Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Royal Cape Cod Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Document GDRs for Psychotropic Medications: Two residents with psychiatric diagnoses and intact cognition were receiving multiple psychotropic meds, including antipsychotic, antidepressant, antianxiety, and mood-stabilizing agents. MD and NP notes repeatedly stated moods and behaviors were stable and current meds should continue, but the record did not show a GDR attempt or a documented clinical contraindication for either resident. The DON stated she could not find such documentation in the medical record.
Failure to Implement Ordered Pressure Ulcer Treatments: Two residents did not receive pressure ulcer care as ordered. One resident with new DTI areas on the buttocks had no physician notification or treatment orders implemented for over two weeks, and staff documented only cleansing and barrier cream use. Another resident with a stage III buttock ulcer had wound consultant recommendations for calcium alginate, but the TAR continued to show xeroform instead, with the order not matching the consultant’s recommendations for an extended period.
Call Lights Kept Out of Reach of Two Residents: Two residents with significant cognitive and functional impairments were observed in bed with their call lights secured above the bed and out of reach on multiple occasions. The CNA stated they should have their call lights within reach and had no alternative device to call for help, and the DON stated all residents' call lights should be within reach.
A resident with Alzheimer’s disease and moderate cognitive impairment developed two new deep tissue injuries on the buttocks, but the nurse did not notify the attending MD or after-hours coverage when the areas were discovered. The wounds were documented in a skin assessment, yet no physician notification was found in the record and treatment/monitoring orders were not implemented until later; the DON stated new skin areas should be reported even if passed in shift report.
A resident with an indwelling Foley catheter, diabetes, enlarged prostate, urinary retention, and UTI had catheter flushes documented in nurse notes, but the chart lacked a physician order specifying the type and amount of irrigating solution. A nurse, the UM, and the DON all confirmed that Foley catheter irrigation required a physician order and should be documented on the TAR, and the facility policy also stated catheter irrigation must be done under physician orders.
Unlocked Treatment Cart: A treatment cart on one unit was observed unlocked and unattended multiple times while residents and outside vendors were nearby. The facility policy required drugs and biologicals to be stored securely and compartments to be locked when not in use, and both an LPN and the DON stated the cart should always be locked when not under direct supervision.
A resident's physician failed to review care and did not write, sign, and date progress notes and orders at each required visit, resulting in missing required documentation.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition at the time.
A nurse administered 110 mg of Methadone to a resident who was prescribed only 10 mg, after failing to verify the resident's identity and the medication dosage. The error was discovered during a narcotic count, and the resident, who had a complex medical history, required hospital evaluation and monitoring after experiencing lethargy and nausea.
Failure to Document GDRs for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents, both with psychiatric diagnoses and receiving multiple psychotropic medications, had documentation of a gradual dose reduction (GDR) attempt or a documented clinical contraindication for not attempting one. The facility policy stated that residents using psychotropic drugs should receive GDRs unless clinically contraindicated, and the attending physician was to lead medication management in collaboration with the interdisciplinary team. Resident #34 was admitted with diagnoses including bipolar disorder, dementia with behavioral disturbances, anxiety disorder, and depression. The record showed daily use of psychotropic medications including Ativan, Cymbalta, Doxepin, Wellbutrin XL, and Lurasidone, and the MDS indicated the resident was cognitively intact with a BIMS score of 15. Pharmacy recommendations noted a prior GDR recommendation for Doxepin, Wellbutrin, Ativan, and Lurasidone had been declined because the resident was having psychiatric symptoms at that time. However, review of MD and NP progress notes from February 2025 through January 2026 showed repeated statements such as moods and behaviors being stable, cooperative, and to continue current psychotropic medications, without documentation that a GDR was attempted or that a GDR was clinically contraindicated. Resident #6 was admitted with diagnoses including anxiety, depression, and PTSD. The record showed daily psychotropic medication use, including Venlafaxine XR, Mirtazapine, Lamotrigine, and Clonazepam, and the MDS indicated the resident was cognitively intact with a BIMS score of 15. Review of MD and NP progress notes from February 2025 through January 2026 repeatedly documented stable moods and behaviors and continuation of current psychotropic medications, but did not include documentation of a GDR attempt or a clinical rationale for why a GDR was contraindicated. During interviews, the DON stated she could not find documentation showing a GDR evaluation or contraindication for either resident and said she was not aware prescribers had to document this information in the medical record.
