Sudbury Pines Extended Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for seven Residents (#18, #24, #58, #61, #26, #39, and #9) out of a total sample of 26 residents. Specifically, 1. For Residents #18, #24, #58, #61, #26 and #39, the facility failed to provide assistance and/or supervision with meals as per the plan of care. 2. For Resident #9, the facility failed to provide assistance with grooming. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), dated March 2018, indicated Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with: d. Dining (meals and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. Resident #78 was admitted to the facility in March 2024 with diagnoses that included metabolic encephalopathy, moderate protein calorie malnutrition and diabetes. Review of Resident #78's MDS, dated [DATE], indicated a Brief Interview for Mental Status score of 6 out of 15, indicating severe cognitive impairment. The MDS further indicated that the Resident did not have any pressure ulcers. Review of the Braden Score for Predicting Pressure Sore Risk Assessment, dated 12/2/24, indicated that Resident #78 was at high risk for development of pressure ulcers with a score of 10. Review of Resident #78's most recent wound consult note, dated 2/28/25, indicated the following: -Stage 3 pressure ulcer (full thickness wound) is located on the sacrum. -Wound size is 1.5 cm (centimeters) length, 1.0 cm width and 0.1 cm depth. -Assessment: Not improved stage 3 pressure ulcer. -Off loading discussed: suggest mattress upgrade. Review of Resident #78's active care plan, dated 5/10/24, indicated, I have pressure ulcer or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure it provided an environment free of potential safety hazards for three Residents (#60, #17, and #41) out of a total sample of 26 residents. Specifically: 1. For Resident #60, the facility failed to ensure nursing provided two-person assistance with a lift (Sara lift, a sit-to-stand style lift). 2. For Resident #17, the facility failed to ensure he/she was consistently provided with a smoking apron while smoking. 3. For Resident #41, the facility failed to ensure nursing provided a bed and chair alarm as ordered by the physician and plan of care. Findings include: 1. Review of the facility policy titled, Lifting Machine, Using a Mechanical, dated as revised July 2017, indicated the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lift device. It is not a substitute for manufacturer's training or instruction. -General Guidelines: 1. At least two (2) nursing assistants are needed to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice were provided for three Residents (#34, #50, and #69) out of sample of 26 residents. Specifically, 1. For Resident #34, the facility failed to ensure that nursing changed Resident #34's oxygen tubing as ordered by the physician. 2. For Resident #50, the facility failed to routinely change and date nebulizer tubing. 3. For Resident #69, the facility failed to ensure oxygen was being administered per the physician's order. Findings Include: Review of the facility policy titled Oxygen Administration, undated, indicated the following: Purpose -The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation -Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. -Review the resident's care plan to assess for any special needs of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Resident #62 was admitted to the facility in November 2021 with diagnoses that included Alzheimer's disease. Review of Resident #62's Minimum Data Set (MDS) Assessment, dated 1/23/25, indicated a Brief Interview for Mental Status score of 0 out of 15, indicating severe cognitive impairment. The MDS further indicated the Resident is dependent for activities of daily living including eating and that the Resident complains of pain or difficulty with swallowing. Review of Resident #62's active eating assistance care plan, dated as revised 2/1/23, indicated, I have been known to try to grab out at others food. I do not know what to do with my utensils, so I need to be fed. I also have been known to take my napkin and put it in my food, my dementia has been progressing. The care plan also indicated, eating goals over the next 90 days: dependent [sic] Review of Resident #62's active cognitive function care plan, revised 9/2/23, indicated I have impaired cognitive function/dementia or impaired thought processes r/t…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, 1. The facility failed to ensure treatment carts and medication rooms were locked while a nurse was not present. 2. The facility failed to ensure drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the medication room and medication carts on two of two units. 3. The facility failed to ensure that medications were dated once opened, according to manufacturer's guidelines. Further, the facility failed to ensure that medications with shortened expiration dates were removed from the medication cart when expired and were not available for administration in two of two medication carts observed. Findings include: Review of the facility policy titled Storage of Medications, dated April 2007, indicated The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 7. Compartments (including, but not limited to, drawers,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interview the facility failed to ensure the physician was notified when one Resident (#28), out of a total sample of 26 residents, was not utilizing a Bipap (Bilevel positive airway pressure, a machine used to treat sleep apnea) machine as indicated in the physician's orders. Findings Include: Resident #28 was admitted to the facility in March 2016 with diagnoses that include acute on chronic respiratory failure, obstructive sleep apnea and paranoid schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 