A list of the most recent deficiencies for Bear Mountain at Sudbury. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-02 | 2023-12-18 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-11-02 | 2023-12-18 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-11-02 | 2023-12-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-02 | 2023-12-18 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-11-02 | 2023-12-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-02 | 2023-12-18 | 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 | 2023-11-02 | 2023-12-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-02 | 2023-12-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-11-02 | 2023-12-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-02 | 2023-12-18 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-11-02 | 2023-12-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-02 | 2023-12-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-02 | 2023-12-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-02 | 2023-12-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-02 | 2023-12-18 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-11-02 | 2023-12-18 | 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 | 2023-11-02 | 2023-12-18 | 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 | 2023-11-02 | 2023-12-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-02 | 2023-12-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-02 | 2023-12-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-14 | 2023-12-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-14 | 2023-12-06 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-08-09 | 2023-08-31 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-13 | 2023-07-17 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-06-13 | 2023-07-17 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-04-14 | 2022-05-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-14 | 2022-05-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-14 | 2022-05-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-14 | 2022-05-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-14 | 2022-05-20 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-04-14 | 2022-05-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-14 | 2022-05-20 | 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 | 2022-04-14 | 2022-05-20 | 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 | 2022-04-14 | 2022-05-20 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-04-14 | 2022-05-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-14 | 2022-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-14 | 2022-05-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-30 | 2022-05-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-30 | 2022-05-20 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-20 | 2022-05-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-20 | 2022-05-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-04-20 | 2022-05-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-20 | 2022-05-06 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-09-11 | 2019-10-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-09-11 | 2019-10-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-11 | 2019-10-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-11 | 2019-10-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-11 | 2019-10-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-11 | 2019-10-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-11 | 2019-10-26 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-09-11 | 2019-10-26 | 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 | 2019-09-11 | 2019-10-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-11 | 2019-10-26 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-09-11 | 2019-10-26 | N |
