Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cape Heritage Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
Trash and refuse were observed overflowing from dumpsters and laundry carts, with bags and debris scattered on the ground and many receptacles left uncovered. Staff and the trash removal contractor reported that trash pickups were frequently missed due to non-payment, leading to ongoing unsanitary conditions. The administrator was unaware of the issue.
Essential kitchen equipment, including the walk-in freezer, stove hood, and ice machine, was not properly maintained. The freezer had a broken door seal, missing strip curtains, and significant ice buildup affecting food storage. The stove hood inspection was overdue, and the ice machine filter had not been changed as scheduled. Staff interviews confirmed lack of awareness and overdue maintenance for this equipment.
The facility did not maintain its septic system drain field or increase septic tank pumping, resulting in effluent water surfacing in the parking lot and creating a strong sewage odor. Staff and consultants confirmed the issue had persisted without resolution, and the facility was unable to provide a timeline or mitigation plan for the ongoing problem.
Surveyors found numerous unresolved maintenance and cleanliness issues on one unit, including broken fixtures, water damage, exposed wiring, and makeshift repairs. Multiple residents reported persistent problems such as broken beds, clogged sinks, and damaged furnishings, while staff interviews revealed inadequate reporting and tracking of maintenance needs. Facility leadership acknowledged the deficiencies and the need for better systems and staff awareness.
A resident with a chronic wound at a former G-tube site did not receive wound care as ordered, including failure to transcribe and implement updated stoma clinic recommendations, use the correct appliance size, and apply stoma powder daily. Documentation showed missed or unsigned treatments, and persistent skin maceration was not reported to the physician or clinic. Staff interviews revealed confusion about current orders and lack of communication with the resident's health care proxy.
Surveyors observed that the facility did not maintain proper food safety and sanitation in a kitchenette and the main kitchen. The kitchenette refrigerator and cabinets were found dirty, with food items mixed with trash and a leaking sink causing stains and soiling. In the main kitchen, multiple food items in the walk-in refrigerator and freezer were unlabeled, undated, improperly stored, or exposed to contamination, with open boxes and condensation present. The food service manager acknowledged that required labeling, dating, and storage practices were not followed.
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at safe and appetizing temperatures. Multiple residents expressed concerns about cold and bland food, and test tray evaluations confirmed that many food items were outside acceptable temperature ranges. The Food Service Director and Dietitian acknowledged these issues.
The facility failed to maintain sanitary conditions in the main kitchen, properly label and date food items, handle ready-to-eat food with proper hygiene, and clean and sanitize food-contact surfaces. Observations included buildup of debris, unlabeled food, improper glove use, and unclean prep tables. The FSD acknowledged these issues, which were not in line with the facility's policies.
The facility failed to maintain resident rooms in good repair, with several rooms having chipped and loose popcorn ceilings. Residents reported the disrepair had persisted for months, with concerns about safety and cleanliness. The Maintenance Director and Administrator were aware but had not yet completed repairs.
A resident reported a threat of harm from a visitor, but the facility failed to report the incident to the Department of Public Health's HCFRS within the required timeframe, despite notifying the police and obtaining a no trespass order.
The facility failed to secure psychotropic medication on a locked dementia unit, leaving a Trazodone tablet unattended on a medication cart, accessible to residents. Nurse #1 admitted the mistake, and both the Unit Manager and DON confirmed that prepared medication should not be left unattended.
A resident with dementia and diabetes experienced significant weight loss, and the facility failed to document the resident's weight as ordered by the physician. Despite orders to weigh the resident weekly, there were no documented weights between certain dates, and the Treatment Administration Record did not include numeric values for the weights.
The facility failed to ensure staff adhered to infection control protocols for PPE use during high-contact resident care activities, as required by the Enhanced Barrier Precautions Policy. Observations revealed staff inconsistently wore gowns and gloves and did not perform hand hygiene, despite posted CDC Enhanced Barrier Precaution signs.
The facility failed to ensure a clean and safe environment by not properly disposing of cigarette butts in designated smoking receptacles. Observations revealed numerous cigarette butts scattered around the smoking area, and staff interviews confirmed that residents were not allowed to smoke without supervision and that cigarette butts should be disposed of properly. The maintenance director admitted that while the cement area was swept daily, the grassy area was not often raked, leading to the accumulation of cigarette butts.
