Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Vantage At Sudbury Llc during CMS and state inspections, most recent first.
Dignity and Meal Assistance Failures During Shared Dining: Residents seated together in a shared dining room were not served meals at the same time, leaving some residents waiting while tablemates ate. Staff acknowledged this was not dignified. A resident with dementia, severe cognitive impairment, and a care plan for supervised meals was left alone after tray setup and spilled food, dropped utensils, and ate with fingers while staff were not present.
Unclean Medication Carts: Three medication carts were observed with dried brown, white, and other unidentified substances on the exterior surfaces and inside drawers, along with open food items, a water pitcher used for med pass, and loose unidentifiable pills mixed with resident medication supplies. Nurses interviewed were unsure what the substances were or when the carts were cleaned, and the DON stated the facility did not have a policy for medication cart cleaning and was concerned about the carts' cleanliness.
Food and beverages were served at improper temperatures during breakfast on multiple meal carts, including hot items that were not hot and cold items that were not cold. Surveyors found this in the kitchen and on test trays in the dining room and on unit carts, and several residents reported that food meant to be served hot was not hot when served.
Locked Wheelchair Brakes Used as a Restraint: Staff locked both brakes on a resident’s wheelchair to limit movement and keep the resident in the activity room, even though the resident could propel the wheelchair with feet and hip thrusts. The resident had dementia and difficulty walking, but the record lacked a pre-restraint assessment, physician order, and resident-centered restraint care plan. Staff and the DON acknowledged that if the resident could not unlock the brakes, the locked wheelchair functioned as a restraint.
Failure to Invite Resident to Care Plan Meetings: A resident with HF and COPD, who was moderately cognitively impaired but able to communicate and understand others, was not invited to participate in care plan meetings and the record lacked any documented rationale for the absence of participation or any refusals. The resident stated he/she had never been invited, and the DON acknowledged the resident should have been invited because it was the resident's right to attend care plan meetings.
Failure to provide foot care and podiatry services: A resident with severe cognitive impairment and total ADL dependence had untrimmed toenails observed on two survey dates, despite daily foot care documentation, a physician order for podiatry consult, and guardian consent for podiatry services. The DON stated the resident should have been placed on the podiatry list but was not seen during two podiatry visits to the facility.
Dirty Oxygen Concentrator Not Maintained: A resident receiving oxygen via NC had an oxygen concentrator cabinet with dried white and brown debris and filters coated in thick gray dust. Staff said the cabinet and filters should be cleaned weekly, but the unit remained unchanged on repeat observation, and the IP and DON were unsure of the facility’s cleaning schedule for oxygen concentrators.
A resident with OA, right hip pain, and a recent THA had PRN oxycodone ordered along with scheduled acetaminophen, but the oxycodone was not confirmed with the pharmacy and was unavailable for about 21 hours. During that time, the resident repeatedly reported severe pain, cried out, and refused care because pain medication was needed, while acetaminophen did not relieve the pain. Staff did not obtain timely alternative or emergency pain orders from the NP/MD until a one-time oxycodone dose was later ordered from the E-kit.
A resident with a suprapubic catheter, UTI history, moderate cognitive impairment, and ESBL history was supposed to be on EBP for direct care. Surveyors observed CNAs assisting the resident with toileting and morning ADL care without gowns, and one CNA also failed to discard gloves and perform hand hygiene before handling clean linens and re-entering the room. The DON stated staff should have been wearing PPE, including gowns and gloves, during direct care.
Failure to issue a NOMNC for a resident discharged from Part A skilled services. A resident admitted for rehab after a hip fracture had skilled days remaining, was discharged home immediately after the last covered skilled day, and the record contained no evidence that the required Medicare non-coverage notice was given.
A resident experienced significant weight loss, dropping from 115 to 101.6 pounds, without proper monitoring or notification to the physician, dietician, or health care proxy. Despite being at risk for weight loss, the facility failed to adhere to its weight monitoring policy, resulting in a lack of timely intervention. Staff interviews revealed unawareness of the resident's condition, highlighting a communication breakdown.
