Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Adviniacare At Provincetown during CMS and state inspections, most recent first.
Grievance Policy Lacked Required Resident Notification: The facility’s grievance policy and Resident Rights poster did not include that residents and reps could file grievances anonymously or provide the required contact info for the grievance official and outside entities such as the State agency, QIO, State Survey Agency, and LTC Ombudsman/protection and advocacy system. In a resident group meeting, 13 of 13 residents said they were unaware of anonymous filing, did not know who the grievance officer was, and did not know where else grievances could be filed.
Failure to Provide Bodily Privacy During Care: Two residents were observed receiving blood draws without privacy, including one in a dayroom with other residents present and another visible from the hallway with the door open. A third resident was observed in bed while an RN applied a pain patch to the lower back with the curtain not pulled and the door wide open, making the resident's body visible from the hallway.
Failure to investigate an allegation of verbal abuse involving a resident. A cognitively intact resident with depression and anxiety was reportedly left on the toilet too long and then yelled at by a CNA after the resident called a family member for help. The grievance was handled as a complaint rather than an abuse allegation, and the DON and Administrator acknowledged that the event was not reported to police or the State Agency and no investigation was completed.
Failure to Report Alleged Verbal Abuse: A resident with depression and anxiety and intact cognition reported that a CNA yelled at the resident after the resident had been left on the toilet too long and family called the nurse’s desk for help. The grievance was documented and signed by the Administrator, but the allegation was not reported to the State Agency or police within the required timeframe, and the DON and Administrator acknowledged the delay.
Failure to Investigate Allegation of Verbal Abuse: A cognitively intact resident with depression and anxiety reported being left on the toilet too long and then yelled at by a CNA after family called for help. The grievance was documented, but the DON found no incident report or investigation, and the Administrator acknowledged the allegation of verbal abuse was not investigated or reported as required.
The facility failed to ensure monthly MRRs were communicated to the prescriber and addressed for two residents. One resident with dementia, Parkinson’s disease, and anxiety had pharmacist recommendations about a Midazolam allergy clarification and lab monitoring for Risperdal that were left blank and unsigned, with no chart evidence that the MD/NP reviewed them. Another resident with anxiety, dementia, and depression had PRN Trazodone orders that were signed on the MRRs, but the record did not show re-evaluation, a progress note with medical justification, or a specified duration for continued use.
Medication Administration Errors Exceeded Allowed Rate: Two nurses made three medication administration errors during a med pass, resulting in a 12% error rate. Errors included giving a resident Tamsulosin at the wrong time, administering the wrong dose of Calcium Carbonate to another resident, and giving generic Levothyroxine instead of ordered brand-name Synthroid with no substitutions. The DON stated meds must be given in the correct time, dose, and formula.
Unsecured Medications Left Unattended During Passes: An RN left a resident holding a medication cup unattended during a med pass, an LPN disposed of a dropped escitalopram tablet in an open, unsecured trash receptacle on the med cart, and another RN left a card of amiodarone tablets unattended on top of the cart in the hallway. The DON stated meds should not be left unattended or disposed of in an unsecured, uncovered trash receptacle.
Missing Pneumococcal Vaccine Consent and Documentation: The facility failed to document pneumococcal vaccine consent or declination, including vaccination status, for three residents. Records lacked Immunization Consent forms and immunization tab entries, and the ICP and DON acknowledged the consents had not been completed or reviewed for the sampled residents.
Failure to Revise Fall Care Plan: A resident with dementia, anxiety, and moderate cognitive impairment had repeated falls, but the fall care plan was not updated to match current needs or the effectiveness of interventions. The record included interventions such as safety education, walker reminders, environmental changes, and toilet assistance after meals, yet observations showed the resident did not use a wheelchair or walker and preferred to stay in the room. Staff interviews showed inconsistent understanding of who updated the care plan, and the DON acknowledged the plan needed revision.
Incomplete Lidocaine Patch Order: A resident with arthritis and a stage 2 pressure ulcer had a physician order for a Lidoderm 5% patch to be applied to the low back in the morning for pain, but the order did not include a duration or time for removal. An RN reviewed the record and stated the order was incomplete because it lacked the removal time.
Air Mattress Set Incorrectly for Resident With Pressure Injuries: A resident with a stage 2 pressure ulcer and an unstageable deep tissue injury had an air mattress ordered for pressure relief and to be set per weight, but staff observed the compressor set to 280 lbs even though the resident's recorded weight was 193 lbs. An LPN reviewed the record and stated the mattress was set too high and should be set close to the resident's weight.
Improper Labeling and Storage of Resident Food Items: Staff failed to properly label, date, and store resident food items in a kitchenette refrigerator. Surveyors found multiple items that were unlabeled, undated, or missing required resident identification and date information, including soup, cheese, tomato sauce, ricotta cheese, olives, and fried chicken. An LPN, dietary aide, FSD, and DON all acknowledged that resident food items needed to be labeled and dated, and several items were described as moldy or not suitable to remain in the refrigerator.
Three residents in the facility were found with inaccessible call bell devices, which were either wrapped around bed rails or hanging towards the floor, making them out of reach. These residents, with varying degrees of cognitive impairment and other medical conditions, were unable to use the call bells to call for assistance. Observations confirmed the inaccessibility of the call bells, and the Director of Nursing acknowledged the issue.
The facility failed to address grievances from Resident Council Meetings over several months. Residents reported long call bell wait times, leading to distressing situations, but these concerns were not documented or resolved. The Activity Director did not complete grievance forms, and the Administrator misunderstood what constituted a grievance, resulting in unresolved issues.
