A list of the most recent deficiencies for Sudbury Pines Extended Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Establish policies and procedures including evacuation. | Fire Safety | 2022-09-21 | 2022-11-05 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-09-21 | 2022-11-05 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-09-21 | 2022-11-05 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-09-21 | 2022-11-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-21 | 2022-11-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-21 | 2022-11-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-21 | 2022-11-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-21 | 2022-11-05 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2022-09-21 | 2022-11-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-21 | 2022-11-05 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-09-21 | 2022-11-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-21 | 2022-11-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-13 | 2022-11-04 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-09-13 | 2022-11-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-13 | 2022-11-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-13 | 2022-11-04 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-09-13 | 2022-11-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-13 | 2022-11-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-13 | 2022-11-04 | N |
| Provide appropriate foot care. | Health | 2022-09-13 | 2022-11-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-09-13 | 2022-11-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-13 | 2022-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-13 | 2022-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-12 | 2022-08-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-29 | 2021-10-30 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-01-24 | 2020-03-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-24 | 2020-03-09 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2020-01-24 | 2020-03-09 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2020-01-24 | 2020-03-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-01-24 | 2020-03-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-24 | 2020-03-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-28 | 2019-03-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-28 | 2019-03-14 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-01-15 | 2019-03-01 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-01-15 | 2019-03-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-01-15 | 2019-03-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-01-15 | 2019-03-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-01-15 | 2019-03-01 | N |
| Provide activities to meet all resident's needs. | Health | 2019-01-15 | 2019-03-01 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-01-15 | 2019-03-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-01-15 | 2019-03-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-15 | 2019-03-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-01-15 | 2019-03-01 | N |
| Provide or obtain dental services for each resident. | Health | 2019-01-15 | 2019-03-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-15 | 2019-03-01 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-01-15 | 2019-03-01 | N |
