Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bear Mountain At Sudbury during CMS and state inspections, most recent first.
A resident experienced significant weight loss, dropping from 115 to 101.6 pounds, without proper monitoring or notification to the physician, dietician, or health care proxy. Despite being at risk for weight loss, the facility failed to adhere to its weight monitoring policy, resulting in a lack of timely intervention. Staff interviews revealed unawareness of the resident's condition, highlighting a communication breakdown.
A resident with Multiple Sclerosis, requiring substantial assistance with feeding, was observed being assisted by a CNA who stood over them during a meal, contrary to the facility's policy for dignified dining. The Nursing Supervisor acknowledged that the CNA should have been seated to maintain a homelike and dignified environment.
The facility failed to obtain informed consent for psychotropic medications for three residents. A resident with Bipolar Disorder was given Seroquel and Zyprexa without consent. Another resident with severe cognitive impairment received Topamax for behaviors without the Health Care Proxy's consent. A third resident with anxiety was administered Hydroxyzine without a signed consent form. The ADON acknowledged these oversights.
A facility failed to accurately execute a MOLST form for a resident, as the form contained an incorrect name despite having the correct date of birth and medical record number. This error was confirmed by a Nursing Supervisor, who stated that the form was invalid, risking the resident's life-sustaining treatment wishes not being honored in an emergency.
A resident with a yeast infection experienced unmanaged itching due to the facility's failure to notify the physician of a recommended treatment change. Despite a consulting physician's recommendation for Boric Acid, the facility did not communicate this to the attending physician, delaying treatment by 19 days.
A resident with severe cognitive impairment and dysphagia was left unsupervised during meals, contrary to their care plan requiring continual supervision. Despite the facility's policy, staff failed to provide necessary oversight, leading to a deficiency noted by surveyors.
A resident in an LTC facility experienced discomfort due to the incorrect re-insertion of a Foley catheter following a failed voiding trial. The facility's policy required adherence to physician's orders for catheter size, but discrepancies were found in the clinical records. The resident had a 16 Fr catheter with a 30 ml balloon instead of the ordered 18 Fr catheter with a 10 ml balloon. The ADON confirmed the error, which led to the deficiency.
A facility failed to document a complete set of vital signs for a resident with end-stage renal disease before dialysis sessions, as ordered by the Physician. The resident's medical records lacked evidence of vital signs assessment on several treatment days, and no progress notes explained the omission. Interviews with staff confirmed the importance of documenting vital signs to ensure the resident's medical stability.
A CNA in a LTC facility failed to follow safe food handling practices by placing a contaminated domed lid over a meal plate and serving it to a resident. The resident, who was severely cognitively impaired due to a CVA, was exposed to potential foodborne illness. A nurse acknowledged the error and removed the meal tray.
The facility failed to follow infection control standards for two residents, leading to deficiencies in care. One resident with a Stage 4 pressure ulcer did not receive Enhanced Barrier Precautions (EBP) as required, as staff did not wear gowns during wound care. Another resident with MRSA infection experienced lapses in hand hygiene and equipment disinfection during treatment. These actions increased the risk of infection transmission, as confirmed by staff interviews.
A resident with end-stage renal disease was receiving dialysis treatments as ordered, but the facility failed to accurately code this in the MDS assessment. The MDS Director admitted the error, noting the absence of a specific policy for MDS completion, relying on the RAI manual instead.
A resident was discharged to an ALF without necessary medical information, including physician's orders and medication list, due to the facility's failure to follow discharge protocols. Despite prior communication about the discharge plans, the facility did not send or communicate the required documents, leading to an unplanned and unsafe discharge.
