Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Norwell Nursing & Rehabilitation Center Llc during CMS and state inspections, most recent first.
A facility failed to follow med administration standards for a resident with psychiatric diagnoses by crushing coated tablets that were ordered whole, mismeasuring MiraLAX, and omitting then later signing off Depakote. It also continued using an expired lansoprazole suspension for a resident with GERD and a G-tube, gave only part of an ordered water bolus to a resident dependent on enteral hydration, and kept documenting a CGM sensor order for a resident with diabetes even though no device was present and staff later confirmed the order was inaccurate.
Medication Storage and Administration Errors: Medication carts were observed unlocked and unattended while residents were nearby or the nurse was out of sight. An LPN left a resident’s MiraLAX mixture at the bedside after partial administration, and another nurse left crushed Ativan in an unlabeled cup in the top drawer of the med cart instead of keeping the controlled medication locked until ready to give it.
Infection Control and Hand Hygiene Failures: Staff entered a resident’s contact precaution room without the required gown, gloves, or hand hygiene while touching the resident and the resident’s environment, despite posted MRSA precautions and a policy requiring PPE for such interactions. In a separate event, a resident with an ostomy and moderate cognitive impairment was observed eating breakfast with visibly soiled hands, and staff reported there was no current process for assisting with hand hygiene before meals.
A resident with dementia and other conditions was manually transferred by two CNAs instead of using a Hoyer lift as required by the care plan, resulting in a skin tear on the resident's wrist. The CNAs did not review the care Kardex, leading to the improper transfer and lack of protective geri-sleeves, highlighting a failure in communication and adherence to care protocols.
Two residents sustained injuries due to improper use of assistive devices during transfers. In one case, a resident with hemiparesis fell and hit their head when a CNA and an uncertified Activity Assistant failed to secure the Hoyer lift sling properly. In another case, a resident with impaired cognition was manually lifted by two CNAs, resulting in a skin tear, as they were unaware of the need for a Hoyer lift.
The facility failed to follow physician's orders for two residents. One resident's antipsychotic medication was not discontinued timely, and another resident's care instructions, including air mattress settings, 1:1 meal supervision, and fall mat placement, were not followed. Staff were unaware of the correct procedures, leading to non-compliance with professional standards.
A resident with polydipsia and dementia was denied fluids of choice despite the removal of a fluid restriction order. Staff inconsistently limited access to ginger ale, contrary to care plans and physician's orders. Observations showed the resident lacked a clock, contributing to confusion about fluid availability. Interviews revealed staff uncertainty in managing the resident's fluid intake, impacting the resident's right to self-determination.
A resident with dementia and a history of falls was found to have an inaccessible call system in their room. Despite the care plan indicating the need for the call light to be within reach, observations showed it was consistently clipped out of reach. Staff interviews confirmed the expectation for accessibility, yet the facility failed to ensure this accommodation.
A resident with vascular dementia and PTSD reported being molested, but the LTC facility failed to investigate or report the allegation as required by their policies. Interviews with staff, including the DON and Administrator, confirmed the lack of action, despite the facility's policy mandating immediate investigation and reporting to the state agency.
A resident with vascular dementia and PTSD reported being molested, but the LTC facility failed to report the allegation to the state agency as required. Despite the facility's policy for immediate reporting, the incident was not documented in the Health Care Facility Reporting System. Interviews with staff, including the DON and Administrator, confirmed the oversight, highlighting a lapse in adherence to reporting protocols.
A resident with vascular dementia and PTSD reported being molested, but the LTC facility failed to investigate the allegation. Despite the resident's cognitive intactness, the DON confirmed no reportable incident was filed, and the Administrator was unaware of the situation. Interviews revealed the facility did not follow its abuse policy, which requires immediate investigation and reporting.
A resident, not approved for self-administration, was found with unsecured medications in their room. Despite facility policies requiring locked storage, surveyors observed eye drops and acetaminophen left out. Staff confirmed the resident should not have had access to these medications.