The facility failed to secure residents' PHI on a nursing unit, as surveyors observed unattended medication carts with open computers displaying sensitive information. In one instance, a computer outside the dining room showed residents' names and photos, visible to others nearby. Another incident involved a computer in the hallway displaying a resident's name and medication list. Nurses acknowledged the need to close screens to protect privacy.
A resident with severe cognitive impairment and a history of falls experienced six unwitnessed falls due to inadequate supervision and ineffective interventions. The facility's fall prevention policies were not consistently implemented, with incomplete evaluations and lack of root cause analysis. Staff interviews revealed failures in documentation and response to falls, contributing to ongoing risks.
The facility failed to maintain sufficient staffing levels, particularly on weekends, as indicated by the PBJ report for FY Quarter 4, 2024. This led to delayed responses to call bell devices, impacting residents' well-being. Interviews and Resident Council minutes highlighted ongoing issues with staffing shortages and long wait times for call bell responses, especially during evening and night shifts.
The facility failed to monitor medication refrigerator temperatures properly, with temperatures recorded only once daily and several instances of out-of-range temperatures. Additionally, medication carts were left unlocked and unattended, posing a security risk. Staff interviews revealed confusion about responsibilities for temperature monitoring and cart security. The DON acknowledged the need for twice-daily temperature checks and locked carts when unattended.
Surveyors found that the facility failed to follow food safety standards, with improperly labeled, dated, and stored food in the kitchen's refrigerator and freezer. Items like hard-boiled eggs, muffins, and deli meats were undated and unlabeled, while some were left open to air. The Food Service Manager confirmed that such practices are against the facility's protocols, which require proper labeling and discarding of food not in original packaging after 48 hours.
A facility failed to accurately document fluid intake for a resident with a 1200 ml/day fluid restriction. The resident's MAR did not reflect correct fluid amounts per shift or 24-hour totals. Staff interviews revealed inconsistencies in documentation practices, with CNAs verbally reporting intake to nurses without a formal recording system. The DON acknowledged the lack of a system to ensure accurate tracking of the resident's fluid intake.
The facility failed to reassess bed safety for two residents with limited mobility when specialty mattresses were introduced, leading to potential entrapment risks. The Maintenance Director conducted annual checks but was unaware of the need for reassessment with new mattresses, resulting in 10 out of 36 beds not being evaluated for safety.
A facility failed to provide a resident and their representative with a summary of the baseline care plan within 48 hours of admission, as required by policy. The resident, admitted with multiple diagnoses, was confused and unable to be interviewed. The family member was uncertain about the care plan, and the baseline care plan document lacked signatures, indicating it had not been reviewed with them. Interviews confirmed the oversight, and the facility's policy was not followed.
The facility failed to obtain a physician's order for Hospice services for a resident and did not transcribe handwritten medication orders into the electronic medical record for another resident. Additionally, the facility did not conduct required neurological checks after unwitnessed falls. The deficiencies involved residents with Parkinson's disease and severe cognitive impairment.
A resident with severe cognitive impairment and a history of falls was moved by two CNAs from the floor to a Broda chair without a nurse's assessment, contrary to the facility's Fall Prevention and Management policy. The incident report lacked staff statements, and the DON was unaware of the CNAs involved. Nurse #6 confirmed the CNAs moved the resident without prior assessment.
A resident with COPD and chronic respiratory failure did not receive proper respiratory equipment care. The nebulizer tubing and mouthpiece were not stored correctly, and the oxygen concentrator was dusty with an unclean filter. Staff interviews revealed confusion over cleaning responsibilities, with the DON confirming a lack of documentation for equipment maintenance.
The facility failed to conduct necessary side rail risk assessments for three residents, including those with Parkinson's and Alzheimer's disease. Initial assessments were not performed upon admission or when new mattresses were introduced, and appropriate alternatives were not attempted before installing side rails. The lack of documentation was confirmed by the DON and a nurse.
The facility failed to address pharmacy consultant recommendations for three residents, including clarifying medication orders and reassessing medication needs. A resident's duplicate Guaifenesin orders were not clarified, another resident's bowel medication orders lacked clarification, and a third resident's need for Protonix and thyroid lab work was not reassessed. The DON acknowledged the lack of documentation and action on these recommendations.
A resident with thrombophlebitis was prescribed Eliquis, an anticoagulant, but the facility failed to monitor for signs of bleeding as required. Although the medication was administered correctly, the monitoring order was not documented in the MAR or TAR, preventing staff from tracking potential side effects. The DON confirmed the oversight, acknowledging the inability to assess the resident's condition accurately.
Grievance Policy Lacked Required Resident Notification
Penalty
Summary
The facility failed to ensure residents were fully aware of the grievance process. Review of the facility’s Grievances policy, last revised 10/2022, showed it did not state that residents and/or their representatives had the right to file grievances anonymously and did not include the contact information for the grievance official, including business address and phone number, or the contact information for independent entities where grievances may be filed. During a tour of the facility’s only unit, the surveyor observed a Resident Rights poster across from the nursing station. The poster stated residents had the right to voice grievances without fear of discrimination or reprisal, to receive information on how to file a grievance or complaint, and to prompt resolution of grievances, but it did not include the right to file anonymously or the required contact information for the grievance official or outside agencies. In a resident group meeting with 13 residents, all 13 said they were not aware of the right to file a grievance anonymously, did not know who the grievance officer was, and were not aware of other entities where grievances could be filed; they stated they would go to the Resident Council President or a staff member if they had an issue and that there was nowhere to file a grievance anonymously. The Administrator and Regional Nurse Educator later reviewed the grievance policy and confirmed it did not include the required anonymous filing information or contact information.
