All citations for Sudbury Pines Extended Care

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Sudbury Pines Extended Care

Last standard health inspection on record

April 22, 2026

Showing 1 to 25 of 37 citations

  1. No harm, with potential for more than minimal harm

    Install emergency lighting that can last at least 1 1/2 hours.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0291, Egress Deficiencies. Inspection of April 22, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 4, 2026).

  2. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of April 22, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 4, 2026).

  3. No harm, with potential for more than minimal harm

    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

    Widespread (many residents). CMS level F.

    Health citation F-0838, Administration Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  4. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of April 22, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 6, 2026).

  5. No harm, with potential for more than minimal harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0550, Resident Rights Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  6. No harm, with potential for more than minimal harm

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  7. No harm, with potential for more than minimal harm

    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0604, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  8. No harm, with potential for more than minimal harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  9. No harm, with potential for more than minimal harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  10. No harm, with potential for more than minimal harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  11. No harm, with potential for more than minimal harm

    Provide safe and appropriate respiratory care for a resident when needed.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0695, Quality of Life and Care Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  12. No harm, with potential for more than minimal harm

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0744, Quality of Life and Care Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  13. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  14. No harm, with potential for more than minimal harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0550, Resident Rights Deficiencies. Inspection of April 22, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 6, 2026).

  15. No harm, with potential for more than minimal harm

    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0605, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of April 22, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 6, 2026).

  16. No harm, with potential for more than minimal harm

    Post nurse staffing information every day.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0732, Nursing and Physician Services Deficiencies. Inspection of April 22, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 6, 2026).

  17. No harm, with potential for more than minimal harm

    Ensure that residents are free from significant medication errors.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0760, Pharmacy Service Deficiencies. Inspection of April 22, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 6, 2026).

  18. No harm, with potential for more than minimal harm

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0607, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of June 10, 2025. Found during a complaint inspection.

    The home has a plan to correct it (July 18, 2025).

  19. No harm, with potential for more than minimal harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0580, Resident Rights Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  20. No harm, with potential for more than minimal harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0609, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  21. No harm, with potential for more than minimal harm

    Respond appropriately to all alleged violations.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0610, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  22. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  23. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  24. No harm, with potential for more than minimal harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

  25. No harm, with potential for more than minimal harm

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0690, Quality of Life and Care Deficiencies. Inspection of March 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2025).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.