A resident with chronic wounds and indwelling medical devices required Enhanced Barrier Precautions (EBP) to prevent MDRO transmission. Despite EBP signs, staff, including CNAs and hospice consultants, were observed not wearing gowns during high-contact care activities. Interviews confirmed the need for EBP, but staff failed to comply with the facility's infection control policy.
Medication Administration, Expired Drug Use, Incomplete G-Tube Hydration, and Inaccurate CGM Documentation
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and medication guidelines for a resident with anxiety, schizophrenia, and depressive disorder with psychotic features who was cognitively intact. During a medication pass, the nurse crushed Seroquel and Zyprexa tablets even though the resident’s profile indicated the medications were to be taken whole, and the nurse also crushed Depakote DR tablets despite the medication being a delayed-release formulation. The nurse did not measure MiraLAX using the bottle cap marked for the ordered 17-gram dose, instead pouring an estimated amount into a medication cup and then transferring it to water. The Depakote was initially omitted and left unsigned on the MAR, and the nurse later signed it as administered after locating the medication card. The facility also failed to remove an expired Lansoprazole oral suspension from use for a resident with GERD and a G-tube. The bottle in the medication refrigerator had a pharmacy beyond-use date of 11/1/25, yet it remained in use and was being administered daily after that date. Staff stated it was the only bottle available and that they had been using it despite the expiration. The MAR reflected ongoing administration of the medication during the period after the beyond-use date. For a resident with traumatic brain injury and dysphagia who was dependent on a G-tube and ordered to receive 200 mL water boluses four times daily, the nurse administered only 120 mL during the observed treatment. The nurse used a 60 mL syringe twice and stopped after delivering two syringefuls, then stated the resident had completed the water administration. The clinical coordinator intervened after recognizing the resident had not received the full ordered amount. In addition, the facility documented a continuous glucose monitoring sensor order for a resident with diabetes for nearly 11 months even though the resident did not have the device on either arm, the resident stated he or she did not have it, and the DON and NP later confirmed the order was inaccurate and should not have remained active.
Medication Storage and Administration Errors
Penalty
Summary
Drugs and biologicals were not stored in accordance with State and Federal laws when medication carts were observed unlocked and unattended on the North and South Units. The facility policy stated that unlocked medication carts are not to be left unattended and that compartments containing drugs and biologicals are to be locked when not in use. Survey observations showed the short hall and long hall medication carts left unlocked in hallways, including times when residents were wandering nearby, when the nurse was out of sight of the cart, and when the nurse walked away from the cart to enter resident rooms or the medication room. Resident #40 was admitted in March 2025 with diagnoses including schizophrenia, anxiety, and major depressive disorder with psychotic symptoms, and had a guardian in place. During medication administration, Nurse #2 prepared MiraLAX mixed with water and entered the resident’s room. After the resident initially refused the drink and then took only a few sips, the nurse placed the cup, still half full of the MiraLAX mixture, on the breakfast tray and left the room. The facility’s policy on administering medications stated that the medication cart is to be kept closed and locked when out of sight of the medication nurse, and the policy on crushed medications stated that crushed medication shall be administered immediately. Resident #50 was admitted in April 2019 with diagnoses including dementia and anxiety and had an order for Ativan 1 mg by mouth in the morning for anxiety. On the South Unit, Nurse #5 removed a one-ounce clear plastic cup containing white powder from the top drawer of the medication cart and later identified it as crushed Ativan. The nurse stated she had crushed the medication and left it in the top drawer until the resident was ready for it. The DON stated that medications should not be pre-poured and left in the top of the medication cart, and that narcotics should be locked in the narcotic drawer and removed when ready to administer.
