Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunny Acres Skilled Nursing And Rehabilitation Ctr during CMS and state inspections, most recent first.
A resident with cognitive impairment and urinary retention was found to have an indwelling urinary catheter of the wrong size, contrary to physician orders for a 14 Fr Foley catheter. Staff did not document any consultation with the physician regarding the change in catheter size, and there was no order specifying the required balloon volume. The resident reported pain, and staff acknowledged the failure to follow the physician's orders.
A unit manager was observed opening an unlocked drawer at the nurses station that contained several over-the-counter medications, including acetaminophen, calcium, aspirin, Beano, and GenTeal tears. These medications were accessible to unauthorized individuals and not protected from environmental factors, contrary to facility policy. The unit manager confirmed that the medications should not have been stored in this manner.
A resident with a history of diabetes mellitus and acute pyelonephritis, who had previously received PCV13 and provided consent for further pneumococcal vaccination, was not administered the recommended pneumococcal vaccine as required by facility policy and CDC guidelines. The DON confirmed the oversight, and no evidence was found in the clinical record of the vaccine being given after admission.
The facility failed to honor the rights of two residents to formulate their own Advanced Directives. In both cases, the Medical Order for Life-Sustaining Treatment (MOLST) forms were signed by the Health Care Proxy (HCP) despite the residents being capable of making their own healthcare decisions. The residents were cognitively intact, and there was no documentation of their incapacity to make healthcare decisions. The Social Worker confirmed that the HCPs were not invoked, and the MOLST forms should have been signed by the residents.
The facility failed to follow physician orders for two residents, leading to deficiencies in care. One resident, at risk for skin breakdown, did not have their heels off-loaded as ordered, resulting in pain and redness. Another resident received an excessive dose of Acetaminophen, exceeding the prescribed limit, due to a lack of alerts in the electronic health records. These incidents highlight the need for adherence to care plans and medication protocols.
A resident with Type 1 Diabetes experienced multiple hypoglycemic episodes, with blood glucose levels falling below 70 mg/dL. The facility staff failed to follow protocols for managing these episodes, including notifying the physician and documenting interventions. The resident expressed anxiety over their blood sugar management, and staff interviews confirmed that necessary physician orders were not in place until a survey began.
The facility failed to ensure RN coverage for at least eight consecutive hours a day, seven days a week, as required. This deficiency was identified through a review of the nursing staff schedule and interviews, revealing no RN coverage on four specific days. The Administrator confirmed no waivers were in place, and the DON acknowledged the lack of payroll evidence for RN coverage. An LPN mentioned an on-call RN was available if needed, but did not specify who it was.
The facility failed to implement proper Contact Precautions for two residents, one with C. diff and another with MRSA. Staff did not consistently wear PPE or perform appropriate hand hygiene for the resident with C. diff, and Contact Precautions were delayed for the resident with MRSA. The deficiencies were due to a lack of communication and understanding among staff regarding infection control protocols.
Failure to Follow Physician Orders for Indwelling Urinary Catheter Size
Penalty
Summary
Facility staff failed to follow physician orders regarding the size of an indwelling urinary catheter for a resident with urinary retention, neurogenic bladder, and other urological conditions. The resident was cognitively impaired, dependent on staff for activities of daily living, and had a physician order specifying the use of a 14 French (Fr) Foley catheter. However, during observation, the resident was found with a 16 Fr/5 ml catheter in place, contrary to the physician's order. There was no documentation indicating that the physician or physician assistant had been notified or consulted about the use of a different catheter size. Additionally, the medical record did not contain an order specifying the balloon size or volume for the catheter, which was noted as necessary by the Director of Nursing. The care plan and physician orders required monthly catheter changes and specified the use of a 14 Fr catheter, but these were not followed. The resident reported experiencing pain with the indwelling catheter, and staff interviews confirmed that the correct catheter size was not used and that the required physician orders for balloon size were missing.
Medications Improperly Stored in Unlocked Drawer at Nurses Station
Penalty
Summary
The facility failed to ensure that medications were stored securely in accordance with its own policy and professional standards. On Unit 1, a surveyor observed a unit manager opening an unlocked drawer at the nurses station that contained six over-the-counter medications, including acetaminophen extended release tablets, calcium tablets, aspirin tablets, Beano extra strength tablets, and GenTeal tears eye drops. The medications were readily accessible to unauthorized individuals and were not protected from improper temperature, humidity, and light controls. During an interview, the unit manager acknowledged that the medications should not have been stored in an unlocked drawer, as this allowed easy access.
Failure to Administer Pneumococcal Vaccine to Eligible Resident
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to a resident who was eligible and had provided consent. According to the facility's policy, residents are to be assessed for pneumococcal vaccine eligibility upon admission and offered the vaccine within thirty days unless medically contraindicated or previously vaccinated. The resident in question, who had a history of diabetes mellitus and acute pyelonephritis, was admitted in February 2022 and had received a dose of Prevnar 13 (PCV13) in May 2019, prior to admission. There was no evidence in the clinical record that the resident had received any additional pneumococcal vaccinations after the PCV13 dose, despite having signed a consent for the vaccine upon admission. CDC guidelines recommend that adults over a certain age who have previously received PCV13 should receive a dose of PCV20 or PCV21 at least one year later. The facility's Director of Nursing confirmed during an interview that the resident should have received the pneumococcal vaccine but had not. The failure to administer the vaccine occurred despite the presence of a signed consent and clear eligibility, as indicated by both facility policy and CDC recommendations.
