Sudbury Pines Extended Care

Inspectors wroteBased on observation, and interview, the facility failed to adhere to professional standards of practice for food safety and sanitation to prevent contamination and the spread of foodborne illness to residents. Specifically, the facility failed to discard spoiled food and food that was past the use by date, failed to label and date prepared food and opened food packaging, and also failed to ensure dietary staff were wearing hair restraints in the main kitchen while preparing food.the facility failed to discard food that was past the use by date and failed to maintain the Station 2 nourishment kitchenette in a clean and sanitary manner.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that two Residents (#5 and #49) out of a total sample of 18 residents, were treated in a dignified manner by Certified Nurse Aides (CNA #2 and #1) who were providing assistance with meals. Specifically, the facility failed to:for Resident #5, provide a dignified dining experience when CNA #2 remained standing over the Resident at his/her bedside while assisting the Resident with his/her breakfast meal.for Resident #49, provide a dignified dining experience to the Resident, when CNA #1 remained standing while providing assistance with the breakfast meal at the Resident's bedside.

Inspectors wroteBased on record review and interview, the facility failed to ensure that one Resident (#3) of five applicable residents sampled for unnecessary medications, out of a total sample of 18 residents, was free from unnecessary psychotropic (any drug that affects behavior, mood, thoughts or perception) medications. Specifically, for Resident #3, the facility failed to ensure that laboratory monitoring was completed as ordered by the Physician for Clozaril (Clozapine: an antipsychotic medication used to treat severe Schizophrenia) medication use and levels, placing the Resident at risk of Clozaril toxicity and medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post daily required nurse staffing information as required. Specifically, the facility failed to:-post the actual hours worked by licensed and unlicensed nursing staff (Registered Nurses [RN], Licensed Practical Nurses [LPN] or Licensed Vocational Nurses [LVN], and Certified Nurses' Aides [CNA]) directly responsible for providing resident care per shift.-maintain a copy of the facility staffing records for 18 months.-post the staffing information in an area easily assessable to residents, staff, visitors.

Inspectors wroteBased on observation, interview, and record review the facility failed to adhere to professional standards of practice for medication administration and ensure that significant medication errors did not occur for one Resident (#54) of four applicable residents for medication administration, out of a total sample of 18 residents. Specifically, for Resident #54, the facility failed to ensure that a Myrbetriq Extended Release Medication (used to treat overactive bladder) was not crushed per the manufacturing and pharmacy instructions on the medication label prior to the Nurse administering the medication to the Resident, when crushing the Myrbetriq Extended Release Medication would increase the likelihood of destroying the extended-release mechanism, causing the entire dose to be released at once (dose dumping), placing the Resident at risk of serious medical side effects.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy when 1) on 5/07/25 Certified Nurse Aide (CNA ) was witnessed by a staff member to slap Resident #1 on the arm and 2) approximately on month prior CNA #1 had been witnessed by another staff member to slap Resident #1 on the arm, however neither staff member reported the alleged incident of abuse immediately as require, therefore placing Resident #1 and other residents at risk for abuse.

Inspectors wroteBased on documentation review and staff interview, the Facility staff failed to comprehensively assess the facility resources needed to provide sufficient support and care for the resident population as outlined in the Facility Assessment.

Inspectors wroteBased on interviews, observations, and policy review, the facility failed to ensure staff treated residents in a dignified manner. Specifically, 1. On the Station 1 and Station 2 Units, the facility failed to provide a dignified dining experience. 2. For Resident #60, the facility failed to ensure staff consistently covered his/her catheter drainage bag.

Inspectors wroteBased on observations and interviews, the facility failed to provide a homelike environment during dining on two of two nursing units. Specifically, on the Station 1 and Station 2 Units, residents were observed eating meals on meal trays in the dining rooms.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accurately assess the use of an alarmed velcro seat belt as a potential restraint for one Resident (#18) out of a total sample of 26 residents.

Inspectors wroteBased 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.

Inspectors wrote4. 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wrote3. 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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). [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote3. 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide an accurate estimated cost of services to residents or their representatives, for two out of two resident records reviewed, to ensure they were informed of their potential financial liabilities of the cost of items and services provided.

Inspectors wroteBased on observation, record review, and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for two Residents (#41 and #60), out of 26 sampled residents. Specifically, 1. For Resident #41, the facility failed to ensure the MDS assessment was accurately coded for upper extremity range of motion (ROM, section GG). 2. For Resident #60, the facility failed to ensure the MDS assessment was accurately coded for cognition (section C).

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete Minimum Data Set (MDS) Assessments for two active Residents (#36 and #3) out of a total sample of 18 active Residents reviewed, and one discharged Resident (#86) out of a total sample of one discharged resident reviewed. Specifically, the facility staff failed to accurately code the MDS Assessment: 1. For Resident #36, relative to the use of Insulin (medication used to control one's blood sugar) injections (administering medication into one's body using a needle). 2. For Resident #3, relative to a skin condition and the use of pain medication for treatment. 3. For Resident #86, relative to discharge status.