A resident with Multiple Sclerosis, requiring substantial assistance with feeding, was observed being assisted by a CNA who stood over them during a meal, contrary to the facility's policy for dignified dining. The Nursing Supervisor acknowledged that the CNA should have been seated to maintain a homelike and dignified environment.
The facility failed to obtain informed consent for psychotropic medications for three residents. A resident with Bipolar Disorder was given Seroquel and Zyprexa without consent. Another resident with severe cognitive impairment received Topamax for behaviors without the Health Care Proxy's consent. A third resident with anxiety was administered Hydroxyzine without a signed consent form. The ADON acknowledged these oversights.
A facility failed to accurately execute a MOLST form for a resident, as the form contained an incorrect name despite having the correct date of birth and medical record number. This error was confirmed by a Nursing Supervisor, who stated that the form was invalid, risking the resident's life-sustaining treatment wishes not being honored in an emergency.
A resident with a yeast infection experienced unmanaged itching due to the facility's failure to notify the physician of a recommended treatment change. Despite a consulting physician's recommendation for Boric Acid, the facility did not communicate this to the attending physician, delaying treatment by 19 days.
A resident with severe cognitive impairment and dysphagia was left unsupervised during meals, contrary to their care plan requiring continual supervision. Despite the facility's policy, staff failed to provide necessary oversight, leading to a deficiency noted by surveyors.
A resident in an LTC facility experienced discomfort due to the incorrect re-insertion of a Foley catheter following a failed voiding trial. The facility's policy required adherence to physician's orders for catheter size, but discrepancies were found in the clinical records. The resident had a 16 Fr catheter with a 30 ml balloon instead of the ordered 18 Fr catheter with a 10 ml balloon. The ADON confirmed the error, which led to the deficiency.
A facility failed to document a complete set of vital signs for a resident with end-stage renal disease before dialysis sessions, as ordered by the Physician. The resident's medical records lacked evidence of vital signs assessment on several treatment days, and no progress notes explained the omission. Interviews with staff confirmed the importance of documenting vital signs to ensure the resident's medical stability.
A CNA in a LTC facility failed to follow safe food handling practices by placing a contaminated domed lid over a meal plate and serving it to a resident. The resident, who was severely cognitively impaired due to a CVA, was exposed to potential foodborne illness. A nurse acknowledged the error and removed the meal tray.
The facility failed to follow infection control standards for two residents, leading to deficiencies in care. One resident with a Stage 4 pressure ulcer did not receive Enhanced Barrier Precautions (EBP) as required, as staff did not wear gowns during wound care. Another resident with MRSA infection experienced lapses in hand hygiene and equipment disinfection during treatment. These actions increased the risk of infection transmission, as confirmed by staff interviews.
A resident with end-stage renal disease was receiving dialysis treatments as ordered, but the facility failed to accurately code this in the MDS assessment. The MDS Director admitted the error, noting the absence of a specific policy for MDS completion, relying on the RAI manual instead.
A resident was discharged to an ALF without necessary medical information, including physician's orders and medication list, due to the facility's failure to follow discharge protocols. Despite prior communication about the discharge plans, the facility did not send or communicate the required documents, leading to an unplanned and unsafe discharge.
A facility failed to document the discharge of a resident with a physician's order for transfer to an Assisted Living Facility with Hospice Services. Despite policies requiring documentation of services, progress, and discharge plans, the resident's medical record lacked necessary discharge documentation. The Director of Nurses acknowledged the expectation for nursing staff to document such discharges, which was not met in this instance.
