Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Nursing Center, Llc during CMS and state inspections, most recent first.
Meals on the Vineyard Sound unit were served over extended periods from breakfast carts, and test trays showed food and drinks that were not at appetizing temperatures. Eggs, ham, biscuits, muffins, oatmeal, milk, and orange juice were repeatedly described as lukewarm, warm, or cold to taste, and an RN, the FSM, the District FSD, the Unit Mgr, the DON, and the Adm all stated the food should have been served warmer and at appropriate temperatures.
Air mattress not set per physician order. A resident with dementia, a BIMS score of 3/15, and a stage 3 pressure ulcer had an order for the air mattress to be set based on the resident’s most recent weight. Surveyors observed the mattress set correctly once, then repeatedly found it set at 143 kg instead of about 72 kg, and both an RN and the UM stated it should have been set for the resident’s body weight.
Failure to Follow Fall Precautions for a High-Risk Resident: A resident with cervical spine fusion, muscle weakness, ataxia, and a history of falls had repeated falls after staff did not consistently follow the resident’s fall precautions. The resident’s care plan and Kardex identified the resident as a fall risk and later as needing assist of two for transfers, but staff were documented assisting with transfers using only one staff member during multiple falls, and one incident involved unlocked bed wheels. Interviews confirmed the resident should have been assisted by two CNAs at the time of the falls.
A nurse failed to perform hand hygiene after glove removal during wound and G-tube dressing care for a resident on EBP, and also left the room wearing the same gown before returning. In a separate event, the nurse used a shared vital signs machine for another resident and returned it without disinfecting it after use; the DON/ADON stated staff were expected to clean shared equipment and remove PPE when exiting an EBP room.
A resident with multiple complex diagnoses was admitted without a baseline care plan being developed and implemented within 48 hours, as required by facility policy. Review of records showed no documentation of a baseline or comprehensive care plan addressing the resident's immediate needs. Interviews with the Unit Manager, ADON, and DON confirmed that the MDS Nurse was responsible for this task, but staff were unaware that it had not been completed.
A resident with chronic pain and a physician's order for PRN Oxycodone did not receive timely or adequate pain management due to delays in medication access, incomplete administration of the ordered dose, and lack of proper documentation. The resident experienced unmanaged severe pain for an extended period, and staff failed to follow procedures for controlled substance administration and documentation.
A resident with multiple complex medical conditions received Oxycodone for pain, but the MAR and Controlled Substance Register contained conflicting documentation regarding administration times, and a PRN dose was not documented in the medical record. Staff interviews confirmed that medication administration was not consistently or accurately recorded, resulting in confusion about when the resident was eligible for their next dose.
A nurse, unfamiliar with the dementia unit, administered a set of medications intended for one resident to another resident with severe cognitive impairment who was unable to identify themselves. The nurse did not verify the resident's identity according to policy, resulting in the administration of multiple medications not ordered for the resident. The error was discovered only after another staff member addressed the resident by the correct name, leading to the resident requiring hospital evaluation and treatment.
A facility failed to ensure a resident's Advance Directives were accurately executed. The resident, diagnosed with Alzheimer's, had a MOLST form completed by the third alternate HCP instead of the primary HCP, who was available and willing to serve. This discrepancy was not identified during required quarterly reviews, leading to a deficiency.
A resident in a LTC facility suffered a traumatic leg wound and developed an unstageable pressure ulcer due to the facility's failure to implement a comprehensive care plan. The resident, requiring maximal assistance for transfers, was improperly moved by a CNA, resulting in injury. Additionally, the facility did not establish a care plan for pressure injury prevention, despite the resident's high risk, leading to a pressure ulcer on the heel.
A nurse in an LTC facility failed to follow infection control procedures while preparing a resident's medications. She used her bare hands to handle medication cards and the cart, and inserted her finger into a medication cup to remove an incorrect dose, potentially contaminating other medications. The DON confirmed this as an infection control issue.