Failure to Provide Bodily Privacy During Care
Penalty
Summary
The facility failed to provide bodily privacy during care for three residents who were observed receiving treatment by health care professionals. Resident #16, who had diagnoses including atrial fibrillation and hyperlipidemia and was assessed with severe cognitive impairment and dependence for activities of daily living, was sitting in a wheelchair in the dayroom with seven other residents present when a Laboratory Technician approached to draw blood and began the procedure without asking to move the resident to a private location or otherwise provide privacy. Resident #14, who had dementia, severe cognitive impairment, and dependence for activities of daily living, was sitting in a wheelchair in his/her room facing the doorway and visible from the hallway when the same Laboratory Technician entered and began a blood draw without asking whether the door should be closed or the resident moved to a more private location. Resident #24, who had Alzheimer's disease, a history of falls, severe cognitive impairment, and required staff assistance for all activities of daily living, was observed in bed while Nurse #2 applied a transdermal analgesic patch to the resident's lower back. The privacy curtain was not pulled and the door was wide open, allowing the care to be easily observed from the hallway. During interview, Nurse #2 stated she did not realize the resident's body was exposed and visible from the hallway and said that if a resident's body is exposed, the privacy curtain should be pulled or the door closed.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to implement its written abuse policies and procedures after an allegation of abuse involving Resident #34. Resident #34 was admitted in October 2023 with diagnoses including depression and anxiety, and the 1/29/26 MDS indicated the resident was cognitively intact with a BIMS score of 15 out of 15. The facility’s Abuse policy stated that allegations of abuse must be immediately reported, investigated, and reported to the police and State Agency within two hours. According to the grievance record, Family Representative #2 reported that on 3/3/26 Resident #34 had been left on the toilet too long and then, when CNA #5 came to assist, the CNA yelled at the resident after the resident had called the family representative to request help. The grievance form documented that CNA #5 was removed from the resident’s assignment and staff were educated, but the department head review and action section was left blank. The Social Worker later stated that the incident was treated as a grievance and not investigated. During interviews, the Social Worker said yelling at a resident is verbal abuse and acknowledged that Resident #34 being yelled at was considered abuse. The DON stated there were no incident/accident reports or investigations for Resident #34 for the prior three months. The DON and Administrator both stated that the event should have been reported to the police and State Agency and investigated, but the facility did not do so. The Administrator also stated the facility did not follow its policy and no investigation had been conducted.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency for Resident #34. The facility’s abuse policy required suspected or alleged abuse, neglect, mistreatment, or misappropriation of property to be reported immediately, with notification to local law enforcement and the appropriate State Agency no later than two hours after the allegation was identified. Resident #34 was admitted in October 2023 with diagnoses including depression and anxiety, and the 1/29/26 MDS indicated the resident was cognitively intact with a BIMS score of 15 out of 15. On 3/4/26, a grievance form documented that Family Representative #2 reported Resident #34 had been left on the toilet too long and then felt a CNA was rude and yelled at the resident after the family member called the nurse’s desk for help. The grievance was signed by the Administrator on 3/5/26, but review of the HCFRS on 3/31/26 showed no report had been submitted for the allegation. During interviews on 4/2/26, the DON stated he was unaware of the incident until surveyor inquiry and acknowledged the resident’s report of being yelled at was an allegation of abuse that should have been reported right away to police and the State Agency within two hours. The Administrator also stated that yelling and shouting at a resident is verbal abuse and confirmed the allegation was not reported until 29 days after it was reported.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse involving Resident #34 was thoroughly investigated. Resident #34 was admitted in October 2023 with diagnoses including depression and anxiety, and the MDS dated 1/29/26 indicated the resident was cognitively intact with a BIMS score of 15 out of 15. The facility policy stated that all alleged abuse, including verbal abuse, must be thoroughly investigated under the direction of the Administrator, with witness statements gathered and a conclusion documented as substantiated or not substantiated. On 3/4/26, Family Representative #2 reported through the grievance process that Resident #34 had been left on the toilet too long and then called the nurse's desk for help. When CNA #5 entered the room, the resident felt the CNA was rude and yelled at the resident for having the family member call the nurses' desk. The grievance form documented that CNA #5 was removed from the resident's assignment and educated, and that staff were re-educated, but the Department Head review and action section was left blank. During interviews, Family Representative #2 described that Resident #34 was uncomfortable after waiting on the toilet and said the CNA yelled at the resident after being called for assistance. The DON stated there were no incident or accident reports or investigations for Resident #34 for the prior three months. The DON later acknowledged that the report of being yelled at was an allegation of abuse, that an investigation should have been conducted, and that a final report should have been submitted to the State Agency within five business days, but none was completed. The Administrator also stated that verbal abuse includes yelling and said the facility made a mistake by not conducting an investigation.