Dignity and Meal Assistance Failures During Shared Dining
Penalty
Summary
The facility failed to ensure that residents in the Concord West, Concord East, and Concord Split nursing units were served their meals at the same time as other residents seated at the same table or in the dining room. During lunch observation, 20 residents were seated in the shared dining room at seven round tables, but at one table three residents had been served while one resident was still waiting for a meal tray. At another table, two residents had been served while one resident remained without a meal and was observed reaching over the table to take a chocolate cake dessert from a resident who had already been served. The waiting resident at the first table continued to wait while the other residents at the table had already started eating. During breakfast observation, residents seated in the dining room were again served at different times rather than together. One resident had a breakfast tray while the remaining residents seated in the room did not. A second resident was served later, and another resident left the dining room to ask a staff member about breakfast before returning and being served. Two residents seated in the dining room were not served until 20 minutes after the other residents had already received their breakfast meals. Staff interviews confirmed that residents seated together should be served at the same time and that it was not dignified for some residents to eat while others at the same table waited and watched. The facility also failed to provide Resident #4 with the supervision and assistance at meals that were identified in the care plan. Resident #4 was admitted with diagnoses including weakness, lack of coordination, and dementia, and the MDS showed severe cognitive impairment with a BIMS score of 3 and partial to moderate assistance needed for eating. The care plan indicated nutritional risk and required supervision during meals, but the active Care Kardex did not reflect that need. During breakfast observation, a CNA set up the tray and left the room. Resident #4 then ate independently, spilled food on the chest, dropped the spoon, and began eating with fingers. Staff interviews stated that Resident #4 required supervision during meals and that staff should have been in the room during meal consumption.
Unclean Medication Carts
Penalty
Summary
Medication storage was not maintained in a clean and sanitary manner for three medication carts observed: Concord East, Concord West, and Concord Split. On 3/4/26, the surveyor observed the Concord East cart soiled externally on the top preparation surface, both sides, front, and back with a splattered, dried brown substance, along with an open applesauce container dated 3/4/26, a water pitcher used for medication administration, and a thick coating of dust on the lower outer perimeter with dried brown and orange splatters mixed in the dust. In the top medication storage drawer, there was a dried pool of white substance and three unidentifiable loose white tablets, and in the third drawer on the right there was a pool of partially dried tacky brown liquid with other bottles of liquid medication used for resident medication administration. The Concord West cart was also observed to be soiled externally at the top of the preparation surface, both sides, and down the front with a dripped dried brown substance, with a thick coating of dust on the lower outer perimeter. On top of the cart were an open applesauce container dated 3/4/26, an unopened nutritional protein shake, and a water pitcher used for medication administration. In the right top drawer containing over-the-counter medications, there was a small dried pool of white chalky substance and two unidentifiable pink pills, and in the bottom right drawer there was a pool of dried dark brown substance. The Concord Split cart had spillage of white and brown substances down both sides and the front-facing drawers, with a partly dried sticky brown pool in the left third drawer and a dried chalky white pool in the right drawer with other medication bottles used for resident medication administration. Nurses interviewed said they were unaware of what the substances were or when the carts were cleaned, and the DON stated the facility did not have a policy for medication cart cleaning and had concern about the lack of cleanliness.
Food and beverages served at improper temperatures during breakfast
Penalty
Summary
The facility failed to provide food and drink at safe and appetizing temperatures during breakfast service on three meal carts serving the Concord East Unit, Concord [NAME] Unit, and the shared Concord Unit Dining Room. Surveyors observed in the Main Kitchen that hot breakfast foods were held above 135 degrees Fahrenheit and cold beverages were held below 41 degrees Fahrenheit while the tray line was in progress, and the loaded breakfast carts left the kitchen at different times for the three areas. Despite this, test trays completed after all resident meal trays were passed showed multiple items that were not at the expected temperature, including milk, orange juice, coffee, scrambled eggs, pureed bread, pureed eggs, pureed ham, pureed oatmeal, toast, and ham slices. The facility's policy stated that food would be served at a safe and appetizing temperature, and Food Committee Meeting Minutes documented resident concerns about cold food and coffee. During the resident group meeting, four of eight residents present said food that was supposed to be served hot was not hot when served. The Food Service Director stated she was concerned that the hot foods were not served hot during the breakfast meal and agreed that foods meant to be served hot should be served hot, and foods and beverages meant to be served cold should be served cold.
