheelchair condition for Resident #3 and commented on speech of Resident #63 |
| Certified Nurse Aide (CNA) #1 | Certified Nurse Aide | Observed feeding practice for Resident #76 |
| Unit Manager (UM) #1 | Unit Manager | Observed unlocked medications for Resident #71 |
| Unit Manager (UM) #2 | Unit Manager | Interviewed regarding notification responsibilities for Resident #63 |
| Director of Clinical Services | Interviewed regarding injury investigation for Resident #63 | |
| Director of Nurses (DON) | Director of Nurses | Interviewed regarding treatment orders and infection control |
| Food Service Director (FSD) | Food Service Director | Interviewed regarding food storage deficiencies |
| Nurse #2 | Named in failure to apply ace wraps for Resident #85 |
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