Failure to Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that two residents received pressure ulcer care and treatment in accordance with professional standards. For one resident, the record showed new deep tissue injuries on the left medial buttock were identified by nursing staff, but no physician notification, treatment order, or wound monitoring order was implemented until 16 days later. The resident had diagnoses including moderate protein-calorie malnutrition and Alzheimer’s disease, and the MDS indicated moderate cognitive impairment with a BIMS score of 8 out of 15. Nursing documentation on the day the areas were found described two deep purple, non-blanchable areas on the left buttocks, but the nurse only cleansed the areas and applied Eucerin cream. The resident’s care plan called for treatment as ordered, monitoring and documenting wound healing, reporting changes to the MD, and weekly treatment documentation. However, the CNA documentation from the period after discovery did not show barrier cream being applied to the left medial buttocks, and the physician’s orders and TAR did not show treatment and monitoring orders for the left buttock wounds until 12/29/25. The infection control nurse stated he was not sure why no new orders were implemented for 16 days after the wounds were discovered. The nurse who first identified the areas stated she did not call the physician or after-hours service and instead documented the areas in the physician communication log, waiting for the physician’s recommendation. The DON stated the on-call provider should have been notified of the new pressure areas and any recommendations documented in the medical record. For the second resident, the facility did not implement wound treatment orders in accordance with the wound consultant’s recommendations for a stage III right medial buttock pressure ulcer. The resident was cognitively intact, had a BIMS score of 15 out of 15, and had a stage III pressure ulcer on admission. The wound consultant’s notes repeatedly recommended cleansing with normal saline, applying calcium alginate, covering with gauze island border dressing, and applying skin prep and house barrier cream to the periwound. Instead, the TAR showed the resident received xeroform with gauze island border dressing and skin prep and house barrier cream throughout the month, and the medical record did not show the treatment order was updated to match the consultant’s recommendation until 19 days after it was first recommended. The record also did not include documentation explaining the change from the consultant’s recommended calcium alginate to xeroform, and the ADON acknowledged the orders did not match the wound consultant’s recommendations and should have been updated.
Call Lights Kept Out of Reach of Two Residents
Penalty
Summary
The facility failed to ensure a reasonable accommodation was made for two residents by not keeping their call system accessible while they were in bed. The facility policy stated residents are to be educated on how to call for help, evaluated for unique needs and preferences, and provided call lights within reach and accessible while in bed or other sleeping accommodations. Resident #66 was admitted with cognitive impairment, had a BIMS score of 3 out of 15, required assistance with activities of daily living, and could ambulate with supervision or touching assistance. Resident #81 was admitted with Alzheimer's Disease and seizures, was rarely or never understood, was dependent on staff for activities of daily living, and was not ambulatory. Observations showed that on multiple occasions both residents' call lights were secured above the bed and out of reach while they were lying in bed. The surveyor observed Resident #66 in bed with both call lights out of reach, and later observed Resident #81 in bed with both call lights again secured above the bed and out of reach. During interview, a CNA stated both residents should have their call lights within reach and did not have an alternative device in place to call for help, and the DON stated all residents' call lights should be within reach.
Failure to Notify Physician of New Pressure Injuries
Penalty
Summary
The facility failed to ensure the physician was notified when Resident #28 developed two new deep tissue injuries on the left buttocks. Resident #28 was admitted in January 2025 with diagnoses including moderate protein-calorie malnutrition and Alzheimer's disease, and the MDS dated 12/23/25 showed the resident was moderately cognitively impaired with a BIMS score of 8 out of 15. On 12/13/25, Nurse #2 observed two deep purple, non-blanchable areas on the left buttocks, documented them in a skin assessment, and cleansed the areas with Eucerin cream. The skin assessment described one area as 3 cm by 0.25 cm with no depth and the second as a dime-sized, 1 cm round area with no depth. The record review showed no documentation that the attending physician or nurse practitioner was notified of the new pressure injuries when they were identified. Physician orders for treatment and monitoring of the left buttock wounds were not implemented until 12/29/25, and the consultant wound physician first assessed the left medial buttock deep tissue injury on 12/26/25. During interviews, the Infection Control Nurse was unsure when he became aware of the areas or why the physician was not notified, and Nurse #2 stated she did not call the physician or after-hours service, instead documenting the areas in the physician communication log for later review. The DON stated that when a new skin area is discovered, the nurse should notify the attending physician or after-hours coverage even if the information is passed in shift report.