Locked Wheelchair Brakes Used as a Restraint
Penalty
Summary
The facility failed to keep one resident free from the use of a physical restraint when staff locked both brakes on the resident’s wheelchair to limit movement while the resident was seated in it. Resident #5 had diagnoses including dementia and difficulty walking, was unable to participate in a BIMS because he/she was rarely or never understood, and had no documented wandering behaviors on the MDS assessment. The medical record did not show a pre-restraint assessment, a physician’s order for restraint, or a resident-centered restraint care plan. During observation, Resident #5 was seated in a wheelchair in the activity room and was seen forward leaning and scooting toward the exit using feet and hip thrusts while the wheelchair brakes were locked. Nurse #1 observed the resident moving in the locked wheelchair, unlocked the brakes, moved the resident to a table, and relocked the brakes. Nurse #1 stated the brakes were locked to keep the resident safe and prevent movement out of the activity room so the resident could be watched. After the nurse returned to the medication cart, the resident again began scooting away from the table with the brakes locked. Activity Staff #1 then observed the resident at the activity room exit, unlocked the brakes, returned the resident to the table, and relocked the brakes. Activity Staff #1 stated the resident was able to move around the unit in the wheelchair and that the brakes were locked so the resident could not move too much and staff would know where the resident was. CNA #5 later stated the resident could move the wheelchair independently and that the brakes should not be locked because locking them would hold the resident back from moving. The DON also stated that if the resident was unable to unlock the wheelchair brakes, then the locked wheelchair would be considered a restraint, and the resident was unable to unlock them when asked.
Failure to Invite Resident to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that Resident #59 was invited to participate in the care plan process and failed to document any reason why the resident did not participate in the initial and quarterly care plan meetings. The resident was admitted in February 2025 with diagnoses including heart failure and COPD. The MDS assessment dated [DATE] indicated the resident was moderately cognitively impaired with a BIMS score of 11 out of 15, spoke English, and could make himself/herself understood and usually understand others. The resident told the surveyor on 3/3/26 at 10:06 A.M. that he/she had never been invited to a care plan meeting. The clinical record showed no documented evidence that the resident participated in the interdisciplinary care plan reviews held on 2/17/25, 6/12/25, 11/11/25, and 2/2/26. The record also did not include a rationale for why the resident did not or could not participate in any of the care plan meetings, and there were no refusals documented. The DON stated on 3/5/26 at 10:32 A.M. that the resident had not been invited to attend the care plan meetings and should have been invited because it was a resident's right to be invited.
Failure to Provide Foot Care and Podiatry Services
Penalty
Summary
The facility failed to provide foot care and treatment in accordance with professional standards of practice for one resident. Resident #9 was admitted with diagnoses including TIA, anoxic brain damage, and gastrostomy, and the most recent MDS indicated the resident was severely cognitively impaired, rarely or never understood, and dependent on staff for all ADLs. The facility policy stated that residents unable to carry out ADLs would receive necessary services to maintain grooming and personal hygiene. The resident also had a physician order for a podiatry consult as needed, and the resident's guardian signed consent for podiatry services shortly after admission. Despite daily foot care being documented, survey observations on 3/3/26 and 3/4/26 showed the resident's toenails were untrimmed, with the free edge of most toenails on both feet grown significantly past the nail bed. During interview, the DON stated the resident should have been seen by podiatry because consent had been obtained and the resident should have been placed on the podiatry list, but had not been seen. The DON also stated podiatry had visited the facility twice since the resident's admission, on 12/19/25 and 2/24/26, and the resident was not seen on either visit.
Dirty Oxygen Concentrator Not Maintained
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for Resident #13 by not ensuring the resident’s oxygen concentrator cabinet and filters were cleaned and maintained as required. Resident #13 was admitted in February 2022 with diagnoses including heart failure and dementia, and the current physician orders directed oxygen at 2 LPM as needed every shift for shortness of breath. The care plan also identified oxygen therapy via nasal cannula as part of the resident’s care. On 3/3/26, the surveyor observed the resident in bed receiving oxygen at 2 LPM via nasal cannula from an oxygen concentrator. The concentrator cabinet had a large area of dried white substance across the top and down the front, with copious dried brown debris on the front and sides. The left and right cabinet filters were coated in thick, fuzzy gray dust. On 3/4/26, the concentrator remained unchanged. During interview, Nurse #4 said the cabinet and filters should be cleaned and wiped down weekly when oxygen tubing is changed, but the unit did not appear to have been cleaned. The Infection Preventionist said oxygen tubing should be changed weekly and stated the dirty concentrator posed infection risk. The DON said she was not aware of a set cleaning schedule for oxygen concentrators.