Meals Served at Improper Temperatures on Vineyard Sound Unit
Penalty
Summary
The facility failed to serve food and drinks at palatable, attractive, and safe appetizing temperatures on the Vineyard Sound unit. Review of the facility matrix showed 36 of 40 residents on that unit had a diagnosis of Alzheimer's disease or dementia. On 12/17/25 and 12/18/25, surveyors observed breakfast meal carts arriving on the unit and trays being served over extended periods of time, with the final trays removed 41 minutes after the first cart arrived on one day and 60 minutes after the second cart arrived, and 32 minutes after the first cart arrived on another day. Meals were observed delivered directly to residents and not heated prior to delivery. Test tray observations confirmed food and drink temperatures that were not appetizing. On 12/17/25, scrambled eggs were 105 F and cold to taste, ham slices were 96.3 F and lukewarm, biscuit was 102.2 F and lukewarm, oatmeal was 120 F with the middle warm but the sides lukewarm, orange juice was 67.3 F and warm, and milk was 59.9 F and warm. On the second tray, ham slices were 94.8 F, biscuit was 96.2 F, orange juice was 63.9 F, and milk was 62.9 F. On 12/18/25, scrambled eggs were 110 F and lukewarm, muffin was 100.6 F and not warm, and oatmeal was 118 F with the middle warm but the sides lukewarm. Nurse #5, the FSM, the District Food Service Manager, the Unit Manager, the DON, and the Administrator all stated that the foods should have been warmer and served at appropriate temperatures.
Air mattress not set per physician order
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of quality for one resident by not implementing the physician’s order for the air mattress setting. Resident #4, who was admitted in September 2009 with dementia, had a BIMS score of 3 out of 15 on the 11/14/25 MDS, indicating cognitive impairment. The same assessment noted one stage 3 pressure ulcer not present on admission and that the resident had a pressure reducing device for the bed. The physician’s order dated 12/4/25 directed staff to set the air mattress pressure according to the resident’s most recent weight, plus or minus 10 pounds, and to document the weight and check placement and function every shift. The resident’s documented weight was 162.5 pounds on 12/2/25. During survey observations, the air mattress was found set to 72 kilograms (158.7 pounds) on 12/16/25, then set to 143 kilograms (315.3 pounds) on 12/17/25 at two separate observations and again on 12/18/25. Nurse #3 stated the mattress should be set for the resident’s body weight, and the Unit Manager stated it should be about 72 kilograms, not 143 kilograms.
Failure to Follow Fall Precautions for a High-Risk Resident
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and adequate supervision for a resident with a documented fall risk. Resident #17 was admitted in July 2025 with diagnoses including cervical spine fusion, history of falling, muscle weakness, and ataxia. The resident’s MDS showed cognitive intactness and partial to moderate assistance needed for bed-to-chair transfers, and the initial fall risk evaluation identified the resident as at risk for falls. The resident experienced multiple falls between July and October 2025. After an unwitnessed fall in the resident’s room, the resident reported getting up to walk after using the bathroom without using the call light and not realizing underwear was around the ankles. A fall care plan was developed identifying the resident as at risk for falls and including interventions such as assisting with ambulation and transfers, keeping the call light within reach, and educating on maintaining a safe environment. After a later fall during a shower transfer, the resident was to be transferred with two staff members until cleared by therapy, but the record did not show that therapy had cleared the resident. Subsequent falls occurred when the resident self-transferred from a wheelchair to bed and when the resident was assisted to the bathroom and during a bed-to-wheelchair transfer. The investigations showed that the bed wheels were not locked during one fall and that the resident was assisted by one staff member instead of the two staff members identified in the care plan and Kardex during the later falls. Nursing documentation and staff interviews confirmed that the resident should have been assisted by two staff members at the time of those falls, but this did not occur.
Infection Control Failures During Wound Care and Shared Equipment Use
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Resident #4, who was admitted in September 2009 and had dementia, a BIMS score of 3 out of 15, and one stage 3 pressure ulcer, was ordered to remain on Enhanced Barrier Precautions related to a G-tube and wounds. During a dressing change to the resident’s sacral pressure ulcer and gastrostomy tube insertion site, Nurse #4 removed gloves after taking off soiled dressings and put on new gloves without performing hand hygiene. The nurse repeated this action after removing the sacral dressing, again donning new gloves without hand hygiene. The nurse later stated she should have sanitized or washed her hands every time she removed her gloves, and the Infection Prevention Nurse/ADON stated staff were expected to perform hand hygiene after removing gloves. During the same dressing care, Nurse #4 removed gloves, performed hand hygiene, and left Resident #4’s room to retrieve additional dressing supplies from the treatment cart in the hallway, but she did not remove her gown before exiting and returned to the room wearing the same gown. The Infection Prevention Nurse/ADON stated staff were expected to remove all PPE when exiting the room for a resident on Enhanced Barrier Precautions. In a separate event, Nurse #4 used a shared portable vital signs machine to obtain Resident #67’s blood pressure and returned the machine to the sitting room without disinfecting it after use. The unit manager stated the machine should have been disinfected after use, the nurse said she should have disinfected the blood pressure cuff, and the Infection Prevention Nurse/ADON stated staff were expected to disinfect shared equipment after it is used.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident with multiple complex medical conditions, including hepatic encephalopathy, severe sepsis with septic shock, alcoholic cirrhosis, type 2 diabetes, anemia in chronic kidney disease, opioid dependence, chronic pain syndrome, neuropathy, gout, obstructive sleep apnea, lumbar radiculopathy, and hypertension. The facility's policy required a baseline care plan to be created within 48 hours to address immediate care needs, but a review of the resident's medical record showed no documentation of such a plan or a comprehensive care plan addressing the resident's needs prior to the survey date. Interviews with facility staff, including the Unit Manager, Assistant Director of Nurses (ADON), and Director of Nurses (DON), revealed that the MDS Nurse was responsible for creating baseline care plans within the required timeframe. However, none of the interviewed staff were aware that the baseline care plan for this resident had not been completed, indicating a lapse in the facility's process for ensuring timely care planning upon admission.