A facility failed to document the discharge of a resident with a physician's order for transfer to an Assisted Living Facility with Hospice Services. Despite policies requiring documentation of services, progress, and discharge plans, the resident's medical record lacked necessary discharge documentation. The Director of Nurses acknowledged the expectation for nursing staff to document such discharges, which was not met in this instance.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, who was assessed as being at risk for weight loss upon admission, maintained acceptable nutritional status. The resident experienced an unplanned and undesired significant weight loss, and after this weight loss was identified, no additional weight monitoring occurred for two months. The facility's policy required weights to be measured weekly for the first three weeks after admission and then monthly if no concerns were noted. However, the resident's weight was not documented for November 2024, and there was no evidence of weight monitoring or notification to the physician, dietician, or health care proxy after the significant weight loss was identified. The resident, who had diagnoses including anemia, chronic obstructive pulmonary disease, depression, and dementia, was admitted in August 2024. The resident's weight dropped from 115 pounds to 101.6 pounds over several months, representing a 12.1% weight loss in 60 days. Despite the facility's policy requiring re-weighing and notification of significant weight changes, there was no documentation of such actions being taken. Interviews with the registered dietician, assistant director of nursing, and director of nurses revealed that they were unaware of the significant weight loss, indicating a breakdown in communication and adherence to the facility's weight monitoring policy.
Undignified Dining Assistance for Resident
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident diagnosed with Multiple Sclerosis, who was moderately cognitively impaired and required substantial assistance with feeding. During a survey, it was observed that a Certified Nurses Aide (CNA) stood over the resident while assisting with a breakfast meal, contrary to the facility's policy that requires staff to be seated next to residents to ensure a dignified and homelike environment. The Nursing Supervisor confirmed that the CNA's actions were not in line with the facility's standards for resident dignity.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform three residents or their representatives in advance of changes to their care plans regarding the use of psychotropic medications. Specifically, the facility did not obtain written consent before administering these medications. Resident #5, who was cognitively intact, was given Seroquel and Zyprexa for Bipolar Disorder and Psychotic Disorder without signed consent. The Assistant Director of Nursing (ADON) acknowledged that the facility should have had a signed consent in place before administering these medications. Resident #4, who was severely cognitively impaired and had a designated Health Care Proxy (HCP), was administered Topamax for behavioral symptoms without obtaining informed written consent from the HCP. The ADON confirmed that the consent should have been reviewed and signed by the HCP before the medication was administered, but this was not done. Resident #58, who was cognitively intact and diagnosed with Major Depressive Disorder and Generalized Anxiety Disorder, was given Hydroxyzine for anxiety without a signed consent form. The ADON stated that a psychotropic medication consent form should have been completed for the administration of Hydroxyzine, but it was not. These deficiencies highlight the facility's failure to adhere to its policy on obtaining informed consent for psychotropic medications.
Inaccurate MOLST Form Execution
Penalty
Summary
The facility failed to accurately execute Advance Directives for a resident, specifically in the completion of the MOLST form. The MOLST form, which is crucial for documenting a resident's wishes regarding life-sustaining treatment, contained an incorrect name, although the date of birth and medical record number were accurate. This error was identified during a review of the resident's clinical record, which indicated that the form was signed by the resident's invoked Health Care Proxy. During an interview, a Nursing Supervisor confirmed that the name on the MOLST form was incorrect, rendering the form invalid. This inaccuracy meant that the resident's documented wishes regarding life-sustaining treatment would not be honored in the event of an emergency, either within the facility or upon transfer to another facility. The facility's policy on Massachusetts Advanced Directives emphasizes the importance of accurately documenting residents' medical decision-making wishes, which was not upheld in this instance.
Failure to Notify Physician of Treatment Change for Yeast Infection
Penalty
Summary
The facility failed to notify the Physician/Non-Physician Practitioner (NPP) of a significant change in condition for a resident, resulting in unmanaged itching and discomfort. The resident, who was cognitively intact and admitted with diagnoses including unspecified disease of the anus and rectum and diabetes mellitus, experienced consistent itching in the genital area. This discomfort was due to a yeast infection, Candida Glabrata, for which a consulting physician recommended treatment with Boric Acid. However, the facility did not report this recommendation to the resident's attending physician or obtain the necessary treatment orders. The facility's policy requires the RN Nurse Supervisor/Charge Nurse to notify the attending physician of significant changes in a resident's condition, including the need to alter medical treatment. Despite this policy, there was no documented evidence that the consulting physician's recommendation was communicated to the facility physician. Interviews with the nursing staff and administration revealed that they were unaware of the recommended treatment until the surveyor's inquiry, which led to a delay of 19 days before the medication was ordered.