Delayed Pain Medication Availability and Lack of Timely Alternative Pain Orders
Penalty
Summary
The facility failed to provide effective pain management for a resident with osteoarthritis, right hip pain, and a recent right hip fracture with total hip arthroplasty. The resident was admitted with orders for PRN oxycodone for moderate pain, scheduled acetaminophen, and pain surveillance each shift. The resident also reported chronic pain affecting sleep, daily activities, mobility, and ADLs, and the care plan directed staff to administer analgesia as ordered, anticipate pain relief needs, respond immediately to pain complaints, and notify the physician if interventions were unsuccessful. After admission, the ordered PRN oxycodone was not confirmed with the pharmacy and was not available for administration for approximately 21 hours. Nursing documentation and interviews indicated that the nurse faxed the prescription but did not receive fax confirmation and did not follow up with the pharmacy to verify receipt. The DON later confirmed the pharmacy never received the prescription. During this period, the resident complained of pain repeatedly, including groaning, crying, and calling out, while staff observed the resident in distress and refusing care because pain medication was needed. The resident received scheduled acetaminophen, but it did not relieve the pain. Although the resident declined PRN acetaminophen because it had not been effective, alternative or emergency pain management instructions were not obtained from the NP/physician in a timely manner. The nurse did not contact the on-call NP before leaving the facility, and the physician later stated staff should have called the on-call NP when the ordered pain medication was unavailable. A one-time 5 mg oxycodone dose was eventually ordered and administered from the emergency kit, and the resident’s pain improved afterward.
Failure to Use Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to adhere to infection control standards of practice for one resident by not appropriately using Enhanced Barrier Precautions during high-contact care. The resident was admitted with diagnoses including UTI, dysfunction of bladder, and urinary retention, had moderate cognitive impairment with a BIMS score of 10, had an indwelling suprapubic catheter, and had a UTI in the last 30 days. The resident’s care plan required Enhanced Barrier Precautions because of the suprapubic catheter and ESBL history, and the physician’s orders directed that EBP be maintained when providing direct care. On 3/3/26, the surveyor observed a CNA enter the resident’s room and ambulate the resident to the bathroom without wearing a PPE gown. The PPE supply bin was positioned outside the room, but no EBP signage was posted. During interview, the CNA stated the resident was on EBP for infection in the urine and that a gown should have been used when assisting the resident to the bathroom, but it was not. The CNA also stated the risk of not wearing a gown was spreading infection to the resident and other residents. On 3/4/26, another CNA was observed entering the resident’s room wearing gloves but no gown and assisting the resident to the bathroom. The CNA then left the room, did not discard gloves and/or perform hand hygiene, gathered clean towels from the hallway linen cart, and re-entered the resident’s room and bathroom without donning a gown. The resident was later observed seated on the toilet while the CNA provided ADL care without a PPE gown, and the resident’s suprapubic catheter was hanging on the handrail in the bathroom. The CNA stated she provided morning care without wearing a gown and should have used one to protect herself and the resident. The DON stated that staff providing direct care for the resident should have had PPE on including a gown and gloves.