Failure to Provide Timely and Adequate Pain Management
Penalty
Summary
A deficiency occurred when a newly admitted resident with chronic pain and a physician's order for PRN Oxycodone IR 10 mg every six hours did not receive adequate and timely pain management. Upon admission, the resident requested pain medication, but the admitting nurse informed the resident that only acetaminophen was available and that obtaining oxycodone from the pharmacy would take time. The nurse attempted to access the emergency medication kit (Cubex) but only administered one 5 mg tablet of oxycodone instead of the ordered 10 mg dose, due to not completing the removal process for the second tablet. The nurse did not document the administration of this medication or the resident's pain assessment in the medical record. The resident did not receive any further oxycodone until approximately 16 hours later, despite having a physician's order for PRN administration every six hours for severe pain. During this period, the resident reported severe pain to a family member and staff, and was only given acetaminophen and topical diclofenac at one point. Documentation in the medical record was inconsistent, with conflicting times recorded for medication administration between the electronic MAR and the handwritten narcotic log. Additionally, the resident's pain level was documented as 10, the highest level, at the time oxycodone was finally administered. Interviews with facility staff revealed that the nurse did not follow proper procedures for accessing and documenting controlled substances, and that there was a lack of communication regarding medication availability and administration. The unit manager confirmed that the nurse failed to access the Cubex correctly and did not document the administration of oxycodone. The DON stated that it was expected for medications to be available and administered as ordered, and that nurses had access to the Cubex for this purpose. The failure to provide timely and appropriate pain management, as well as the lack of documentation and communication, led to the resident experiencing unmanaged severe pain.
Inconsistent Documentation of Controlled Substance Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident when documentation in the Medication Administration Record (MAR) and the Controlled Substance Register regarding the administration of Oxycodone conflicted. Specifically, the MAR indicated that the resident received Oxycodone IR 10 mg at 2:26 A.M., while the Controlled Substance Register documented administration at 4:00 A.M. on the same day. Additionally, there was no documentation in the medical record to support that a nurse administered a PRN dose of Oxycodone IR 5 mg at 12:35 A.M. on a different date, despite this being recorded elsewhere. These discrepancies made it unclear which record was accurate and resulted in confusion regarding when the resident was eligible for their next dose. The resident involved had multiple complex diagnoses, including hepatic encephalopathy, severe sepsis, alcoholic cirrhosis, type 2 diabetes, anemia in chronic kidney disease, opioid dependence, chronic pain syndrome, neuropathy, gout, sleep apnea, lumbar radiculopathy, and hypertension. Interviews with facility staff confirmed that nurses did not consistently document all administered medications in the medical record, and that the times recorded in the MAR and Controlled Substance Register did not always match. This lack of accurate and consistent documentation was contrary to facility policy and led to errors in determining appropriate medication administration times.