Failure to Communicate and Address Monthly Medication Reviews
Penalty
Summary
The facility failed to ensure monthly medication regimen reviews (MRR) were communicated to the Physician/Nurse Practitioner and reviewed and responded to in a timely manner for two residents. The facility policy required the licensed pharmacist to complete monthly MRRs and for the unit manager/designee to make sure all recommendations were acted upon, reported to the resident physician, and documented in the resident chart. The report found that these steps did not occur for the cited residents. For one resident with diagnoses including dementia with behaviors, Parkinson’s disease, and anxiety, the medical record showed an allergy to Midazolam and orders for Lorazepam and Risperdal. The consultant pharmacist’s 10/13/25 MRR noted that the resident had an allergy to Midazolam but was currently receiving Ativan and asked for clarification or an allergy override if there was no issue. A later 2/8/26 MRR recommended monitoring lipids and A1c because the resident was receiving Risperdal. The response sections were blank and unsigned, and the record did not show that the Physician or NP reviewed or addressed these recommendations or that staff notified them and documented the notification. For another resident with diagnoses including anxiety, dementia, and depression, the record showed a PRN Trazodone order for agitation/anxiety. The consultant pharmacist’s MRRs dated 10/12/25, 12/8/25, and 2/8/26 stated that PRN psychotropic medications must be re-evaluated after 14 days and, if continued, required medical justification in a progress note and a specified number of days for the order to continue. Although the prescriber signed the MRRs, the medical record did not show that the Trazodone was re-evaluated, that medical justification for continued use was documented in a progress note, or that the order included a specific duration.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure it was free from a medication error rate greater than 5% when two nurses observed during a medication pass made three errors out of 25 opportunities, resulting in a 12% medication error rate. The report states that the errors affected three residents and involved administration of medications not in accordance with the orders, including required time frame, dose, and formula. For one resident, a nurse administered Tamsulosin during the morning medication pass even though the medication card and physician’s order indicated it was to be given at bedtime; the nurse stated she did not review the medication card instructions and thought it was scheduled for the morning. For another resident, a nurse administered Calcium Carbonate 750 mg even though the physician’s order was for Calcium Carbonate 500 mg daily in the morning. For a third resident, a nurse administered Levothyroxine 75 mcg generic instead of the ordered brand-name Synthroid 75 mcg, no substitutions; the report notes the resident representative requested brand-name Synthroid because the generic was not as effective, and the DON stated medications must be given in the correct time, dose, and formula.
Unsecured Medications Left Unattended During Passes
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles during medication administration for one unit. During a medication pass, Nurse #3 prepared multiple medications for Resident #1, including tamsulosin, multivitamin with minerals, vitamin C, oxycodone, guaifenesin, ferrous sulfate, and docusate sodium, then left the resident holding the medication cup with four pills and stepped into the hallway with her back to the resident. Nurse #3 later stated she should not have left the resident unattended and that medication must be in view of the nurse. During another medication pass, Nurse #2 administered escitalopram to Resident #32, dropped the tablet on the floor, picked it up, and disposed of it in an opened, uncovered, and unsecured trash receptacle on the medication cart. The surveyor later observed the unsecured trash receptacle still on the cart with the trash bag containing the escitalopram tablet. In a separate observation, Nurse #3 prepared and administered medications to Resident #14 and left a medication card containing eight amiodarone 400 mg tablets on top of the medication cart in the hallway, unattended and unsecured. The DON stated that medication should not be left unattended or unsecured in a resident's room or in the hallway and should not be disposed of in an unsecured and uncovered trash receptacle.
Missing Pneumococcal Vaccine Consent and Documentation
Penalty
Summary
The facility failed to maintain accurate documentation of pneumococcal vaccination consent or declination, including education regarding the benefits and potential risks associated with the vaccine, for three residents out of a sample of five. The facility policy stated that residents were to be assessed for pneumococcal vaccine eligibility prior to or upon admission, offered the vaccine series within 30 days when indicated, and that refusals were to be documented in the medical record. However, the records for Residents #20, #24, and #26 did not include documentation showing they were given the opportunity to consent to or decline the pneumococcal vaccine, and no Immunization Consent form was found for any of the three residents. Further review of the medical records for Residents #20, #24, and #26 did not identify pneumococcal vaccination status in the immunization tab or elsewhere in the chart. During interview, Nurse #1 stated vaccination consents were scanned into the EMR and agreed that consent forms should have been completed and filed in the record, but none were located for the three residents. The Infection Control Preventionist stated she was overseeing the vaccination program and was behind on obtaining pneumococcal consents, and that the consent form had not been reviewed with the three residents. The DON also stated there had not been a focus on pneumococcal vaccinations by the last administration and did not find documentation in the sampled records showing the CDC guidance had been met.
Failure to Revise Fall Care Plan
Penalty
Summary
The facility failed to implement and revise the care plan for a resident admitted with diagnoses including dementia and anxiety who had moderate cognitive impairment on the MDS and was identified as having two or more falls. The resident’s fall care plan, initiated for fall risk, included interventions such as education on safety needs, reminders to use a walker, environmental adaptations, reporting falls, and other measures added over time. The facility policy stated that if a resident continues to fall, staff and the physician will re-evaluate the situation and assess for changes in or additions to interventions. The resident’s incident reports documented multiple falls and related interventions, including a slip from a wheelchair, safety education, toilet assistance after meals, and appropriately sized cuffed pants. However, the revised fall care plan did not include documented evidence of toilet assist after meals, and the care plan was not revised to reflect that the resident no longer used a wheelchair, preferred to stay in the room, or did not use a walker. During observations, the resident was seen standing from bed, self-transferring to a chair, and later walking to the bathroom without a walker. The resident stated he/she did not use a wheelchair, did not like to leave the room, and did not like to go to activities or the day room. Staff interviews showed inconsistent understanding of the resident’s current needs and care plan management. A CNA stated the resident did not use a wheelchair and did not need assistance to use the bathroom, while a nurse stated nurses do not update care plans and believed the MDS nurse did so. The RNC stated the nurse documenting the fall incident report was expected to place the intervention into the care plan and that falls were reviewed and updated as needed. The DON reviewed the current fall care plan and stated he was not aware the resident no longer used a wheelchair or preferred to stay in the room, and acknowledged the resident had a fall with interventions that were not revised. The DON stated the current care plan needed to be revised, and there was no documented evidence that the interdisciplinary team reviewed the effectiveness of the interventions being used to prevent falls.