Improper Disposal and Containment of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that trash, garbage, and refuse were properly disposed of and contained within receptacles constructed with tight-fitting lids, as required by the 2022 Food Code. Observations made by the surveyor revealed that both the recyclable cardboard and general refuse dumpsters were overflowing, with numerous trash bags, cardboard boxes, and miscellaneous debris scattered on the ground inside the fenced dumpster area. Additional trash, including black and clear plastic bags, was found overflowing from laundry carts and a dolly cart outside the fenced area, with several bags having fallen onto the ground. Many of these receptacles and carts were uncovered, further contributing to unsanitary conditions. Interviews with facility staff and the outside trash removal contractor indicated that the trash overflow was a frequent occurrence due to irregular trash pickups, which the contractor attributed to non-payment by the facility. Dietary staff confirmed that trash often overflows because it is not picked up regularly. The facility administrator stated she was unaware of the trash not being removed or of any payment issues. No information about residents' medical history or condition was provided in relation to this deficiency.
Failure to Maintain Kitchen Equipment in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential mechanical equipment in the main kitchen in a safe and operable condition. Observations revealed that the walk-in freezer door could not fully seal due to ice buildup, with only two intact plastic freezer strip curtains and significant ice accumulation at the base of the door and inside the freezer. Frozen condensation was present on the ceiling, metal racks, and inside food boxes and packaging, including hamburger tubes encased in frozen condensation. The Director of Maintenance confirmed the freezer was frozen over when he started, the strip curtains were broken, and the door was not sealing. Additionally, the stove hood inspection was found to be overdue by 269 days, as indicated by the inspection sticker and confirmed by dietary staff. The ice machine filter was also overdue for replacement by three and a half months, with maintenance staff stating that a company is responsible for changing the filter and it had not been done. The Administrator was aware of the overdue hood inspection but not the freezer condensation or overdue ice machine service. The Food Service Manager was not aware of the regular maintenance schedule for the kitchen equipment, stating that maintenance handles all service and regular maintenance.
Failure to Maintain Septic System Results in Wastewater Surfacing
Penalty
Summary
The facility failed to maintain its septic system drain field in working order and did not increase the frequency of septic tank pumping to prevent liquid wastewater from running into the parking lot. Observations revealed water bubbling out from a manhole cover in the lower parking lot, creating a stream of water with a strong sewage odor. Interviews with consultants confirmed that the water was effluent that should have been leaching into the ground, but was instead surfacing due to the drain field not functioning properly. The last recorded septic tank pumping was in March, and no additional pumping had occurred since then, despite ongoing issues, especially during periods of heavy rain. Staff interviews indicated a lack of awareness and communication regarding the septic system's condition and maintenance schedule. The Maintenance Director had only recently started and was unaware of the full history, while the Regional Maintenance Director and Administrator could not provide a timeline of when the problem began or what mitigation steps had been taken. The facility did not provide the requested documentation or a mitigation plan during the survey, and the issue of wastewater surfacing in the parking lot remained unresolved at the time of the survey exit.
Failure to Maintain a Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for residents on one unit, as evidenced by multiple maintenance and cleanliness issues observed during surveyor tours and confirmed by resident interviews. Specific deficiencies included loose and duct-taped keypads, missing bathroom light panels with exposed bulbs, broken heating panels, unpainted and water-damaged walls, peeling wallpaper, cracked and stained ceiling tiles, missing molding, frayed and ripped curtains, and missing or makeshift room number displays. Additional issues were found in common areas, such as an unlocked electrical panel with exposed wires, missing molding, water-damaged countertops, cabinets held together with zip ties, and a rotting exterior door with visible holes. Resident rooms also had problems such as dirty air conditioner filters, water damage, and damaged wheelchairs. Residents reported ongoing problems, including broken beds held together with duct tape, clogged sinks, and maintenance issues that had persisted since admission. Staff interviews revealed that maintenance relied on a notebook system for reporting issues, which was inconsistently used and primarily addressed staff-related concerns rather than resident needs. Both the Director and Regional Director of Maintenance acknowledged the poor condition of the unit and the inadequacy of the current reporting and tracking system. The Administrator confirmed expectations for a safe and homelike environment and recognized the need for improved processes and staff awareness regarding environmental standards.