Failure to Honor Residents' Rights to Formulate Advanced Directives
Penalty
Summary
The facility failed to honor the rights of two residents to formulate their own Advanced Directives. For one resident, the facility staff executed a Medical Order for Life-Sustaining Treatment (MOLST) form that was signed by the resident's Health Care Proxy (HCP) despite the resident being capable of making their own healthcare decisions. The resident's cognitive capacity was confirmed by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, and there was no documentation of the resident's incapacity to make healthcare decisions. The Social Worker confirmed that the HCP was never invoked, and the MOLST form should have been signed by the resident. Similarly, for another resident, the MOLST form was signed by the HCP without evidence of the resident's incapacity to make healthcare decisions. The resident was also cognitively intact, as indicated by a BIMS score of 14 out of 15, and the HCP was not invoked. The Social Worker acknowledged that the MOLST form should have been signed by the resident. In both cases, the facility's actions were inconsistent with their policy, which requires a physician's evaluation and documentation of a resident's decision-making capacity before invoking an HCP.
Failure to Follow Physician Orders for Heel Off-loading and Acetaminophen Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice for two residents, leading to deficiencies in care. For Resident #58, the facility staff did not follow the physician's order to off-load the resident's heels while in bed, despite the resident being at risk for skin breakdown and having an active order to do so. Observations by the surveyor on multiple occasions revealed that the resident's heels were in direct contact with the mattress, and no interventions were made to off-load the heels. The resident reported pain in the heels, describing it as feeling like electricity or fire, and the Director of Nursing confirmed the presence of redness and abnormal tissue texture on the resident's right heel. For Resident #56, the facility staff failed to comply with the physician's order regarding the administration of Acetaminophen. The resident was prescribed a maximum of 3 grams of Acetaminophen in a 24-hour period, but the staff administered 3,650 mg, exceeding the prescribed limit. This over-administration occurred despite the facility's policy requiring medications to be administered in accordance with prescriber orders. The nurse responsible for administering the medication acknowledged the error and stated that the electronic health records did not provide alerts for maximum dosage limits, placing the responsibility on the nurse to manually track medication administration. These deficiencies highlight a lack of adherence to physician orders and facility policies, resulting in potential harm to the residents. The failure to off-load Resident #58's heels increased the risk of pressure injuries, while the excessive administration of Acetaminophen to Resident #56 posed a risk of liver damage. Both incidents demonstrate a need for improved compliance with care plans and medication administration protocols to ensure resident safety and well-being.
Failure to Manage Hypoglycemia in Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with Type 1 Diabetes Mellitus, specifically in managing hypoglycemic episodes. The resident, who was admitted in September 2023, experienced multiple instances of low blood glucose levels, with readings below 70 mg/dL on several occasions. Despite the facility's policy requiring immediate notification of the physician and specific interventions for hypoglycemia, these protocols were not followed. The resident expressed anxiety about the management of their blood sugar levels, fearing for their safety, particularly at night. The facility's records showed that the nursing staff did not initiate the hypoglycemic protocol or notify the physician during any of the documented low blood glucose events. The resident's care plan included monitoring blood glucose levels and administering medications as ordered, but these actions were not consistently implemented. Interviews with facility staff, including the Unit Manager and Director of Nursing, confirmed that the necessary physician's orders for diabetic care were not in place until the start of the facility's recertification survey. The staff acknowledged that they failed to document the treatment of the resident's low blood sugars in the nursing progress notes, as required by the facility's policy.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of the facility's Licensed Nurses schedule and interviews, which revealed that there was no RN coverage on four specific days between 5/26/24 and 6/22/24. Specifically, there was no evidence of RN coverage on 6/1/24, 6/2/24, 6/8/24, and 6/16/24. During interviews, the Administrator confirmed that no nursing staff waivers were in place, and the Director of Nursing acknowledged the lack of payroll evidence for RN coverage on those dates. An LPN who worked on some of the days in question mentioned that an RN was always on-call if needed, but did not specify who the on-call RN was.
Failure to Implement Contact Precautions for Residents with C. diff and MRSA
Penalty
Summary
The facility failed to implement proper Contact Precautions for two residents, leading to potential transmission of communicable diseases. For Resident #49, who was diagnosed with Clostridium difficile (C. diff), staff did not consistently wear the required Personal Protective Equipment (PPE) or perform appropriate hand hygiene with soap and water after exiting the resident's room. Despite the presence of a Contact Precautions sign, staff members were observed entering and exiting the room without donning PPE and using alcohol-based hand rub instead of washing with soap and water, as required for C. diff. Interviews with staff revealed a lack of understanding and communication regarding the specific precautions needed for C. diff. For Resident #58, who was diagnosed with a Methicillin-resistant Staphylococcus aureus (MRSA) infection in the urine, the facility failed to implement Contact Precautions in a timely manner. Despite the urine culture results indicating a MRSA infection, no order for Contact Precautions was obtained, and no signage was posted outside the resident's room. Staff members were observed providing care without wearing gowns or gloves, and the necessary precautions were not implemented until several days after the diagnosis was confirmed. The Infection Preventionist acknowledged that the precautions should have been implemented immediately upon receiving the test results. The deficiencies in infection control practices were attributed to a lack of communication and understanding among staff regarding the specific requirements for Contact Precautions. The facility's policies and CDC guidelines were not adequately followed, resulting in potential exposure to infectious agents. The Infection Preventionist noted that the responsibility to implement precautions fell on the nursing staff when she was not present, but this protocol was not followed, leading to delayed implementation of necessary precautions for Resident #58.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chelmsford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New England Pediatric Care | 1.4 mi | ★★★★★ | 7 | 0 |
| Life Care Center Of Merrimack Valley | 1.5 mi | ★★★★★ | 6 | 0 |
| Palm Springs Post Acute | 2.4 mi | ★★★★★ | 12 | 0 |
| Regalcare At Lowell | 2.7 mi | ★★★★★ | 21 | 1 |
| Vantage At Lowell Llc | 3.2 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.