Independent · Federal inspection records, searchable
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Nursing Home Violations Public inspection data, searchable
Facility profile · CCN 225710

Bear Mountain At Sudbury

48 federal citations on record , and 1 federal enforcement actions totaling $15,672.

Record summary

Federal record · Q1 2026
48
Total citations
36
Last 3 years
1
Actual harm+
1
Federal penalties
$15,672
Total fines
2
Overall ★ rating

Most common violation categories here

Quality of Care15 Resident Rights13 Care Planning7 Medication & Pharmacy6 Nutrition & Dietary2

Most common F-tags at this facility

F5523 F5502 F5782 F5802 F6412

Citation history

48 on record
SurveyF-TagViolationSeveritySource
Jan 15, 2025F692Provide enough food/fluids to maintain a resident's health.DComplaint
Nov 5, 2024F880Provide and implement an infection prevention and control program.DStandard
Nov 5, 2024F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.DStandard
Nov 5, 2024F698Provide safe, appropriate dialysis care/services for a resident who requires such services.DStandard
Nov 5, 2024F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DStandard
Nov 5, 2024F677Provide care and assistance to perform activities of daily living for any resident who is unable.DStandard
Nov 5, 2024F641Ensure each resident receives an accurate assessment.BStandard
Nov 5, 2024F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DStandard
Nov 5, 2024F578Honor 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.DStandard
Nov 5, 2024F552Ensure that residents are fully informed and understand their health status, care and treatments.DStandard
Nov 5, 2024F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.DStandard
Jun 18, 2024F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DComplaint
Jun 18, 2024F624Prepare residents for a safe transfer or discharge from the nursing home.DComplaint
Nov 2, 2023F760Ensure that residents are free from significant medication errors.DStandard
Nov 2, 2023F759Ensure medication error rates are not 5 percent or greater.DStandard
Nov 2, 2023F758Implement 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.DStandard
Nov 2, 2023F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.DStandard
Nov 2, 2023F693Ensure 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.DStandard
Nov 2, 2023F692Provide enough food/fluids to maintain a resident's health.GStandard
Nov 2, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DStandard
Nov 2, 2023F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DStandard
Nov 2, 2023F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DStandard
Nov 2, 2023F660Plan the resident's discharge to meet the resident's goals and needs.DStandard
Nov 2, 2023F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DStandard
Nov 2, 2023F645PASARR screening for Mental disorders or Intellectual DisabilitiesDStandard
Nov 2, 2023F641Ensure each resident receives an accurate assessment.BStandard
Nov 2, 2023F625Notify 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.BStandard
Nov 2, 2023F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.BStandard
Nov 2, 2023F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.DStandard
Nov 2, 2023F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DStandard
Nov 2, 2023F578Honor 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.DStandard
Nov 2, 2023F552Ensure that residents are fully informed and understand their health status, care and treatments.DStandard
Nov 2, 2023F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.EStandard
Aug 9, 2023F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.DComplaint
Jun 13, 2023F675Honor each resident's preferences, choices, values and beliefs.EComplaint
Jun 13, 2023F583Keep residents' personal and medical records private and confidential.DComplaint
Apr 14, 2022F880Provide and implement an infection prevention and control program.FStandard
Apr 14, 2022F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FStandard
Apr 14, 2022F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.EStandard
Apr 14, 2022F758Implement 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.DStandard
Apr 14, 2022F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.DStandard
Apr 14, 2022F695Provide safe and appropriate respiratory care for a resident when needed.DStandard
Apr 14, 2022F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.DStandard
Apr 14, 2022F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DStandard
Apr 14, 2022F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DStandard
Apr 14, 2022F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DStandard
Apr 14, 2022F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DStandard
Apr 14, 2022F552Ensure that residents are fully informed and understand their health status, care and treatments.DStandard

Federal enforcement history

Federal regulators have imposed 1 enforcement actions against this facility, including 1 civil money penalties totaling $15,672 .

DateTypeFinePayment denial
Nov 2, 2023Fine$15,672—
About this record A citation is a finding by a state survey team working under federal contract. It is not a court judgment. The description above is drawn verbatim from federal public datasets. Facilities have the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.

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