Failure to Issue Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide notice of a change in Medicare coverage for Resident #75 by not issuing a Notice of Medicare Non-Coverage (NOMNC) when the resident had skilled days remaining, was being discharged from Medicare Part A services, and was leaving the facility immediately after the last covered skilled day. Resident #75 was admitted in June 2025 for short term rehabilitation following a fall with hip fracture, and the social service progress note indicated a discharge plan to return home. Records showed the resident’s last covered skilled day was 8/3/25, and physician, social service, and nursing progress notes documented discharge home on 8/4/25. Review of the clinical record found no evidence that a NOMNC was issued, and the Director of Clinical Operations stated during interview that the facility had no evidence that the notice was provided.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, who was assessed as being at risk for weight loss upon admission, maintained acceptable nutritional status. The resident experienced an unplanned and undesired significant weight loss, and after this weight loss was identified, no additional weight monitoring occurred for two months. The facility's policy required weights to be measured weekly for the first three weeks after admission and then monthly if no concerns were noted. However, the resident's weight was not documented for November 2024, and there was no evidence of weight monitoring or notification to the physician, dietician, or health care proxy after the significant weight loss was identified. The resident, who had diagnoses including anemia, chronic obstructive pulmonary disease, depression, and dementia, was admitted in August 2024. The resident's weight dropped from 115 pounds to 101.6 pounds over several months, representing a 12.1% weight loss in 60 days. Despite the facility's policy requiring re-weighing and notification of significant weight changes, there was no documentation of such actions being taken. Interviews with the registered dietician, assistant director of nursing, and director of nurses revealed that they were unaware of the significant weight loss, indicating a breakdown in communication and adherence to the facility's weight monitoring policy.
Undignified Dining Assistance for Resident
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident diagnosed with Multiple Sclerosis, who was moderately cognitively impaired and required substantial assistance with feeding. During a survey, it was observed that a Certified Nurses Aide (CNA) stood over the resident while assisting with a breakfast meal, contrary to the facility's policy that requires staff to be seated next to residents to ensure a dignified and homelike environment. The Nursing Supervisor confirmed that the CNA's actions were not in line with the facility's standards for resident dignity.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform three residents or their representatives in advance of changes to their care plans regarding the use of psychotropic medications. Specifically, the facility did not obtain written consent before administering these medications. Resident #5, who was cognitively intact, was given Seroquel and Zyprexa for Bipolar Disorder and Psychotic Disorder without signed consent. The Assistant Director of Nursing (ADON) acknowledged that the facility should have had a signed consent in place before administering these medications. Resident #4, who was severely cognitively impaired and had a designated Health Care Proxy (HCP), was administered Topamax for behavioral symptoms without obtaining informed written consent from the HCP. The ADON confirmed that the consent should have been reviewed and signed by the HCP before the medication was administered, but this was not done. Resident #58, who was cognitively intact and diagnosed with Major Depressive Disorder and Generalized Anxiety Disorder, was given Hydroxyzine for anxiety without a signed consent form. The ADON stated that a psychotropic medication consent form should have been completed for the administration of Hydroxyzine, but it was not. These deficiencies highlight the facility's failure to adhere to its policy on obtaining informed consent for psychotropic medications.
Inaccurate MOLST Form Execution
Penalty
Summary
The facility failed to accurately execute Advance Directives for a resident, specifically in the completion of the MOLST form. The MOLST form, which is crucial for documenting a resident's wishes regarding life-sustaining treatment, contained an incorrect name, although the date of birth and medical record number were accurate. This error was identified during a review of the resident's clinical record, which indicated that the form was signed by the resident's invoked Health Care Proxy. During an interview, a Nursing Supervisor confirmed that the name on the MOLST form was incorrect, rendering the form invalid. This inaccuracy meant that the resident's documented wishes regarding life-sustaining treatment would not be honored in the event of an emergency, either within the facility or upon transfer to another facility. The facility's policy on Massachusetts Advanced Directives emphasizes the importance of accurately documenting residents' medical decision-making wishes, which was not upheld in this instance.
Failure to Notify Physician of Treatment Change for Yeast Infection
Penalty
Summary
The facility failed to notify the Physician/Non-Physician Practitioner (NPP) of a significant change in condition for a resident, resulting in unmanaged itching and discomfort. The resident, who was cognitively intact and admitted with diagnoses including unspecified disease of the anus and rectum and diabetes mellitus, experienced consistent itching in the genital area. This discomfort was due to a yeast infection, Candida Glabrata, for which a consulting physician recommended treatment with Boric Acid. However, the facility did not report this recommendation to the resident's attending physician or obtain the necessary treatment orders. The facility's policy requires the RN Nurse Supervisor/Charge Nurse to notify the attending physician of significant changes in a resident's condition, including the need to alter medical treatment. Despite this policy, there was no documented evidence that the consulting physician's recommendation was communicated to the facility physician. Interviews with the nursing staff and administration revealed that they were unaware of the recommended treatment until the surveyor's inquiry, which led to a delay of 19 days before the medication was ordered.