Failure to Implement and Document Wound Care Orders for Resident with Gastrocutaneous Fistula
Penalty
Summary
A deficiency occurred when a resident with a chronic wound at a former gastrostomy tube site did not receive necessary wound care and services as ordered and recommended by consulting specialists. The facility failed to transcribe and implement updated wound care recommendations from the stoma clinic, including the use of a specific appliance size and frequency of stoma powder application. The orders in the medical record did not match the supplies being used, and the most recent recommendations for a smaller appliance size were not reflected in the physician's orders or in the supplies available to staff. Additionally, the daily application of stoma powder, as recommended after a hospital visit for maceration, was not transcribed into the electronic medication administration record (eMAR/eTAR), resulting in missed treatments. Documentation revealed multiple missed or unsigned wound care treatments, including appliance changes and application of silver nitrate and stoma powder. The transition from paper to electronic charting further contributed to incomplete transcription of orders, and there were several instances where the required treatments were not documented as completed. Progress notes indicated ongoing maceration of the skin around the wound, but there was no evidence that the physician or stoma clinic was notified of this persistent issue, as required by facility policy. Interviews with nursing staff and management confirmed a lack of clarity regarding the current treatment orders and the rationale for appliance selection. Staff were unsure why the orders and supplies did not match, and there was no documentation that the resident or their health care proxy was educated about or involved in decisions regarding changes to the wound care regimen. The Director of Nursing acknowledged that the orders and supplies should match, and that the physician and stoma clinic should have been notified of the ongoing maceration, but this did not occur.
Failure to Maintain Food Safety and Sanitation Standards in Kitchen and Kitchenette
Penalty
Summary
The facility failed to maintain food safety and sanitation standards in both a kitchenette and the main kitchen, as observed by surveyors. In one of the unit kitchenettes, the refrigerator contained a clear basket of creamers mixed with a used disposable wipe, artificial sweetener packets, alcohol prep pad cartons, and cartons of lactose-free milk. The door shelf held rolled-up used napkins, unlabeled peppermint patties, mayonnaise packets, and a carton of milk. A black insulated container was found on its side, unlabeled and stuck in a dried, sticky liquid on the shelf. The upper cabinets were visibly dirty with loose cup covers, random cups, and spoons. Under the sink, a leaking drainpipe had caused a large black stain on the cabinet floor, with a soiled white towel placed directly under the leak. In the main kitchen's walk-in refrigerator, multiple food items were found unlabeled, undated, or improperly stored. These included a large container of cooked macaroni, an unidentified food item wrapped in plastic, an unsealed package of partially cooked bacon, a metal container of cut watermelon, and several dishes of cut vegetables and salads. Some items were labeled with dates that exceeded the facility's policy for discarding potentially hazardous foods, while others were not labeled or dated at all. Raw chicken and hamburger were stored in reusable plastic bags without labels or dates and placed on top of other food items without drip trays, contrary to professional standards and facility policy. The walk-in freezer was also found to be in poor condition, with boxes stacked on the floor, heavy frozen condensation on the ceiling and boxes, thick ice buildup around the door, and open boxes with internal bags exposed to frozen condensation. Several food items, such as pancakes, biscuits, strawberries, pie crusts, and frozen patties, were not properly sealed. The food service manager confirmed that food should be labeled, dated, and discarded if older than three days, and that boxes and bags should be sealed to prevent condensation, but these practices were not followed.