Infection Control and Hand Hygiene Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program for two residents. One resident was on contact precautions for colonized MRSA in leg wounds, with physician orders directing staff to maintain contact precautions every shift. The room had a posted sign instructing staff to clean hands before entering and when leaving, and for providers and staff to put on gloves and a gown before room entry and discard them before room exit. The facility policy stated that contact precautions included gloves and gown for all interactions that may involve contact with the resident or the resident’s environment. For the resident on contact precautions, the surveyor observed multiple staff members enter the room and interact with the resident or the resident’s environment without wearing PPE or completing hand hygiene. A CNA entered the room without PPE or hand hygiene, assisted the resident in the bathroom, touched the wheelchair, and touched the resident when asked to wipe the resident’s buttocks. Other observations included a CNA entering without hand hygiene to handle the breakfast tray and touch the tray table, a nurse administering medications without PPE while touching the resident’s bed and hands, the Staff Development Coordinator entering with cranberry juice and touching the resident and environment, another CNA touching the tray table and bed, the Business Office Manager leaning against the bed and touching the footboard, and another nurse entering and touching the call light and tray table without PPE. During interviews, staff gave differing explanations about when PPE was required, while the DON stated that anyone entering the room should wear the required PPE as described on the signage and that it was required for touching the resident or the resident’s environment. For the second resident, who had moderate cognitive impairment and an ostomy appliance, the surveyor observed the resident eating breakfast with visibly soiled hands that had a brown, odorous substance on the fingers and under the nails. The resident said staff usually managed the ostomy bag but did not offer or assist with hand hygiene before meals. On another observation, the Social Worker delivered the breakfast tray and assisted with utensils while the resident’s hands remained visibly soiled, and the resident began eating with those hands. Staff stated there was no current process they were aware of for providing or offering hand hygiene before meals, and one CNA said there were no wipes on trays and hand hygiene was not part of meal service. The DON stated that hand hygiene should be completed for all residents prior to the meal pass.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to ensure that staff consistently implemented and followed the care plan interventions for a resident who required a Hoyer lift for transfers and geri-sleeves to protect fragile skin. On a specific date, the resident was manually lifted and transferred from the bed to a wheelchair by two CNAs instead of using the Hoyer lift as specified in the care plan. This deviation from the care plan resulted in the resident sustaining a skin tear on the right wrist, which required medical attention. The resident involved had a history of dementia, adult failure to thrive, falls, and anxiety, and was dependent on staff for all care. The care plan, last revised shortly before the incident, clearly indicated the need for a Hoyer lift for transfers and the application of geri-sleeves to both upper extremities. However, on the day of the incident, one of the CNAs involved admitted to not reviewing the resident's care Kardex, which led to the improper manual transfer and the absence of the geri-sleeve on the resident's right arm. Interviews with the CNAs and the nurse on duty revealed a lack of awareness and communication regarding the resident's specific transfer needs. The facility's incident report noted the skin tear but lacked statements from the CNAs involved. The Director of Nurses was unaware of the manual transfer and emphasized the expectation that all staff should be aware of their assigned residents' physical status before providing care.
Improper Use of Assistive Devices Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure the proper use of assistive devices during resident transfers, leading to incidents involving two residents. In the first incident, a resident with right-sided hemiparesis and moderate cognitive impairment required a Hoyer lift for transfers. On the day of the incident, a CNA and an Activity Assistant, who was not certified in using the mechanical lift, attempted to transfer the resident. The CNA did not verify the proper attachment of the sling straps, resulting in the resident sliding to the floor and sustaining a head laceration that required medical attention. In the second incident, another resident with significantly impaired cognition and a history of falls was manually lifted by two CNAs instead of using the required Hoyer lift. The CNAs were unaware of the resident's transfer needs, leading to a skin tear on the resident's wrist during the manual transfer. The CNAs did not consult the resident's care Kardex, which indicated the necessity of a Hoyer lift for transfers. Both incidents highlight a lack of adherence to the facility's policy on mechanical lift usage, which mandates that only trained and certified staff should perform such transfers. The failure to follow established procedures and ensure staff competency in using assistive devices resulted in injuries to the residents during transfers.