Missing Physician Order for Foley Catheter Flushes
Penalty
Summary
The facility failed to ensure professional standards of care were met for one resident by allowing Foley catheter flushes without a physician's order. Resident #3 was admitted with diagnoses including type II diabetes, enlarged prostate, urinary retention, and urinary tract infection, and the MDS indicated the resident had an indwelling catheter. The resident's nurse progress notes documented Foley catheter flushing on 1/11/26, 1/9/26 at 23:09 and 7:27, and 1/2/26, but the January 2026 physician's orders did not include an order for flushing the Foley catheter. During interviews, a nurse stated that Foley catheter flushes require a physician's order specifying the amount and type of fluid and should be documented on the TAR. The Unit Manager reviewed the orders and confirmed there was no order to flush the resident's Foley catheter. The DON also stated that Foley catheter flushes required a physician's order and should have been documented on the TAR. The facility's policy stated urinary catheters shall be irrigated by a licensed nurse using sterile technique under physician orders, and that orders shall include the type and amount of irrigating solution or medication.
Unlocked Treatment Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility’s policy titled Storage of Medications stated that drugs and biologicals are to be stored in a safe, secure, and orderly manner, and that compartments containing drugs and biologicals are locked when not in use. Despite this, the Unit Three treatment cart was observed unlocked and unattended while residents and outside vendors were in the vicinity. The surveyor observed the Unit Three treatment cart unlocked at multiple times on 1/15/26, including 10:11 A.M., 10:20 A.M., 10:30 A.M., 10:47 A.M., 2:03 P.M., 2:18 P.M., and 2:28 P.M. The cart was observed unlocked for a total of 36 minutes between 10:11 A.M. and 10:47 A.M., and for a total of 25 minutes between 2:03 P.M. and 2:28 P.M. During interviews, Nurse #1 stated the treatment cart should be locked at all times, and the DON stated treatment carts should always be locked when not in use or in direct supervision of the nurse. The DON and surveyor reviewed the observations, and the DON said the treatment cart should have been locked.
Physician Documentation and Review Deficiency
Penalty
Summary
The deficiency occurred when the resident's physician did not review the resident's care, nor did they write, sign, and date progress notes and orders at each required visit. This lapse was identified during the survey and was based on the absence of proper documentation by the physician as required for ongoing resident care. The report specifically notes the lack of physician review and documentation at the mandated intervals, which is necessary to ensure continuity and appropriateness of care for the resident.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Significant Medication Error Due to Failure to Verify Resident and Dosage
Penalty
Summary
A significant medication error occurred when a nurse administered 110 mg of Methadone to a resident who was prescribed only 10 mg. The nurse failed to properly verify the resident's identity and the medication dosage, instead relying solely on the date labeled on the Methadone bottle. The Methadone bottles were stored in a secured narcotic drawer, with each resident's medication separated and labeled with their name, dose, and administration date. Despite these safeguards, the nurse did not check the name or dosage on the bottle before removing it from the drawer or before administering it to the resident. The error was discovered during the narcotic count at the end of the nurse's shift, when it was noted that the Methadone bottle for another resident, who was not present in the facility at the time, was missing. The nurse then realized that the wrong Methadone bottle had been administered. The resident who received the incorrect dose was cognitively intact and had a complex medical history, including chronic respiratory failure, COPD, substance abuse, and other significant health conditions. Following the administration of the incorrect dose, the resident experienced lethargy and nausea and required transfer to the hospital for evaluation and monitoring. Interviews with the nurse involved and the DON confirmed that the nurse did not follow the facility's medication administration policy, which requires verification of the right resident, right medication, and right dose before administration. The nurse admitted to not checking the name or dosage on the Methadone bottle and acknowledged the failure to follow proper procedures. The resident expressed increased anxiety about medication administration following the incident.
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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.
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Nursing homes near Buzzards Bay
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 | 2 mi | ★★★★★ | 0 | 0 |
| Cape Heritage Rehabilitation & Health Care Center | 4.9 mi | ★★★★★ | 0 | 0 |
| Tremont Rehabilitation & Skilled Care Center | 6.3 mi | ★★★★★ | 5 | 0 |
| Royal Megansett Nursing & Rehabilitation | 7.5 mi | ★★★★★ | 0 | 0 |
| Sippican Rehabilitation And Healthcare Center | 8.9 mi | ★★★★★ | 4 | 0 |
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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.