Cycle 1
Health 2024-11-05 · Fire 2024-11-05
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Sudbury, MA
Bear Mountain At Sudbury
2-star overall rating with 2-star inspections with $15,672 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
136 Boston Post Road, Sudbury, MA
(978) 443-2722
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
142
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bear Mountain Healthcare
Operator or chain grouping
Approved since
1996-07-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.71
Registered nurse staffing
LPN hours / resident day
0.82
Licensed practical nurse staffing
Aide hours / resident day
2.20
Nurse aide staffing
Weekend hours
3.50
Weekend nurse staffing
RN turnover
63%
Annual RN turnover
Total nurse turnover
38%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.9
0.9 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.5
0.1 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
92.2%
1.2 pts worse
|
93.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.8% |
94.8%
5 pts worse
|
95.5%
5.7 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.5%
1.2 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 10.1% |
12.0%
1.9 pts better
|
11.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.0% |
5.2%
1.8 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.6% |
19.2%
11.4 pts worse
|
19.6%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 26.0% |
22.5%
3.5 pts worse
|
16.7%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.9% |
17.7%
1.8 pts better
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.0% |
17.6%
0.4 pts worse
|
14.9%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.0%
0.1 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
2.0%
1.7 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.0% |
21.7%
1.3 pts worse
|
19.8%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
4.6%
1.4 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.1% |
77.1%
2 pts better
|
81.7%
2.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
11.8%
0.2 pts worse
|
12.0%
About the same
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 71.8% |
77.7%
5.9 pts worse
|
79.7%
7.9 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 42.8% |
25.8%
17 pts worse
|
23.9%
18.9 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-02 · Fire 2023-11-02
23 health deficiencies
Top issue: Resident Rights (7 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-04-14 · Fire 2022-04-14
15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-11-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-03
F · Potential for more than minimal harm
2023-11-02
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-08
F · Potential for more than minimal harm
2023-11-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-06
F · Potential for more than minimal harm
2022-04-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-05-06
F · Potential for more than minimal harm
2022-04-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-19
F · Potential for more than minimal harm
2022-04-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-05-19
F · Potential for more than minimal harm
2022-04-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-18
D · Potential for more than minimal harm
2024-11-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-05
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-05
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-19
B · Minimal harm
2024-11-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-06-18
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-07-26
G · Actual harm
2023-11-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-18
E · Potential for more than minimal harm
2023-11-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-02
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-02
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-02
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-02
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-02
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-02
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-02
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-02
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-02
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-18
B · Minimal harm
2023-11-02
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-12-18
B · Minimal harm
2023-11-02
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2023-12-18
B · Minimal harm
2023-11-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-08-09
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-06-13
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-06-13
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-07-17
F · Potential for more than minimal harm
2022-04-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-05-20
F · Potential for more than minimal harm
2022-04-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-20
E · Potential for more than minimal harm
2022-04-14
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-14
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-14
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-14
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-14
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-05-20
Penalties and ownership
What sits behind the stars
$15,672
2023-11-02
Fine
Fine · fine $15,672
Fine
Ownership
Bear Mountain Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Divver, James
W-2 Managing Employee · Individual
Doyle, Thomas
5% Or Greater Direct Ownership Interest · Individual
Doyle, Thomas
Corporate Officer · Individual
Wynne, John
5% Or Greater Direct Ownership Interest · Individual
Wynne, John
Corporate Officer · Individual
Ziskin, Scott
5% Or Greater Direct Ownership Interest · Individual
Ziskin, Scott
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Oak Knoll Rehabilitation And Healthcare Center
Framingham, MA
1-star overall rating with 1-star inspections with $211,819 in total fines with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Sudbury Pines Extended Care
Sudbury, MA
2-star overall rating with 2-star inspections with 24 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Royal Wayland Rehabilitation And Nursing Center
Wayland, MA
5-star overall rating with 5-star inspections with $10,725 in total fines
Jump out