Incomplete Lidocaine Patch Order
Penalty
Summary
The facility failed to ensure staff provided care and services consistent with accepted standards of clinical practice for one resident in the sample. Resident #1 was admitted in January 2026 with diagnoses including arthritis and a stage 2 pressure ulcer. The resident’s MDS assessment dated 2/12/26 indicated the resident was cognitively intact with a BIMS score of 14 out of 15 and received pain medication daily. Review of the medical record showed a physician’s order for Lidoderm Patch 5% (Lidocaine) to be applied to the low back topically in the morning for low back pain. During interview, Nurse #3 reviewed the record and stated the order did not include a duration or a time for removal. She said Lidocaine 5% patches can be applied for up to 12 hours but may be ordered for different durations, and that the physician’s order should have been complete and included a duration/time of removal.
Air Mattress Set Incorrectly for Resident With Pressure Injuries
Penalty
Summary
The facility failed to ensure that one resident with a stage 2 pressure ulcer to the left buttock and an unstageable deep tissue injury to the right heel received pressure injury care consistent with the physician's order. The resident was admitted in January 2026, had diagnoses including pressure injuries, and the MDS dated 2/12/26 documented a BIMS score of 14 out of 15, one stage 2 pressure ulcer, one unstageable deep tissue injury, and use of a pressure-reducing device for the bed. The physician ordered an air mattress for pressure relief and directed that it be set per the resident's weight, with functionality checked every shift. The resident's last recorded weight was 193.0 lbs on 2/18/26, but on 3/31/26 and again on 4/1/26 the air mattress compressor was observed set to 280 lbs. During the 4/1/26 observation, Nurse #3 reviewed the record and stated the mattress was set too high and should be set close to the resident's weight as indicated in the physician's orders. The care plan also directed staff to utilize an air mattress set per the resident's weight.
Improper Labeling and Storage of Resident Food Items
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation in one of two kitchenettes by not properly dating, labeling, and storing food and drink items. The deficiency was identified during observation and interview in the Living Room refrigerator, where the surveyor found multiple resident food items that were unlabeled, undated, or missing required information such as the resident’s name and date brought in or opened. Observed items included a paper bag with fried chicken pieces labeled only with packed and sell-by dates but no resident name or date brought in, a gray insulated cup with soup that was labeled only with a resident’s initials and no date, an opened container of sliced cheese with a black, fuzzy-looking substance on some slices, a jar of tomato sauce and a container of ricotta cheese that lacked resident identification and date opened, a half sandwich dated 3/26/26, and an open jar of olives without resident name or date opened. When the refrigerator was rechecked later the same day, several of the same items remained present, including the ricotta cheese, tomato sauce, sliced cheese, olives, and the undated soup cup. During interview, Nurse #5 said food brought in for a resident must be labeled with the resident’s name and dated, then discarded after 72 hours, and that unlabeled or undated food should be thrown out. She also stated the soup did not look good, the sliced cheese looked moldy, and the ricotta, tomato sauce, and olives should not be in the refrigerator and needed to be discarded. Dietary Aide #1 said resident items needed to be labeled with the resident’s name and date brought in and that foods not labeled and/or dated must be discarded. The Food Service Manager and DON both stated that nursing was responsible for discarding food items not labeled and dated appropriately, while the Food Service Manager also said dietary staff had been told not to discard food in the refrigerator.
Inaccessible Call Bells for Residents
Penalty
Summary
The facility failed to ensure that three residents had their call bell devices accessible and within reach while in their beds, as observed by surveyors. Resident #4, who was admitted in December 2020 with diagnoses including unspecified dementia and overactive bladder, was found with the call bell device wrapped around the left upper side rail and hanging down toward the floor, making it inaccessible. The resident expressed unawareness of the call bell's location and was unable to use it to call for assistance. Resident #27, admitted in January 2021 with severe cognitive impairment and other diagnoses, also had an inaccessible call bell. The device was wrapped around the right upper side rail and the push button was underneath the mattress, out of reach. The resident was unable to locate the call bell and expressed an inability to call for help. Observations confirmed the call bell's inaccessibility on multiple occasions. Resident #12, admitted in March 2016 with Parkinson's disease and dementia, was observed with the call bell cord wrapped around the upper side rail and hanging down towards the floor, out of reach. Despite being fed by a CNA who had a beeper for call light alerts, the resident's call bell remained inaccessible. The Director of Nursing acknowledged that all residents should have call bell devices within reach, but this was not the case for the residents involved.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to address and promptly resolve grievances brought forward during Resident Council Meetings held from March 2024 through January 2025. The facility's policy required that concerns raised during these meetings be recorded in minutes and followed with a concern/response form filled out by the designated staff representative. These forms were to be addressed to the corresponding Department Head to provide a resolution within seven days. However, the review of the grievance book indicated that concerns documented during the Resident Council meetings were not documented on a grievance/complaint/concern form, and no follow-up or resolution was provided for the issues raised. During interviews, residents expressed ongoing issues with long call bell wait times, particularly during the evening and night shifts, which had not been resolved. Residents reported waiting 15 minutes or longer for assistance, leading to situations where they soiled themselves due to the delay. Despite these concerns being repeatedly raised in Resident Council meetings, residents did not receive any follow-up or discussion about the issues until the next monthly meeting. The Activity Director, responsible for organizing the meetings, admitted to not completing grievance forms for issues raised, as she did not consider them grievances. The Administrator, identified as the Grievance Official, confirmed that only one grievance was filed in the grievance book for the period in question. She did not consider the residents' complaints to rise to the level of a grievance, as she believed a grievance required an outcome associated with it. This misunderstanding of what constitutes a grievance contributed to the facility's failure to address and resolve the residents' concerns, as documented in the Resident Council Minutes.