Failure to Follow Physician's Orders for Two Residents
Penalty
Summary
The facility failed to adhere to professional standards of practice by not following physician's orders for two residents. For one resident, the facility did not timely discontinue an antipsychotic medication, Abilify, as recommended by a Psychiatric Nurse Practitioner. Although the recommendation to stop the medication was made on September 15, 2024, and noted in a nursing progress note on September 19, 2024, the order was not implemented until October 11, 2024. The delay was attributed to the Director of Nurses (DON) not being present at the behavior meeting where the recommendation was made, and thus the order was not updated in the electronic medical record in a timely manner. For another resident, the facility failed to implement several physician's orders. The resident, who was severely cognitively impaired and dependent on staff for eating, had specific orders for air mattress settings, 1:1 supervision during meals, and a fall mat to be placed beside the bed. The air mattress was observed to be incorrectly set at approximately 350 pounds, despite the resident's weight being 135 pounds. Staff, including a CNA and a nurse, were unaware of the correct settings. Additionally, the resident was observed eating alone without the required supervision and not positioned at the prescribed 90-degree angle, which was necessary due to the resident's dysphagia. Furthermore, the facility did not comply with the order to have a fall mat on the left side of the resident's bed. Observations over several days showed the absence of the fall mat, and staff were unaware of this requirement. Interviews with the DON and other staff confirmed that the physician's orders were not followed, which included the use of the fall mat as a safety intervention for the resident.
Facility Fails to Honor Resident's Right to Fluids of Choice
Penalty
Summary
The facility failed to uphold the rights of a resident, identified as Resident #60, by restricting their access to fluids of choice despite the removal of a fluid restriction order three weeks prior. Resident #60, who was admitted with diagnoses including polydipsia and dementia, was cognitively intact and had a history of behaviors related to excessive fluid intake. The care plans for Resident #60 included various strategies to manage these behaviors, such as encouraging the use of a personal tumbler and setting boundaries. However, observations during the survey revealed that staff continued to limit the resident's access to fluids, particularly ginger ale, even though there was no current fluid restriction in place. On multiple occasions, Resident #60 requested ginger ale from the nursing staff and was either denied or told to wait, despite the absence of a fluid restriction. The staff's actions were inconsistent with the resident's care plan and the physician's orders, which did not include any fluid restrictions. The surveyor observed that the resident was not provided with a clock in their room, which contributed to their confusion about the timing of fluid availability. Additionally, the staff did not consistently check the resident's tumbler to ensure it was filled with water, as outlined in the care plan. Interviews with staff members, including CNAs, nurses, and the Unit Manager, revealed a lack of clarity and consistency in the approach to managing Resident #60's fluid intake. The Unit Manager admitted to trying to limit sugary drinks due to the resident's diabetes, although there were no specific dietary restrictions in place. The Director of Nurses acknowledged that the staff were still trying to determine effective approaches to manage the resident's behaviors and emphasized the importance of focusing on the resident's quality of life. Despite these acknowledgments, the facility's actions resulted in a failure to honor the resident's right to self-determination and access to fluids of choice.
Inaccessible Call System for Resident
Penalty
Summary
The facility failed to ensure a reasonable accommodation for a resident by not providing an accessible call system. The resident, admitted in March 2017, had diagnoses including dementia and a history of falling. The Minimum Data Set (MDS) assessment indicated that the resident was rarely or never understood and was dependent on staff for activities of daily living, requiring supervision or touching assistance for ambulation. The resident's care plan highlighted the risk for falls due to various factors, including deconditioning and dementia, and specified that the call light should be within reach to request assistance. During multiple observations by the surveyor over two days, the call light cord was consistently found gathered and clipped above the bed, out of the resident's reach. Interviews with staff, including a nurse, the Director of Nursing, and a unit manager, confirmed that the call light should be accessible to the resident at all times. Despite this, the facility did not ensure the call system was within reach, failing to accommodate the resident's needs and preferences as required.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to implement its policies and procedures regarding an allegation of sexual abuse involving a resident. The resident, who was admitted with diagnoses including vascular dementia and PTSD, reported to a nurse that they had been molested after being found on the floor. Despite the facility's policy requiring immediate investigation and reporting of such allegations, the incident was neither investigated nor reported to the appropriate state agency as required. Interviews with facility staff, including the Director of Nurses and the Administrator, revealed that there was no record of the incident being reported or investigated. The Administrator and Unit Manager confirmed that the facility's policy mandates ensuring resident safety, reporting allegations to the state agency, and conducting a thorough investigation. However, these steps were not followed in this case, resulting in a failure to address the alleged abuse appropriately.