11/26/24 indicated that a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the Resident is cognitively intact. The MDS further indicated oxygen use, and did not indicate the use of non-invasive mechanical ventilation (Bipap). Review of Resident #28's physician orders indicated the following orders, dated 2/12/25: -BIPAP: Change BIPAP Device water daily (use sterile or distilled water). [sic] -BIPAP: Apply BIPAP Device at night and as needed (titrate oxygen to maintain SATS (oxygen saturation)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to report a bruise of unknown origin to the State Agency within the mandated time-frame for one Resident (#24) out of a total of 26 sampled residents. Findings include: Review of the facility policy titled Abuse Prohibition, reviewed 10/21/24, indicated It is the policy of the facility to assure an environment free of abuse, neglect, mistreatment and misappropriation of resident property. At risk resident: Resident with the highest risk, i.e., at risk of abuse and neglect include resident who have dementia; residents with no/few visitors; residents who are totally dependent on care; residents with communication disorders. Protection and Notification: Upon receiving an allegation of abuse, supervisors will take necessary steps to protect all residents and then immediately notify the Director of Nursing Services who will notify the Administrator. If the Director of Nursing is unavailable then the report will go directly to the Administrator. The facility will report and investigate all allegations of resident abuse,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to thoroughly investigate an bruise of unknown origin, for one Resident (#24) out of a total sample of 26 residents. Specifically for Resident #24 who on 2/16/25 was found to have a bruise under his/her left eye by a Certified Nurses Aide, the facility staff failed to complete a thorough investigation. Findings include: Review of the facility policy titled Abuse Prohibition, reviewed 10/21/24, indicated It is the policy of the facility to assure an environment free of abuse, neglect, mistreatment and misappropriation of resident property. At risk resident: Resident with the highest risk, i.e., at risk of abuse and neglect include resident who have dementia; residents with no/few visitors; residents who are totally dependent on care; residents with communication disorders. Protection and Notification: Upon receiving an allegation of abuse, supervisors will take necessary steps to protect all residents and then immediately notify the Director of Nursing Services who will notify the Administrator. If the Director of Nursing is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Resident #50 was admitted to the facility in June 2021 with diagnoses including acute respiratory failure with hypoxia, shortness of breath, bacterial pneumonia, and asthma. Review of Resident #50's most recent Minimum Data Set (MDS), dated [DATE], indicated that he/she had a Brief Interview for Mental Status (BIMS) exam score of 9 out of a possible 15, indicating he/she has moderate cognitive impairments. Further review of the MDS indicated Resident #50 requires dependent assistance for daily self-care activities and is on oxygen therapy. Review of Resident #50's physician orders indicated the following: -Oxygen 2-3 liters via nasal cannula to maintain O2 Sats above 88% - document that O2 on by initialing (3 OF 3), every shift, initiated 3/14/24. -Place portable liquid oxygen on when out of room, initiated 4/24/24. Review of Resident #50's oxygen care plan indicated the following: -Oxygen settings: I have O2 (oxygen) via nasal prongs/mask @ (2-3) L (liters) continuously, initiated 3/14/24. -Provide me…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure the comprehensive care plan was revised by the interdisciplinary team for two Residents (#28 and #70) out of a total sample of 26 residents, after each assessment, including both the comprehensive and quarterly review assessments. Specifically, the facility failed to review and revise the care plan after quarterly assessments were completed to reflect the current status of the Residents. Findings Include: Review of facility policy titled Care Plans, Comprehensive Person- Centered, reviewed 10/21/24, indicated the following: -A comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -The comprehensive person-centered care plan will: -g. Incorporate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#24), out of a total sample of 26 residents. Specifically, the facility failed to assess the Resident who is dependent on staff for care was found with a bruise under his/her left eye. Findings include: Resident #24 was admitted to the facility in July 2021 with diagnoses that included Alzheimer's disease, dysphagia, anxiety and depression. Review of Resident #24's most recent Minimum Data Set (MDS) assessment, dated 1/14/25, indicated he/she was assessed by nursing staff to have moderate cognitive impairments. The MDS further indicated he/she needed partial/moderate assistance from staff for eating. On 3/4/25 at 7:40 A.M. , the surveyor observed Resident #24 in bed with a dark purple bruise under his/her left eye. On 3/4/25 at 11:52 A.M., the surveyor observed Resident #24 in the dining room with a dark purple bruise under his/her left eye. Review of Resident #24's weekly skin check, dated 2/18/25, indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to provide treatment and services related to an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body), for one Resident (#60) out of a total sample of 26 residents. Specifically for Resident #60, the facility staff failed to a.) implement the physician's orders related to the correct the indwelling catheter balloon size and b.) change the urinary drainage bag as ordered by the physician, increasing the Resident's risk for indwelling urinary catheter complications. Findings include: Review of the facility policy titled, Catheter Care, Urinary, dates as revised September 2014, indicated the purpose of this procedure is to prevent catheter-associated urinary tract infections. 