Failure to Secure Residents' Protected Health Information
Penalty
Summary
The facility failed to ensure the security and confidentiality of residents' protected health information (PHI) on one nursing unit. On two separate occasions, surveyors observed unattended medication carts with open computers displaying sensitive resident information. The first incident occurred outside the main dining room, where a computer on a medication cart was left open, showing various residents' names, photos, and identifying information. This information was visible to residents, a visitor, and a dietary aide in the vicinity. Nurse #3 acknowledged that she should have closed the computer screen to maintain privacy. The second incident was observed in the unit hallway, where another unattended medication cart had an open computer displaying a resident's name and medication list. This information was visible to a consultant mobile imaging provider and a non-clinical staff member. Nurse #5 admitted responsibility for the cart and recognized the need to close the computer screen to protect the resident's private health information. The Director of Nursing confirmed that nursing staff should log out or close computer screens when carts are unattended to safeguard residents' PHI.
Inadequate Fall Prevention and Supervision in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision and effective interventions to prevent avoidable accidents, specifically for a resident with a history of falls. The resident, who was admitted in October 2024, had severe cognitive impairment and was dependent on staff for transfers and toileting. Despite being identified as a major fall risk, the initial Fall Risk Evaluation was incomplete and unsigned, lacking a fall risk score to guide care plan development. The resident experienced six unwitnessed falls from October 2024 to February 2025, indicating a lack of effective fall prevention measures. The facility's policies on Fall Prevention and Management and Accidents and Incidents were not consistently implemented. After each fall, the investigations often lacked a root cause analysis and staff statements, and new interventions were either not added or were ineffective. For instance, after a fall on 10/24/24, a fall mat was provided, but this intervention was only added to the care plan six days later. Similarly, after a fall on 11/9/24, no new interventions were added to the care plan, despite the existing interventions being ineffective. Interviews with staff revealed further deficiencies in documentation and response to falls. A fall on 1/7/25 was not documented in the medical record, and there was no incident report available. Staff interviews indicated that the fall occurred when a CNA left the resident on the toilet to attend to another resident who was screaming for help. The nurse on duty did not respond to the screaming resident, and the fall was not documented because the nurse wanted to consult with the DON on how to document it without making it sound severe. This lack of documentation and failure to implement effective interventions contributed to the ongoing risk of falls for the resident.
Staffing Deficiencies and Delayed Call Bell Responses
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, particularly on weekends, as evidenced by the Payroll-Based Journal (PBJ) report submitted to CMS for Fiscal Year Quarter 4, 2024. The report indicated excessively low weekend staffing without any nurse staffing waivers in place. The facility's staffing plan outlined a minimum requirement of licensed nurses and certified nursing assistants (CNAs) for each shift, but the actual staffing levels frequently fell short of these requirements. Interviews with the Administrator and Director of Nursing (DON) revealed that staffing was based on census rather than hours per patient day (HPPD), and there were challenges with geographical location and travel, leading to reliance on a single agency for staffing, which was not consistently utilized. The deficiency was further highlighted by the facility's inability to respond to call bell devices in a timely manner, as voiced by residents and documented in Resident Council minutes. Residents reported long wait times for call bell responses, sometimes resulting in soiling themselves due to delays. Interviews with staff and residents indicated that staffing shortages were more pronounced during the summer and on weekends, with frequent call-outs exacerbating the issue. Despite efforts to adjust staffing based on census, the facility consistently failed to meet the minimum staffing requirements, impacting the residents' ability to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The Resident Council minutes from various months in 2024 consistently documented grievances regarding call bell response times, with residents expressing concerns about the lack of timely responses, especially during evening and night shifts. The Activity Director acknowledged that education and audits of call bell response times did not begin until January 2025, several months after the grievances were initially raised. This delay in addressing the concerns contributed to the ongoing issues with staffing and resident care, as the facility struggled to maintain adequate staffing levels and respond promptly to residents' needs.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to properly monitor and record the temperatures of a medication refrigerator, which is crucial for maintaining the integrity of stored medications and vaccines. The refrigerator was observed with a temperature of 55 degrees Fahrenheit, which is outside the recommended range of 36 to 46 degrees Fahrenheit. The temperature log showed that temperatures were only recorded once daily, and there were several days with no recorded temperatures or temperatures that were out of range. Staff interviews revealed a lack of clarity on who was responsible for monitoring and recording the temperatures, and there was confusion about how to retrieve temperature data from the monitoring device. Additionally, the facility did not ensure that medication carts were locked when not under the direct supervision of a licensed nurse. On two separate occasions, medication carts were observed unlocked and unattended in areas accessible to residents and visitors. In one instance, a nurse admitted to leaving the cart unlocked while away from the area. In another instance, a medication cart was left unlocked in a hallway, out of sight of the nursing desk, while a nurse was at the desk and a CNA was occupied elsewhere. The Director of Nursing acknowledged that medication refrigerator temperatures should be checked twice daily and that medication carts must be locked when unattended. However, there was a lack of proper procedures and accountability in place to ensure these practices were consistently followed, leading to potential risks to the safety and efficacy of medications and vaccines stored in the facility.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, as observed by surveyors during an inspection of the main kitchen's cook's refrigerator and walk-in freezer. The inspection revealed multiple instances of improperly labeled, dated, and stored food items. Specifically, the cook's refrigerator contained undated and unlabeled peeled hard-boiled eggs, muffins, and sliced deli meats. Additionally, some food items, such as raw hamburger patties and cooked elbow pasta, were either improperly dated or left open to air, compromising their safety. The walk-in freezer also contained unsecured and open bags of corn kernels and carrot slices, exposing them to potential environmental contaminants. During an interview, the Food Service Manager acknowledged that all food stored in the refrigerator and freezer should be labeled, dated, and properly stored to ensure food safety. The manager stated that food not in its original packaging should be discarded after 48 hours, and any improperly labeled, dated, or stored food should be discarded. The failure to follow these protocols poses a risk of foodborne illness to residents, who are considered high-risk individuals.