Failure to Provide Supervision During Meals
Penalty
Summary
The facility failed to provide necessary supervision during mealtimes for a resident who required assistance due to severe cognitive impairment and other medical conditions. The resident, diagnosed with Alzheimer's Disease, Major Depressive Disorder, Adult Failure to Thrive, and Dysphagia, was care planned to receive continual supervision while eating. However, observations revealed that the resident was left unsupervised during breakfast on multiple occasions, despite the care plan and facility policy requiring staff presence. On one occasion, the resident was observed lying in bed with a breakfast tray set up, but no staff member was present to assist or supervise. The resident expressed difficulty in holding a milk container without assistance. Despite the care plan indicating the need for continual supervision, staff members were observed entering and exiting the room without providing the necessary oversight during the meal. Interviews with the Assistant Director of Nursing and other staff confirmed that the resident was supposed to be continually supervised during meals due to the risk associated with their medical conditions. The lack of supervision was acknowledged by the staff, indicating a failure to adhere to the care plan and facility policy, which led to the deficiency noted by the surveyors.
Incorrect Foley Catheter Size Leads to Resident Discomfort
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling urinary/Foley catheter. The deficiency involved the incorrect re-insertion of a Foley catheter following a failed voiding trial. The facility's policy required adherence to physician's orders regarding the size of the Foley catheter and balloon. However, the resident's clinical records indicated discrepancies in the catheter size, with the physician's orders specifying an 18 Fr catheter with a 10 ml balloon, while the resident had a 16 Fr catheter with a 30 ml balloon in place. The resident, who was cognitively intact and dependent on toileting, expressed discomfort with the catheter. The Assistant Director of Nursing confirmed the incorrect catheter size during an observation. The failure to verify and assess the correct catheter size as per the physician's orders led to the deficiency, as the incorrect size could potentially cause discomfort and harm to the resident.
Failure to Document Vital Signs Before Dialysis
Penalty
Summary
The facility failed to ensure that Physician's orders were correctly administered for a resident requiring dialysis care. Specifically, the facility did not assess a complete set of vital signs, including blood pressure, temperature, pulse, respiration rate, and oxygen saturation, prior to the resident's dialysis sessions on multiple occasions. This oversight was identified for a resident with end-stage renal disease who was dependent on renal dialysis, as per the Physician's orders dated September 11, 2024, which specified that vital signs should be taken before the resident departed for dialysis on designated days. The medical records for the resident showed no evidence of the required vital signs being assessed on several dialysis treatment days, and there was no documentation in the progress notes explaining why the vital signs were not completed. Interviews with the Assistant Director of Nursing and a nurse revealed that the vital signs should have been documented as ordered, and if they were not obtained, a progress note should have been written to address the omission. The failure to document vital signs as ordered put the resident at risk for dialysis-related complications.
Failure to Follow Safe Food Handling Practices
Penalty
Summary
The facility failed to adhere to safe and sanitary food service practices, which are essential to prevent foodborne illnesses. During a meal service observation, a Certified Nurses Aide (CNA) was seen mishandling a domed lid that had fallen onto the floor. The CNA picked up the contaminated lid and placed it back over a meal plate, which was then served to a resident. This action was contrary to the facility's policy, which mandates that all employees demonstrate competency in preventing foodborne illnesses through safe food handling practices. The resident involved in this incident was admitted to the facility with a diagnosis of Cerebral Vascular Accident (CVA) and was noted to be severely cognitively impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of seven out of 15. The incident was observed by a surveyor, and a nurse present at the time acknowledged that the CNA's actions were inappropriate. The nurse subsequently removed the contaminated meal tray from the resident's access.
Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility failed to adhere to infection control standards for two residents, leading to deficiencies in their care. For one resident with a Stage 4 pressure ulcer, the facility did not follow the physician's orders for Enhanced Barrier Precautions (EBP), which required the use of gowns and gloves during high-contact care activities. During an observation, a nurse and the nursing supervisor entered the resident's room and provided wound care without donning gowns, despite the availability of gowns and gloves at the entrance. This oversight was acknowledged by the staff during interviews, where they admitted forgetting to wear gowns, which were necessary to prevent infection transmission. Another resident, diagnosed with Methicillin Resistant Staphylococcus Aureus (MRSA) infection of wounds, also experienced a lapse in infection control practices. During wound care treatment, a nurse failed to perform hand hygiene between glove changes and did not disinfect the treatment cart before removing it from the resident's room. The nurse admitted to not washing or sanitizing hands before donning and doffing gloves and acknowledged the need to disinfect the treatment cart, which was not done. These deficiencies highlight the facility's failure to implement proper infection prevention measures as per their policies and physician orders. The lack of adherence to EBP and hand hygiene protocols during wound care increased the risk of infection transmission among residents, as observed and confirmed through staff interviews.
Inaccurate MDS Coding for Dialysis Treatment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessment was coded accurately for a resident with end-stage renal disease (ESRD). The resident, who was admitted in September 2024, had physician orders for dialysis on Tuesdays, Thursdays, and Saturdays. Despite receiving dialysis treatments consistently from September through early November 2024, the resident's most recent MDS assessment incorrectly indicated that the resident was not receiving dialysis. The MDS Director acknowledged during interviews that the assessment completed on September 30, 2024, was coded incorrectly and should have reflected the resident's dialysis treatment. The facility did not have a specific policy for MDS completion, relying instead on the Resident Assessment Instrument (RAI) manual for guidance. This oversight in accurately coding the MDS assessment led to the deficiency identified by the surveyors.
Failure to Ensure Safe and Orderly Resident Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who was scheduled to be transferred to an Assisted Living Facility (ALF) with Hospice services. Despite the family's clear communication of their intention to have the resident discharged by Mother's Day, the facility was not prepared for the discharge on the anticipated date. The necessary medical information, including the physician's orders and medication list, was not sent to or communicated with the receiving ALF, which was essential for meeting the resident's medical and personal care needs. Interviews revealed that the facility's protocol for unplanned discharges was not followed. The Hospice Social Worker had informed the facility about the discharge plans, and an ambulance was scheduled to transport the resident. However, the Unit Manager admitted that the discharge paperwork was not faxed to the ALF, and the Director of Nursing confirmed that the protocol to send at least a face sheet and medication list was not adhered to. The receiving ALF confirmed that no discharge paperwork or communication was received on the day of the resident's arrival.
Failure to Document Resident Discharge
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who had a physician's order for discharge to an Assisted Living Facility with Hospice Services. The facility's policy on Charting and Documentation requires that all services provided, progress toward care plan goals, and changes in the resident's condition be documented in the medical record. Additionally, the Discharge Planning Process policy mandates that the evaluation of discharge needs and plans be documented in a timely manner. However, for this resident, there was no documentation in the Nurse Progress Notes or a discharge summary completed by the provider to support the discharge. The resident, admitted in April 2024, had diagnoses including a left femur fracture, status post hemiarthroplasty, and urinary retention. Despite the physician's order for discharge on 5/12/24, the medical record lacked documentation of the discharge process. During an interview, the Director of Nurses expressed that it was expected for nursing staff to document a resident's discharge to another facility, which was not done in this case. The absence of documentation was confirmed when facility staff were unable to locate a discharge summary upon request.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 838 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sudbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Knoll Rehabilitation And Healthcare Center | 2.2 mi | — | 2 | 0 |
| Sudbury Pines Extended Care | 2.3 mi | — | 0 | 0 |
| Royal Wayland Rehabilitation And Nursing Center | 3.5 mi | — | 0 | 0 |
| Campion Health & Wellness, Inc | 4 mi | — | 0 | 0 |
| St Patrick's Manor | 4.2 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bear Mountain At Sudbury.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.