Failure to Ensure Food Palatability and Temperature
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at safe and appetizing temperatures. Multiple residents expressed concerns about the temperature and quality of the food, with complaints ranging from food being ice cold, bland, and visually unappealing. These concerns were consistently raised during Resident Council meetings and individual interviews with the survey team. Specific examples included residents stating that their food was often cold, with some resorting to ordering takeout or having family members bring them food due to the poor quality of the facility's meals. Test tray evaluations conducted by the survey team further confirmed these issues. During a lunch test tray, the food truck left the kitchen at 1:16 P.M. and arrived on the unit at 1:17 P.M., but the food temperatures recorded at 1:35 P.M. showed mixed vegetables at 124°F, a dinner roll at 127°F, and lasagna at 152°F. Similarly, a breakfast test tray showed an omelet and hashbrown at 123°F and orange juice at 56°F. The Food Service Director (FSD) acknowledged the issues but declined to taste the test trays. The Dietitian also noted that meal temperatures have been inconsistent, particularly for breakfast. Review of Room Test Tray Evaluation forms indicated that many food items were outside the acceptable temperature ranges. Examples included a pulled pork sandwich at 134.2°F, mixed vegetables at 122°F, and milk at 60.6°F upon delivery. These findings were consistent across multiple test trays conducted on different dates, with the Dietitian and Administrator both acknowledging the ongoing issues with food temperatures. The Administrator confirmed that he was aware of the residents' concerns and had experienced similar issues during his evaluations.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain the main kitchen in a sanitary condition, as observed by the surveyor. There was a buildup of food crumbs and debris along the perimeter of the kitchen floor, dried food splashes on large bins, dirty wheeled carts, cobwebs on shelving, and various items and debris on the floor in the dry storage room. The facility's policy required the kitchen to be kept clean and sanitary, but the most recent documentation of the Closing Check List was from several months prior, indicating a lack of regular cleaning and maintenance. The Food Service Director (FSD) acknowledged these issues during interviews, stating that the kitchen should be free of dust and debris to prevent contamination of food and surfaces. The facility also failed to properly label and date food items in the main kitchen refrigerators and dry storage areas. The surveyor found multiple opened food items without labels or dates, including ham luncheon meat, pre-cooked meatballs, cottage cheese, side salads, cubed potatoes, shredded cheese, muffin mix, and brown powder. The facility's policy required all food items to be labeled and dated, but this was not followed. The FSD and Regional FSD confirmed that all open food items should be labeled and dated, and acknowledged the discrepancies found by the surveyor. Additionally, the facility did not handle ready-to-eat food with proper hand hygiene and single-use gloves, leading to potential cross-contamination. The surveyor observed dietary staff making sandwiches without gloves, using soiled oven mitts, and handling food with the same gloves used for other tasks. The FSD admitted that oven mitts had not been laundered for months and that staff should change gloves and wash hands between tasks. Furthermore, the facility failed to clean and sanitize food-contact surfaces and utensils between uses. The surveyor observed staff placing sandwiches directly on a prep table and reusing a knife without cleaning or sanitizing them. The Regional FSD confirmed that these practices were not in line with the facility's policies and could lead to cross-contamination.
Facility Failed to Maintain Resident Rooms in Good Repair
Penalty
Summary
The facility failed to ensure resident rooms were maintained in good repair to promote a homelike environment on one of three units. Specifically, the facility did not repair areas of chipped and loose textured ceiling, also known as popcorn ceiling, in five resident rooms. During observations and interviews, several residents reported that the popcorn ceiling had been in disrepair for several months, with some areas peeling and falling. One resident mentioned that a piece of the ceiling fell and hit them on the head, although no injury occurred. The residents expressed concerns about the unsightly appearance and potential hazards of the peeling ceiling. The Maintenance Director acknowledged awareness of the issue and stated that efforts were being made to chip away loose areas and secure a vendor for repairs. The Administrator was also aware of the situation. Despite these acknowledgments, the ceiling remained in disrepair, affecting the residents' perception of their living environment and raising concerns about safety and cleanliness.
Failure to Report Alleged Abuse Incident in Required Timeframe
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident and a visitor within the required timeframe. Resident #66, who was admitted with diagnoses including dementia, diabetes mellitus, and PTSD, reported to the social worker that a visitor had threatened to harm them if they did not produce certain baseball cards. This incident was reported to the social worker on 3/24/24, but the facility did not submit a report to the Department of Public Health's Health Care Facility Reporting System (HCFRS) as required by their policy. Interviews with the Director of Social Services, Unit Manager, and Administrator confirmed that while the police were notified and a no trespass order was obtained to ensure the resident's safety, the incident was not reported in the HCFRS. The facility's policy mandates that such allegations be reported immediately, but not later than 2 hours if the events involve abuse or result in serious bodily injury, or within 24 hours if they do not. The failure to report the incident in the HCFRS constitutes a deficiency in adhering to the required reporting procedures.
Failure to Secure Psychotropic Medication
Penalty
Summary
The facility failed to ensure that psychotropic medication was secured and not accessible to residents on the [NAME] unit, a locked dementia unit where 28 of 30 residents were diagnosed with Alzheimer's/dementia. Specifically, Nurse #1 was observed popping one Trazodone 12.5 mg tablet into a medication cup and placing it on top of the medication cart. Nurse #1 then walked down the hall to the nurses' station, leaving the medication cup unattended on the cart outside of room [ROOM NUMBER]. Four residents were observed standing around the medication cart, with one resident resting their hand on the cart. During interviews, Nurse #1 admitted to making a mistake by leaving the prepared medication unattended. Unit Manager #2 confirmed that prepared medication should never be left unattended. The Administrator and the Director of Nurses (DON) also stated that prepared medication should not be unattended and accessible to residents. The facility's policy indicated that medications should be stored in a locked mobile medication cart accessible only to licensed nursing personnel or in a locked medication room.