Failure to Report Alleged Abuse Timely
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the state agency in a timely manner, as required by their policy and state law. The resident, who was admitted in June 2018 and diagnosed with vascular dementia and PTSD, reported to a nurse that they had been molested after being found on the floor. Despite the facility's policy requiring immediate reporting of such allegations to the Executive Director and the state agency, the incident was not reported through the Health Care Facility Reporting System. Interviews with facility staff, including the Director of Nurses, Unit Manager, and Administrator, revealed that the alleged abuse was not reported to the state agency. The Director of Nurses confirmed that there was no reportable incident for the resident in the last six months, and the Administrator admitted to being unaware of the allegation. The failure to report the incident was acknowledged by the Director of Nurses, indicating a lapse in following the facility's abuse policy and state reporting requirements.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving a resident who was cognitively intact, as indicated by a BIMS score of 12 out of 15. The incident occurred when the resident was found on the floor and reported to a nurse that they had been molested. Despite this serious allegation, the Director of Nurses (DON) confirmed that there was no reportable incident for the resident in the last six months, and the Administrator was unaware of the alleged abuse. Interviews with facility staff, including the Unit Manager and the Administrator, revealed that the facility did not follow its own abuse policy, which mandates immediate investigation and reporting of such allegations. The policy requires that incidents be reported to the Director of Nursing Services or a manager immediately, and an investigation should be initiated. However, the DON admitted that the allegation had not been investigated, which is a clear violation of the facility's procedures for handling abuse allegations.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe storage of medications and biologicals for one resident, who was not approved for self-administration of medications. Despite a policy indicating that drugs and biologicals must be stored in locked compartments, surveyors observed multiple instances where medications were left unsecured in the resident's room. Specifically, two bottles of eye drops and one bottle of acetaminophen were found on the resident's nightstand and windowsill over several days. Interviews with the resident and staff revealed that the resident's family provided the medications, and the resident self-administered them without recording the administration details. Staff, including a nurse, a unit manager, and the Director of Nursing, confirmed that the resident was not capable of self-administering medications and should not have had access to them in their room. This oversight indicates a failure to adhere to the facility's medication storage policies and procedures.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for Resident #36, who was at increased risk of multidrug-resistant organism (MDRO) transmission due to chronic wounds and indwelling medical devices. Despite the presence of Enhanced Barrier Precautions (EBP) signs at the entrance to the resident's room, staff members, including Certified Nursing Assistants (CNAs) and hospice consultants, were observed not adhering to the required gown and glove protocol during high-contact care activities such as personal hygiene assistance and resident transfers. This non-compliance was observed on multiple occasions over the course of the survey. Resident #36, who was admitted to the facility in June 2018, was cognitively intact and had a care plan and physician orders indicating the need for EBP due to wounds. Interviews with staff, including the Unit Manager and Director of Nurses, confirmed the requirement for EBP during high-contact care activities. However, there was a clear disconnect between the policy and its implementation, as evidenced by the staff's failure to don gowns during these activities, which was contrary to the facility's infection control policy and the guidelines provided by the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC).
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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 Norwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southwood At Norwell Nursing Ctr | 0.9 mi | ★★★★★ | 9 | 0 |
| Queen Anne Nursing Home, Inc | 2.3 mi | ★★★★★ | 0 | 0 |
| Linden Ponds | 3.2 mi | ★★★★★ | 4 | 0 |
| Webster Park Rehabilitation And Healthcare Center | 3.3 mi | ★★★★★ | 4 | 0 |
| Southshore Health Care Center | 3.6 mi | ★★★★★ | 23 | 0 |
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