1. Review the resident's care plan to assess for any special needs of the resident. Resident #60 was admitted to the facility in September 2022 with diagnoses including neuromuscular dysfunction of the bladder, diabetes, and Parkinson's disease. Review of the most recent Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and interviews, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#35) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 26 residents. Specifically, for Resident #35 the facility failed to ensure nursing did not obtain blood pressures from his/her arm with the AV (arteriovenous fistula, is when an artery and vein connect directly, allowing blood to flow) fistula. Findings include: Review of the facility policy titled, Pre-Dialysis and Post Dialysis Treatment, dated 9/26/24, indicated the purpose of this policy is to ensure safe monitoring guidelines to assess dialysis patients before and after treatment to identify complication for early intervention. Resident #35 was admitted to the facility in October 2017 with diagnoses including end stage renal disease, diabetes, and glaucoma. Review of the most recent Minimum Data Set (MDS) assessment, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a comprehensive plan of care was developed for Trauma Informed Care for one Resident (#3) who had a history of trauma out of a total sample of 26 residents. Specifically, for Resident #3, the facility failed to develop a comprehensive trauma care plan, with individualized triggers. Findings Include: Review of the facility policy titled Behavioral Assessment, Intervention and Monitoring, dated 12/16, indicated the following: Policy Statement -Behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. Policy Interpretation and Implementation -Interventions and approaches will be based on a detailed assessment of physical, psychosocial and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, as a minimum: -A description of the behavioral symptoms, including frequency, intensity, duration, outcomes, location, environment, and precipitating factors or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide a diet of personal preferences to one Resident (#3) out of a total sample of 26 residents. Specifically, the facility failed to provide a banana for all three meals per his/her meal ticket. Findings Include: Resident #3 admitted to the facility in April 2022 with diagnoses that included Type 2 Diabetes Mellitus, dysphagia, and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/9/25, indicated the Resident was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #3 requires dependent assistance for self-care activities. During an observation on 3/4/25 at 8:08 A.M., Resident #3 was observed eating breakfast in the dining room. The breakfast included pureed meat and eggs, honey thickened coffee and cranberry juice. Further review of Resident #3's meal ticket indicated the following Assist Instructions: High protein. Banana with all meals. Resident #3 did not receive a banana for breakfast. During an observation on 3/5/25 at 8:05 A.M. and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain accurate medical records for two Residents (#24 and #50) out of a total sample of 26 residents. Specifically, 1. For Resident #24, the facility failed to document a bruise below his/her left eye that was first observed on 2/16/25 by nursing staff. 2. For Resident #50, the nursing staff documented in the Treatment Administration Record (TAR) that a nebulizer tubing was replaced when it was not. Findings Include: Review of the facility policy titled Charting and Documentation, dated 7/17, indicated the following: Policy Statement - All services provided to the residents, progress toward the care plan goals, and any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to coordinate an assessment with the pre-admission screening and resident review (PASRR- is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR requires that: 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and 3) receive the services they need in those settings) program for one Resident (#3) out of a total sample of 18 total residents. Specifically, the facility failed to refer Resident #3 for a Resident Review (person-centered assessment taking into account all relevant information) when he/she was admitted to the facility with a diagnosis of Schizoaffective Disorder (serious chronic mental illness), was being treated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide respiratory care and services in accordance with professional standards of practice, for one Resident (#58) out of a total sample of 18 residents. Specifically, the facility failed to: 1. Obtain a Physician's order to determine the appropriate liter flow for Oxygen administration to Resident #58, for a Resident with diagnoses that require prescribed flow rates to prevent hypercapnia (high carbon dioxide levels in the blood). 2. Store and handle oxygen tubing in a sanitary manner, to decrease the risk of contamination and infection for the Resident. Findings include: Review of the facility's policy titled Oxygen Administration, undated, indicated a Physician's order was necessary for the administration of Oxygen. Review of the facility's policy titled Nasal Cannula Oxygen Administration, undated, indicated the following: -The nasal cannula delivers oxygen in low concentrations. -Verify the Physician's order . -Set the liter flow. -Place tips of the cannula into the patient's nostrils, loop the tubing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.