Failure to Prevent Significant Medication Error Due to Improper Resident Identification
Penalty
Summary
A significant medication error occurred when a nurse administered a set of medications intended for one resident to another resident with severe cognitive impairment. The resident who received the incorrect medications was unable to identify themselves and had no physician's orders for any of the medications given. The medications administered included multiple drugs such as an antidepressant, anticoagulant, antipsychotic, nitrates, proton pump inhibitor, laxatives, cardiac glycoside, antihypertensives, and others. The nurse failed to verify the resident's identity using the facility's established procedures and did not check the resident's photo or confirm with another staff member prior to administration. The nurse involved was working on the dementia unit for the first time and was unfamiliar with the residents. She prepared the medications for one resident, entered the shared room, and found only one person present. Believing there was only one resident in the room, she addressed the resident by the intended recipient's name. The resident, who was severely cognitively impaired, nodded in response, and the nurse proceeded to administer the medications. It was only after a CNA entered the room and addressed the resident by a different name that the nurse realized the error. Interviews with facility leadership and staff confirmed that the nurse did not follow the five rights of medication administration and did not positively identify the resident before giving the medications. The resident who received the incorrect medications required transfer to the hospital for evaluation and treatment, including monitoring and intravenous therapy, due to the effects of the medication error. The facility's policies on medication administration and error prevention were not followed during this incident.
Failure to Accurately Execute Advance Directives
Penalty
Summary
The facility failed to accurately execute Advance Directives for a resident diagnosed with Alzheimer's disease. The resident's medical record indicated a Health Care Proxy (HCP) was activated due to the resident's incapacity to make health care decisions. However, the Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) form was completed by the third alternate HCP instead of the primary HCP, who was available and willing to serve. This discrepancy was not identified during the quarterly reviews of the MOLST, as required by the facility's policy. Interviews with facility staff revealed that the MOLST was initiated at the hospital and should have been reviewed multiple times since the resident's admission. The Social Worker acknowledged the oversight and confirmed that the primary HCP was not asked to complete the MOLST. The Assistant Director of Nursing also confirmed that the primary HCP should have signed the MOLST, as they were available and willing to serve. This failure to ensure the MOLST was valid and accurately reflected the primary HCP's signature led to the deficiency.
Failure to Implement Comprehensive Care Plan Leads to Resident Injury and Pressure Ulcer
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident, resulting in two significant deficiencies. Firstly, the facility did not implement a care plan to ensure the resident was transferred with the assistance of two people, as required. Despite the resident's need for maximal assistance due to conditions such as muscle weakness and delirium, a CNA attempted to transfer the resident alone, leading to a significant injury. The resident was dependent on a mechanical lift for safe transfers, but this protocol was not followed, resulting in a traumatic wound to the resident's right lower leg. Secondly, the facility failed to develop and implement a care plan for pressure injury prevention for the resident, who was assessed to be at risk for skin breakdown. The resident was admitted with conditions that increased the risk of pressure ulcers, such as cellulitis and edema. Despite these risk factors, the facility did not conduct regular skin assessments or implement pressure relief interventions. Consequently, the resident developed a facility-acquired unstageable pressure ulcer on the right heel, which was not identified until a wound care clinic visit. The facility's policies on safe lifting and pressure ulcer prevention were not adhered to, contributing to the deficiencies. The resident's care plan did not reflect the necessary interventions for safe transfers and pressure ulcer prevention, and staff were not adequately trained or informed about the resident's specific needs. The lack of proper documentation and communication among staff further exacerbated the situation, leading to the resident's injuries and the development of a pressure ulcer.
Infection Control Breach During Medication Preparation
Penalty
Summary
The facility failed to adhere to infection control and prevention measures during the preparation of medication for administration. On the Nantucket Unit, a nurse was observed preparing a resident's morning medications without following proper infection control procedures. The nurse touched multiple medication cards and the medication cart drawer handle with her bare hands. She then mistakenly dispensed a 30 mg tablet of mirtazapine instead of the prescribed 7.5 mg dose. Upon realizing the error, the nurse used her bare finger to remove the incorrect tablet from the medication cup, potentially contaminating the other medications already in the cup. The nurse acknowledged her failure to follow accepted infection control practices when it was pointed out by the surveyor. The Director of Nursing confirmed that the nurse's action of inserting her finger into the medication cup was an infection control issue. The incident highlights a lapse in following the facility's policy for administering medications safely and in accordance with established infection control procedures.
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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 Falmouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jml Care Center Inc | 1.1 mi | ★★★★★ | 0 | 0 |
| Royal Megansett Nursing & Rehabilitation | 6.2 mi | ★★★★★ | 0 | 0 |
| Royal Of Cotuit | 8.5 mi | ★★★★★ | 11 | 0 |
| Bourne Manor Extended Care Facility | 12 mi | ★★★★★ | 0 | 0 |
| Navigator Homes Of Martha's Vineyard | 12.4 mi | ★★★★★ | 10 | 0 |
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