Inaccurate Documentation of Fluid Intake for Resident with Fluid Restriction
Penalty
Summary
The facility failed to maintain accurate documentation of fluid intake for a resident with a prescribed fluid restriction of 1200 milliliters per day. The resident, who had diagnoses including congestive heart failure and hyponatremia, was observed consuming fluids that were not accurately recorded in the Medication Administration Records (MAR) for March 2025. The records did not reflect the correct amounts of fluid intake for each shift or the total for a 24-hour period. The facility's policy required the nursing and dietary departments to collaborate on fluid distribution and documentation, but this was not effectively implemented. Interviews with nursing staff revealed inconsistencies in documenting fluid intake, with some nurses only recording the fluids they personally administered and not including house supplements. Certified Nursing Assistants (CNAs) reported that they verbally communicated fluid intake to nurses, but there was no designated place for them to document it. The Director of Nurses acknowledged that the current practice did not ensure accurate tracking of the resident's fluid intake, as there was no system in place to verify if the resident's daily fluid restriction was met or exceeded.
Failure to Reassess Bed Safety with Specialty Mattresses
Penalty
Summary
The facility failed to conduct a new assessment of bed, side rails, and mattresses for potential entrapment risks when the mattress was changed for two residents with limited mobility. Resident #12, who had Parkinson's disease and dementia, was observed with bilateral side rails and an air mattress set to 120 pounds. The facility's policy required checking compatibility and ensuring proper installation of bed components, but there was no reassessment after the air mattress was introduced. Similarly, Resident #15, with severe cognitive impairment and a history of falls, was found with a perimeter air mattress that was not aligned with the bed frame, creating large gaps between the mattress and the head and footboards. The Maintenance Director admitted to conducting bed entrapment checks only once a year and was unaware of the need to reassess beds when specialty mattresses were added. The last assessment was in August 2024, and it was discovered that 10 out of 36 beds with specialty mattresses had not been reassessed for entrapment risks. The Director of Nursing confirmed that these beds should have been reassessed, indicating a lapse in following the facility's policy and procedures for ensuring resident safety.
Failure to Provide Baseline Care Plan Summary to Resident and Representative
Penalty
Summary
The facility failed to provide a resident and their representative with a summary of the baseline care plan within 48 hours of admission, as required by the facility's policy. The resident, who was admitted with multiple diagnoses including repeated falls, dementia, and metabolic encephalopathy, was observed to be confused and unable to be interviewed. The resident's family member expressed uncertainty about the resident's care and mentioned that no formal meeting had occurred to discuss the care plan. The baseline care plan document lacked signatures from the resident and their representative, indicating it had not been reviewed with them. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the baseline care plan had not been provided to the resident or their representative. The DON acknowledged that a care plan meeting had not yet taken place, and the Administrator admitted that the staff should have offered the care plan summary to the resident's representative but did not. The facility's policy requires that a baseline care plan be developed and shared with the resident and their representative within 48 hours of admission, but this was not adhered to in this case.
Failure to Ensure Proper Documentation and Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of clinical practice for two residents. For one resident, the facility did not obtain a physician's order for the provision of Hospice services. The resident, who had diagnoses including Parkinson's disease and dementia, was admitted to the facility in March 2016. Despite receiving Hospice care, there was no physician's order documented in the medical record. Interviews with the nursing staff and the Director of Nursing confirmed the absence of a physician's order for Hospice services. For another resident, the facility failed to transcribe handwritten physician's telephone orders for Carbidopa-Levodopa ER capsules into the electronic medical record. This resident, admitted in October 2024, had severe cognitive impairment and a history of falls. The handwritten orders, which included instructions to open the capsules and mix them with food or supplements, were not entered into the electronic medical record. The Director of Nursing acknowledged that the orders should have been transcribed but were not. Additionally, the facility did not conduct neurological checks after the resident sustained unwitnessed falls. The resident experienced five unwitnessed falls between October 2024 and February 2025, but neurological assessments were not conducted following three of these falls. The facility's policies required neurological checks for any unwitnessed fall, but the Director of Nursing confirmed that these assessments were not completed as required.