Failure to Document Resident Weight as Ordered
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident, specifically Resident #66, who had diagnoses of dementia and diabetes. The deficiency was identified when the facility did not document the resident's weight as ordered by the physician. The Minimum Data Set (MDS) assessment indicated that Resident #66 had experienced significant weight loss and was not on a prescribed weight loss regimen. A progress note dated 2/9/24 indicated that the resident's weights were trending down, and a new order was obtained to weigh the resident weekly for four weeks, then monthly. However, the weight summary showed no documented weights between 2/16/24 and 3/7/24, despite the Treatment Administration Record (TAR) indicating that the resident had been weighed on 2/24/24 and 3/2/24 without numeric values recorded. During interviews, the Unit Manager (UM) confirmed that the facility did not use a weight book and that weights were supposed to be recorded in the resident's TAR or electronic medical record. Upon review, it was found that the weights had not been documented as required. The Director of Nurses (DON) stated that the expectation was for weights to be obtained and documented in the resident's record as ordered, which was not done in this case.
Failure to Adhere to Infection Control Protocols for PPE Use
Penalty
Summary
The facility failed to maintain an infection prevention and control program, specifically in ensuring staff adhered to infection control protocols for personal protective equipment (PPE) use. Observations revealed that staff did not consistently wear gowns and gloves during high-contact resident care activities, as required by the facility's Enhanced Barrier Precautions Policy. For instance, a Certified Nursing Assistant (CNA) was observed sorting linen and changing a resident into a hospital gown with only one glove on and no additional PPE, despite a CDC Enhanced Barrier Precaution sign posted at the entrance of the room. Another instance involved two CNAs shifting a resident in bed while only wearing gloves and not performing hand hygiene upon exiting the room. Additionally, a CNA was seen feeding a resident and touching both the resident's face and her own face without gloves, and later improperly donning a gown and gloves after being informed of the required precautions. Interviews with staff, including the Infection Control Nurse (ICN) and the Director of Nurses (DON), confirmed that staff should follow the Enhanced Barrier Precautions signs posted outside of the rooms, which include wearing gowns and gloves during high-contact care activities and performing hand hygiene when entering and exiting the rooms. However, the observations indicated a lack of adherence to these protocols, leading to potential risks of transmission of communicable diseases and infections within the facility.
Improper Disposal of Cigarette Butts in Smoking Area
Penalty
Summary
The facility failed to ensure a functional, safe, and clean environment by not properly disposing of cigarette butts in designated smoking receptacles. Observations on multiple occasions revealed numerous cigarette butts scattered on the pavement and in the grass around the smoking area, despite the presence of a receptacle. Interviews with staff members confirmed that residents were not allowed to smoke without a staff member present and that all cigarette butts should be disposed of in the receptacle. However, the maintenance director admitted that while the cement area was swept every morning, the grassy area was not often raked, leading to the accumulation of cigarette butts. The facility's policy on smoking, revised in November 2020, aimed to provide a healthy and safe environment by limiting tobacco use and ensuring proper disposal of cigarette butts. Despite this policy, the surveyor's observations and staff interviews indicated non-compliance. The administrator acknowledged that the smoking area should be cleaned frequently and that cigarette butts should not be on the ground, but the maintenance director's comments highlighted a gap in the cleaning routine, particularly in the grassy area around the smoking zone.
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 160 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 Sandwich
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bourne Manor Extended Care Facility | 4.3 mi | ★★★★★ | 0 | 0 |
| Royal Cape Cod Nursing & Rehabilitation Center | 4.9 mi | ★★★★★ | 6 | 0 |
| Royal Of Cotuit | 9.6 mi | ★★★★★ | 11 | 0 |
| Royal Megansett Nursing & Rehabilitation | 9.8 mi | ★★★★★ | 0 | 0 |
| Tremont Rehabilitation & Skilled Care Center | 11.2 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cape Heritage Rehabilitation & Health Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.