Cycle 1
Health 2025-03-06 · Fire 2025-03-06
24 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Sudbury, MA
Sudbury Pines Extended Care
2-star overall rating with 2-star inspections with 24 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
642 Boston Post Road, Sudbury, MA
(978) 443-9000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
92
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-01-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.48
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
4.08
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,329
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.13
Performance 20.91% · Measure score 1.13 · Achievement 1.13 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.47
Performance 7.09% · Measure score 2.47 · Achievement 2.47 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Baseline 92.73% · Performance 93.75% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.28
Baseline 4.04 hours · Performance 4.01 hours · Measure score 3.28 · Achievement 3.28 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.66% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 10.87% · Lower 95% interval 7.26% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 88% |
95.27%
7.3 pts worse
|
Numerator 22 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 25 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.1% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 28 · Observed rate 7.14% · Lower 95% interval 4.05% |
| Staff COVID-19 vaccination coverage | 18.28% |
8.2%
10.1 pts better
|
Numerator 17 · Denominator 93 |
| Staff flu vaccination coverage | 59.18% |
42%
17.2 pts better
|
Numerator 58 · Denominator 98 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.9
1 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
92.2%
5.7 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 98.8% · Q3 97.7% · Q4 96.6% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.5% |
94.8%
0.7 pts better
|
95.5%
About the same
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.5%
2 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.2% · Q3 1.2% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.6% |
12.0%
7.4 pts better
|
11.4%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 8.6% · Q3 5.3% · Q4 1.2% · 4Q avg 4.6% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
5.2%
0.1 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 9.1% · Q3 2.5% · Q4 1.3% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.7% |
19.2%
15.5 pts worse
|
19.6%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 34.6% · Q3 36.1% · Q4 36.9% · 4Q avg 34.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 45.7% |
22.5%
23.2 pts worse
|
16.7%
29 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.4% · Q2 44.7% · Q3 47.7% · Q4 50.0% · 4Q avg 45.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.8% |
0.1%
1.7 pts worse
|
0.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.3% · Q4 2.3% · 4Q avg 1.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.3% |
17.7%
4.4 pts better
|
16.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 21.0% · Q3 9.4% · Q4 11.2% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.4% |
17.6%
3.2 pts better
|
14.9%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 19.7% · Q3 11.1% · Q4 17.6% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
1.0%
1.3 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.0% · Q3 2.1% · Q4 1.9% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.1% |
2.0%
5.1 pts worse
|
1.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 3.7% · Q3 6.0% · Q4 8.5% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.7% |
21.7%
16 pts better
|
19.8%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 7.7% · Q3 2.4% · Q4 3.6% · 4Q avg 5.7% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.6%
0.6 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.2% · Q3 3.9% · Q4 1.2% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 57.9% |
77.1%
19.2 pts worse
|
81.7%
23.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 57.9% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-15 · Fire 2024-03-15
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-09-13 · Fire 2022-09-13
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-27
D · Potential for more than minimal harm
2025-03-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-27
D · Potential for more than minimal harm
2024-03-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-05-09
F · Potential for more than minimal harm
2022-09-13
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-11-05
F · Potential for more than minimal harm
2022-09-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-05
E · Potential for more than minimal harm
2022-09-13
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-11-05
E · Potential for more than minimal harm
2022-09-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-11-05
E · Potential for more than minimal harm
2022-09-13
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2022-11-05
E · Potential for more than minimal harm
2022-09-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-05
E · Potential for more than minimal harm
2022-09-13
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-09-13
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-09-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-09-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-09-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-05
C · Minimal harm
2022-09-13
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-11-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-07-18
F · Potential for more than minimal harm
2025-03-06
F838 · Administration Deficiencies
Health
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.
Corrected 2025-04-20
E · Potential for more than minimal harm
2025-03-06
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 2025-04-20
E · Potential for more than minimal harm
2025-03-06
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-04-20
E · Potential for more than minimal harm
2025-03-06
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 2025-04-20
E · Potential for more than minimal harm
2025-03-06
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 2025-04-20
E · Potential for more than minimal harm
2025-03-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-20
E · Potential for more than minimal harm
2025-03-06
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 2025-04-20
E · Potential for more than minimal harm
2025-03-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-20
E · Potential for more than minimal harm
2025-03-06
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-04-20
E · Potential for more than minimal harm
2025-03-06
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-06
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 2025-04-20
D · Potential for more than minimal harm
2025-03-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-06
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 2025-04-20
D · Potential for more than minimal harm
2025-03-06
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 2025-04-20
D · Potential for more than minimal harm
2025-03-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-06
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 2025-04-20
D · Potential for more than minimal harm
2025-03-06
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-06
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-06
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-06
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 2025-04-20
C · Minimal harm
2025-03-06
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-04-20
B · Minimal harm
2025-03-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-20
D · Potential for more than minimal harm
2024-03-15
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-29
B · Minimal harm
2024-03-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-29
E · Potential for more than minimal harm
2022-09-13
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-11-04
E · Potential for more than minimal harm
2022-09-13
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 2022-11-04
D · Potential for more than minimal harm
2022-09-13
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 2022-11-04
D · Potential for more than minimal harm
2022-09-13
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-09-13
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 2022-11-04
D · Potential for more than minimal harm
2022-09-13
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 2022-11-04
D · Potential for more than minimal harm
2022-09-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-09-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-09-13
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-09-13
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-04
Penalties and ownership
What sits behind the stars
Ownership
Henderson, Roberta
5% Or Greater Direct Ownership Interest · Individual
Henderson, Roberta
Operational/Managerial Control · Individual
Henderson, Roberta
Corporate Officer · Individual
Jain, Sandeep
Operational/Managerial Control · 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
Bear Mountain At Sudbury
Sudbury, MA
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
#3
Alliance Health At Marie Esther
Marlborough, MA
4-star overall rating with 4-star inspections with $7,901 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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