Sudbury Pines Extended Care

In the surveyor’s words

From the most serious findings on record at Sudbury Pines Extended Care, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF838Mar 6, 2025

  Based 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. Findings include: Review of the Facility Assessment, dated 1/9/25, indicated the following: - Religious, ethnic, or cultural factors that affect the delivery of care and services, such as: Facility Answer: -Food and Nutrition requirements: many modified diets for dysphagia, puree or moist ground with thickened liquids. -Activities: no significant factors identified. -Language translation requirements: One resident speaks Creole understands simple English and this resident has expressive aphasia in both English and primary language. […]

• No harm, potential for more than minimal, patternF812Apr 22, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF550Mar 6, 2025

  Based 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. Findings include: Review of the facility policy titled Dignity, dated August 2009, indicated Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. […]

• No harm, potential for more than minimal, patternF584Mar 6, 2025

  Based 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. Findings include: Review of the facility policy titled Homelike Environment, dated 3/5/25, indicated To create a more homelike safe environment that offers our residents greater dignity and autonomy, ensuring resident's preferences, needs and values guide decisions and care. On 3/4/25 at 8:09 A.M., the surveyor observed Station 2's dining room, all residents were served their meals on meal trays and staff did not remove the meal trays. […]

• No harm, potential for more than minimal, patternF604Mar 6, 2025

  Based 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. Findings include: Review of the facility policy titled Use of Restraints, dated April 2017, indicated 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. […]