Failure to Provide Supervision During Meals
Penalty
Summary
The facility failed to provide necessary supervision during mealtimes for a resident who required assistance due to severe cognitive impairment and other medical conditions. The resident, diagnosed with Alzheimer's Disease, Major Depressive Disorder, Adult Failure to Thrive, and Dysphagia, was care planned to receive continual supervision while eating. However, observations revealed that the resident was left unsupervised during breakfast on multiple occasions, despite the care plan and facility policy requiring staff presence. On one occasion, the resident was observed lying in bed with a breakfast tray set up, but no staff member was present to assist or supervise. The resident expressed difficulty in holding a milk container without assistance. Despite the care plan indicating the need for continual supervision, staff members were observed entering and exiting the room without providing the necessary oversight during the meal. Interviews with the Assistant Director of Nursing and other staff confirmed that the resident was supposed to be continually supervised during meals due to the risk associated with their medical conditions. The lack of supervision was acknowledged by the staff, indicating a failure to adhere to the care plan and facility policy, which led to the deficiency noted by the surveyors.
Incorrect Foley Catheter Size Leads to Resident Discomfort
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling urinary/Foley catheter. The deficiency involved the incorrect re-insertion of a Foley catheter following a failed voiding trial. The facility's policy required adherence to physician's orders regarding the size of the Foley catheter and balloon. However, the resident's clinical records indicated discrepancies in the catheter size, with the physician's orders specifying an 18 Fr catheter with a 10 ml balloon, while the resident had a 16 Fr catheter with a 30 ml balloon in place. The resident, who was cognitively intact and dependent on toileting, expressed discomfort with the catheter. The Assistant Director of Nursing confirmed the incorrect catheter size during an observation. The failure to verify and assess the correct catheter size as per the physician's orders led to the deficiency, as the incorrect size could potentially cause discomfort and harm to the resident.
Failure to Document Vital Signs Before Dialysis
Penalty
Summary
The facility failed to ensure that Physician's orders were correctly administered for a resident requiring dialysis care. Specifically, the facility did not assess a complete set of vital signs, including blood pressure, temperature, pulse, respiration rate, and oxygen saturation, prior to the resident's dialysis sessions on multiple occasions. This oversight was identified for a resident with end-stage renal disease who was dependent on renal dialysis, as per the Physician's orders dated September 11, 2024, which specified that vital signs should be taken before the resident departed for dialysis on designated days. The medical records for the resident showed no evidence of the required vital signs being assessed on several dialysis treatment days, and there was no documentation in the progress notes explaining why the vital signs were not completed. Interviews with the Assistant Director of Nursing and a nurse revealed that the vital signs should have been documented as ordered, and if they were not obtained, a progress note should have been written to address the omission. The failure to document vital signs as ordered put the resident at risk for dialysis-related complications.
Failure to Follow Safe Food Handling Practices
Penalty
Summary
The facility failed to adhere to safe and sanitary food service practices, which are essential to prevent foodborne illnesses. During a meal service observation, a Certified Nurses Aide (CNA) was seen mishandling a domed lid that had fallen onto the floor. The CNA picked up the contaminated lid and placed it back over a meal plate, which was then served to a resident. This action was contrary to the facility's policy, which mandates that all employees demonstrate competency in preventing foodborne illnesses through safe food handling practices. The resident involved in this incident was admitted to the facility with a diagnosis of Cerebral Vascular Accident (CVA) and was noted to be severely cognitively impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of seven out of 15. The incident was observed by a surveyor, and a nurse present at the time acknowledged that the CNA's actions were inappropriate. The nurse subsequently removed the contaminated meal tray from the resident's access.
Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility failed to adhere to infection control standards for two residents, leading to deficiencies in their care. For one resident with a Stage 4 pressure ulcer, the facility did not follow the physician's orders for Enhanced Barrier Precautions (EBP), which required the use of gowns and gloves during high-contact care activities. During an observation, a nurse and the nursing supervisor entered the resident's room and provided wound care without donning gowns, despite the availability of gowns and gloves at the entrance. This oversight was acknowledged by the staff during interviews, where they admitted forgetting to wear gowns, which were necessary to prevent infection transmission. Another resident, diagnosed with Methicillin Resistant Staphylococcus Aureus (MRSA) infection of wounds, also experienced a lapse in infection control practices. During wound care treatment, a nurse failed to perform hand hygiene between glove changes and did not disinfect the treatment cart before removing it from the resident's room. The nurse admitted to not washing or sanitizing hands before donning and doffing gloves and acknowledged the need to disinfect the treatment cart, which was not done. These deficiencies highlight the facility's failure to implement proper infection prevention measures as per their policies and physician orders. The lack of adherence to EBP and hand hygiene protocols during wound care increased the risk of infection transmission among residents, as observed and confirmed through staff interviews.
Inaccurate MDS Coding for Dialysis Treatment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessment was coded accurately for a resident with end-stage renal disease (ESRD). The resident, who was admitted in September 2024, had physician orders for dialysis on Tuesdays, Thursdays, and Saturdays. Despite receiving dialysis treatments consistently from September through early November 2024, the resident's most recent MDS assessment incorrectly indicated that the resident was not receiving dialysis. The MDS Director acknowledged during interviews that the assessment completed on September 30, 2024, was coded incorrectly and should have reflected the resident's dialysis treatment. The facility did not have a specific policy for MDS completion, relying instead on the Resident Assessment Instrument (RAI) manual for guidance. This oversight in accurately coding the MDS assessment led to the deficiency identified by the surveyors.
Failure to Ensure Safe and Orderly Resident Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who was scheduled to be transferred to an Assisted Living Facility (ALF) with Hospice services. Despite the family's clear communication of their intention to have the resident discharged by Mother's Day, the facility was not prepared for the discharge on the anticipated date. The necessary medical information, including the physician's orders and medication list, was not sent to or communicated with the receiving ALF, which was essential for meeting the resident's medical and personal care needs. Interviews revealed that the facility's protocol for unplanned discharges was not followed. The Hospice Social Worker had informed the facility about the discharge plans, and an ambulance was scheduled to transport the resident. However, the Unit Manager admitted that the discharge paperwork was not faxed to the ALF, and the Director of Nursing confirmed that the protocol to send at least a face sheet and medication list was not adhered to. The receiving ALF confirmed that no discharge paperwork or communication was received on the day of the resident's arrival.
Failure to Document Resident Discharge
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who had a physician's order for discharge to an Assisted Living Facility with Hospice Services. The facility's policy on Charting and Documentation requires that all services provided, progress toward care plan goals, and changes in the resident's condition be documented in the medical record. Additionally, the Discharge Planning Process policy mandates that the evaluation of discharge needs and plans be documented in a timely manner. However, for this resident, there was no documentation in the Nurse Progress Notes or a discharge summary completed by the provider to support the discharge. The resident, admitted in April 2024, had diagnoses including a left femur fracture, status post hemiarthroplasty, and urinary retention. Despite the physician's order for discharge on 5/12/24, the medical record lacked documentation of the discharge process. During an interview, the Director of Nurses expressed that it was expected for nursing staff to document a resident's discharge to another facility, which was not done in this case. The absence of documentation was confirmed when facility staff were unable to locate a discharge summary upon request.
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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 Sudbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Knoll Rehabilitation And Healthcare Center | 2.2 mi | ★★★★★ | 2 | 0 |
| Sudbury Pines Extended Care | 2.3 mi | ★★★★★ | 0 | 0 |
| Royal Wayland Rehabilitation And Nursing Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Campion Health & Wellness, Inc | 4 mi | ★★★★★ | 0 | 0 |
| St Patrick's Manor | 4.2 mi | ★★★★★ | 0 | 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.