Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Pavilion , The during CMS and state inspections, most recent first.
The facility failed to maintain and store respiratory equipment safely for two residents. One resident's oxygen concentrator and filter were dusty and not cleaned as per orders, while another resident's CPAP equipment was improperly stored, exposing it to contamination. Staff acknowledged the lapses, which were against facility policy.
A facility failed to create a trauma-informed care plan for a resident with PTSD, neglecting to identify and mitigate specific trauma triggers. Despite the resident's willingness to share their trauma and triggers, staff were unaware of these details, and care plans lacked clarity on the resident's specific needs. The Director of Social Services admitted that the care plans did not clearly indicate the resident's triggers, potentially leading to re-traumatization.
A facility failed to maintain monthly medication regimen reviews (MRRs) as part of a resident's permanent medical record and did not address pharmacy consultant recommendations timely. The facility's policy required MRR reports to be provided to the DON, attending physician, and Medical Director, and kept in the resident's health record. However, the facility lacked Consultation Report forms for certain months, and a recommendation was re-issued due to inaction. The Unit Manager had to contact the Consultant Pharmacist to retrieve missing reports, and the DON confirmed that irregularities should be addressed before the next MRR.
A facility failed to maintain accurate medical records for a resident, resulting in a discrepancy between the resident's MOLST and current physician's orders. The resident's MOLST indicated a do-not-resuscitate status, but the facility's records showed conflicting orders, listing the resident as a full code. Staff interviews revealed a lack of awareness regarding the resident's legal guardianship and the validity of the MOLST, leading to potential delays in emergency medical treatment. The facility's policies on health information management and advanced directives were not effectively implemented, as the MOLST remained in the chart despite being invalid.
Failure to Maintain and Store Respiratory Equipment Safely
Penalty
Summary
The facility failed to maintain and store respiratory equipment in a safe and sanitary manner for two residents. For one resident, the oxygen concentrator and external filter were observed to be laden with dust, and the filter was not cleaned as per the physician's orders. The nursing staff admitted to not cleaning the filter despite the order to do so weekly and as needed. The Director of Nursing confirmed that the expectation was for the nursing staff to clean the concentrator and filter weekly and as needed. For another resident, the CPAP tubing and nasal pillow mask were not stored in a sanitary manner when not in use. The equipment was observed hanging over the bedrail, exposed to environmental debris and potential contamination. The resident was unable to manage the CPAP equipment due to a recent stroke, and the staff was responsible for its application, removal, and proper storage. The Unit Manager and Director of Nursing acknowledged that the equipment should have been stored in a respiratory equipment bag to protect it from contamination. The facility's policy on equipment change and disinfection was not followed, leading to the unsanitary conditions observed. The policy required thorough cleaning of equipment surfaces and proper storage of supplies in labeled treatment bags. The failure to adhere to these guidelines resulted in the deficiencies noted by the surveyors.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a person-centered plan of care for a resident with PTSD, which included identifying and mitigating trauma triggers to avoid potential re-traumatization. The facility's policy on trauma assessment and care guidelines required that trauma survivors receive culturally competent, trauma-informed care, and that care plans include trauma triggers and interventions. However, the care plans for the resident did not specify the resident's triggers, despite the resident expressing a desire to discuss their trauma and triggers during assessments. The resident, who was admitted with diagnoses including depression, anxiety, and PTSD, was moderately cognitively impaired and had a trauma-informed assessment completed. The assessment revealed that the resident had experienced childhood trauma, which still affected them, and they had a community therapist for ongoing sessions. Despite this, interviews with staff indicated a lack of awareness regarding the resident's PTSD triggers, with staff members unaware of specific triggers that should be avoided to prevent exacerbating the resident's anxiety or PTSD. The Director of Social Services acknowledged that while the resident's trauma and triggers were documented in progress notes, they were not clearly indicated in the care plans. This lack of clarity in the care plans meant that staff were not adequately informed about the resident's specific triggers, which could lead to potential re-traumatization. The care plans included general interventions for anxiety and depression but failed to address the resident's specific PTSD triggers.
Failure to Maintain and Address Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews (MRRs) were maintained as part of the permanent medical record and that recommendations made by the pharmacy consultant were addressed in a timely manner for a resident. The facility's policy required that the consultant pharmacist provide MRR reports to the Director of Nursing (DON), attending physician, and Medical Director, and that these reports be maintained in the resident's permanent health record. However, for one resident, the facility did not have the Consultation Report forms for February and April 2024 in the medical record, and the May 2024 recommendation was a re-issued recommendation from February 2024 that had not been addressed. During an interview, the Unit Manager was unable to locate the Consultation Report forms and had to contact the Consultant Pharmacist to retrieve them. The DON confirmed that MRRs are completed monthly and that irregularities should be addressed before the next MRR. The failure to maintain these records and address the recommendations in a timely manner led to the deficiency identified by the surveyors.
Inconsistent Medical Records and MOLST Discrepancy
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards of practice for a resident, leading to a discrepancy between the resident's Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) and the current physician's orders. The resident, who had diagnoses including Alzheimer's disease and dementia, was admitted with a MOLST indicating a do-not-resuscitate status, but the facility's records showed conflicting orders, listing the resident as a full code. This inconsistency was not addressed, and the MOLST remained in the resident's chart despite being deemed invalid due to the resident's incapacitated status and the lack of authority granted to the legal guardian to make advanced directive decisions. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's legal guardianship and the validity of the MOLST. The Director of Social Services and the Director of Nursing acknowledged that the MOLST was completed without knowledge of the resident's legal guardian status, and the guardian did not have the authority to make advanced directive decisions. The facility's process for verifying and updating code status during emergencies relied on the paper MOLST, which was inconsistent with the electronic medical record, potentially delaying emergency medical treatment. The facility's policies on health information management and advanced directives were not effectively implemented, as evidenced by the failure to ensure that the resident's medical records accurately reflected their treatment preferences and legal status. Staff interviews highlighted the reliance on paper records during emergencies, which could lead to confusion and delays in care. The medical records department confirmed that the MOLST should have been removed from the resident's chart once it was deemed invalid, but this action was not taken, resulting in ongoing discrepancies in the resident's code status.
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 85 citations issued within 25 miles in the last 12 months — 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 Hyannis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cape Regency Rehabilitation & Health Care Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Mayflower Place Nursing & Rehabilitation Center | 3.3 mi | ★★★★★ | 8 | 0 |
| Windsor Nursing & Retirement Home | 7.3 mi | ★★★★★ | 6 | 0 |
| Royal Of Cotuit | 7.9 mi | ★★★★★ | 11 | 0 |
| Cape Heritage Rehabilitation & Health Care Center | 12.4 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.