Failure to Follow Fall Management Policy
Penalty
Summary
The facility failed to adhere to its Fall Prevention and Management policy when a resident experienced an unwitnessed fall. The policy requires a complete head-to-toe assessment by a nurse before moving a resident who has fallen, unless there is a life-threatening safety concern. However, two CNAs moved the resident from the floor to a Broda chair without a nurse's assessment. The resident, who had severe cognitive impairment and a history of falls, was found on the floor with discoloration on the right cheek after the fall. The incident report did not include statements from the staff involved, and the Director of Nursing was unaware of which CNAs moved the resident. Interviews revealed that CNA #3 and another unidentified CNA moved the resident without waiting for a nurse's assessment. Nurse #6 confirmed witnessing the CNAs lifting the resident without prior assessment. The facility's failure to follow its policy resulted in a deficiency in promoting and managing safe nursing care.
Deficiency in Respiratory Equipment Care
Penalty
Summary
The facility failed to provide proper care and storage of respiratory equipment for a resident with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. The resident was observed using a nebulizer machine, but the tubing and mouthpiece were not stored in a plastic bag as required by the facility's policy, potentially exposing them to environmental contaminants. Additionally, the oxygen concentrator used by the resident was found to be covered in dust and hair, with the external rear filter also laden with dust. Interviews with staff revealed a lack of clarity regarding the responsibility for cleaning and maintaining the oxygen concentrators. Nurse #3 indicated that housekeeping was responsible for wiping down the equipment, while Housekeeper #1 stated that cleaning oxygen concentrators was not part of her duties. The Maintenance Director also confirmed that neither housekeeping nor maintenance staff were responsible for cleaning the concentrators or filters, attributing the task to nursing staff. The Director of Nursing (DON) acknowledged that the nebulizer equipment should have been stored properly and that there was no physician's order for cleaning the oxygen concentrator or its filter. The DON stated that the night shift nursing staff was responsible for monitoring and cleaning the equipment weekly, but there was no documentation to confirm that these tasks were being performed. This lack of documentation and clarity in responsibilities contributed to the deficiency in providing safe and appropriate respiratory care for the resident.
Failure to Conduct Side Rail Risk Assessments
Penalty
Summary
The facility failed to conduct necessary assessments for the risk of entrapment with the use of side rails for three residents. For Resident #12, who was admitted in March 2016 with diagnoses including Parkinson's disease and dementia, the facility did not perform an initial side rail assessment upon admission or when the resident received an air overlay pressure reducing mattress. This oversight meant there was no evaluation to ensure the resident was not at risk of entrapment and that the bed's dimensions were suitable for the resident's size and weight. Resident #15, admitted in October 2024 with Parkinson's disease and severe cognitive impairment, also did not receive an initial side rail assessment. Additionally, the facility did not attempt appropriate alternatives before installing the side rails, nor did they conduct an assessment when the resident received a perimeter air mattress. The medical record lacked documentation of these assessments, and the Director of Nursing confirmed the absence of such records. For Resident #33, admitted in November 2022 with Alzheimer's disease, the facility failed to attempt appropriate alternatives before installing side rails and did not conduct a quarterly bed rail assessment. The last recorded side rail assessment was in October 2023, and no subsequent assessments were found. Nurse #1 confirmed the lack of documentation for side rail assessments following the October 2023 assessment.
Failure to Address Pharmacy Consultant Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed in a timely manner and maintained as part of the permanent medical record for three residents. For Resident #7, the facility did not act upon the June 2024 consultant pharmacist's recommendation to clarify the need for two as-needed Guaifenesin orders. The Director of Nursing (DON) acknowledged that there was no documentation indicating that the recommendation had been addressed, which signifies that the action was not completed. For Resident #16, the facility did not address the consultant pharmacist's recommendation for an order clarification regarding the resident's bowel medications. The recommendation was made in June 2024, but the medical record lacked evidence that the nursing staff reviewed and addressed the order clarification request. The DON confirmed that there was no documentation to show that the recommendation had been acted upon. Resident #2's medical record did not contain the consultant pharmacy recommendation dated June 5, 2024, which included suggestions for a thyroid lab and a reassessment of the ongoing need for Protonix. The Pharmacy Consultant confirmed that these recommendations were communicated to the DON, but the medical record did not reflect any review or action taken by the physician or physician extender. The DON later provided copies of the recommendations, but there was no evidence of timely action taken in response to them.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for adverse consequences of anticoagulant medications. The resident, who was admitted in February 2018, had a diagnosis of thrombophlebitis and was prescribed Eliquis, an anticoagulant, to manage this condition. The physician's orders required monitoring for signs and symptoms of bleeding or bruising every shift while the resident was on Eliquis. However, a review of the medical records from January 2025 through March 2025 revealed that although Eliquis was administered as ordered, there was no documentation indicating that staff monitored the resident for bleeding as required. During an interview, the Director of Nursing acknowledged that the monitoring order was not included in the Medication Administration Record or Treatment Administration Record, which prevented the staff from documenting any potential side effects. This oversight meant that the facility could not determine if the resident was experiencing any adverse effects from the medication.
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 24 citations issued within 25 miles in the last 12 months — including the 1 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 Provincetown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cape Cod Post Acute Care | 24 mi | ★★★★★ | 0 | 0 |
| Regalcare At Harwich | 24.6 mi | ★★★★★ | 6 | 0 |
| Plymouth Harborside Healthcare | 24.8 mi | ★★★★★ | 18 | 1 |
| Life Care Center Of Plymouth | 25.1 mi | ★★★★★ | 0 | 0 |
| Plymouth Rehabilitation & Health Care Center | 25.3 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.