Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Of Cotuit during CMS and state inspections, most recent first.
A facility failed to keep smoking materials securely stored for multiple independent smokers on one unit. Surveyors observed several residents with COPD, nicotine dependence, or tobacco use repeatedly smoking while their lock boxes were empty or did not contain lighters and cigarettes, and staff interviews confirmed that residents were expected to return supplies to the boxes but often did not. One resident with moderate cognitive impairment was also observed carrying a lighter and cigarette from a pocket, and another resident with a smoking agreement was found using supplies that were not consistently secured.
A resident admitted with falls, compression fractures, dementia, anxiety, and depression later had schizoaffective disorder added to the record, but the facility did not initiate a new PASRR Level II review. The SW said she oversees PASARR and was unaware of the new diagnosis, and the DON stated the Level II screen should have been completed when the diagnosis was added.
Failure to develop and implement a comprehensive care plan for a resident’s hearing impairment and hearing aid use. The resident had severe hearing loss, cognitive impairment, and bilateral hearing aids, but staff observed the hearing aids charging out of the resident’s sight while the resident yelled for them and said they were needed to communicate while awake. The record had no orders for the hearing aids and no communication care plan addressing the resident’s hearing aid needs, and the admitting nurse, UM, and DON all acknowledged the omission.
A resident with ESRD and dialysis had a physician order to keep occlusive dressing supplies at the bedside every shift, but surveyors repeatedly did not find the supplies there, and the resident said they were not kept at the bedside. In a separate issue, another resident had a schizoaffective disorder diagnosis added to the chart after admission without supporting documentation in the medical record, and the UM, SW, and DON all noted the record lacked documentation supporting the diagnosis.
Failure to implement OT splinting recommendation for a resident with traumatic brain injury, swan neck deformity, and trigger finger. OT evaluated the resident for pain, decreased ROM, and decreased strength and documented a figure eight splint with a wear schedule and caregiver training, but no physician order was obtained for staff to don/doff the splint. Surveyors observed the resident without the splint, and staff interviews showed CNA and nursing staff were unaware or did not follow through with the ordered splinting process.
Failure to develop a trauma-informed care plan for a resident with PTSD and a traumatic life event. The resident’s social service assessment documented PTSD and a traumatic accident, but the comprehensive care plan did not include the history or individualized interventions. A CNA was unaware of any PTSD-related triggers or restrictions, and the SW and DON acknowledged the resident did not have a care plan specific to PTSD or the traumatic event.
Unlabeled Open Multi-Dose Tuberculin Vials: The facility failed to ensure open multi-dose Tuberculin vials in one medication storage room were labeled with an opened date and discard date. A nurse observed three open vials in use with no opened date and stated she did not know when they were opened; the DON confirmed that multi-dose vials require labeling with the open and discard date upon opening.
Failure to document and provide influenza vaccination process: Two residents had no record of screening, education on vaccine benefits and side effects, consent or refusal documentation, or vaccine administration for the seasonal flu shot. One resident had a guardian who had consented to annual influenza vaccination, but the vaccine was not given and no education or refusal was documented; another resident with heart disease also had no documentation of education, consent, or refusal, and the ICN and DON confirmed the missing records.
Failure to document COVID-19 vaccine education, consent, and refusal for two residents. One resident had a guardian and diagnoses including DM2 and HTN, and another resident had heart disease. The ICN confirmed neither resident received the vaccine and that the chart lacked documentation of education, consent, or refusal, while the DON stated each resident should have had documented education and either vaccine administration or refusal.
Smoking Area Not Properly Maintained: Surveyors observed numerous cigarette butts scattered on the pavement, in the mulch, and under chairs in the designated smoking area, despite the presence of cigarette receptacles. Staff interviews showed residents were independent smokers, CNAs were not assigned to clean the area, and the Maintenance Director did not have a cleaning schedule or anyone assigned to maintain the area. The DON and Administrator were unsure why the area had not been maintained.
A resident with significant physical impairments and a high risk for falls slid off the bed during care and was lowered to the floor by a CNA. The nurse on duty did not notify the physician or complete an incident report, nor did she inform the next shift nurse, resulting in a lack of timely physician notification as required by facility policy.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices.
The facility failed to provide RN coverage for at least eight hours on two consecutive days, as required by regulations. This deficiency was identified through a review of nursing schedules, which showed no RN coverage on those days. Interviews with staff confirmed the absence of RN coverage, with the Administrator and Scheduling Coordinator acknowledging the issue and the Director of Nurses being unaware of the situation.
The facility failed to document and address grievances from the Resident Council, particularly regarding missing laundry and communication issues with CNAs. The Activity Director did not log missing items or file grievances, and staff attended meetings uninvited, inhibiting open discussion. Miscommunication between the Activity Director and Administrator led to unresolved issues, violating residents' rights.
The facility failed to follow its grievance process for addressing missing items reported by residents, including laundry and personal belongings. Despite multiple reports during Resident Council meetings and individual grievances, the facility did not file or investigate these concerns adequately. Two residents experienced significant losses, including a cell phone and clothing, without proper documentation or resolution. Staff interviews revealed a lack of communication and adherence to the grievance policy, with the Administrator unaware of specific missing items and acknowledging procedural failures.
A facility failed to implement physician-recommended wound care for a resident with a Stage I pressure injury on the left medial knee, leading to the injury's progression to Stage II. Despite the wound physician's recommendations for daily skin prep, the order was not transcribed or executed, as confirmed by staff interviews. The resident, with multiple health issues and dependent on staff for mobility, did not receive the necessary treatment due to this oversight.
The facility failed to maintain adequate staffing levels, particularly on weekends, as indicated by the PBJ report for FY Quarter 4, 2024. The staffing pattern required two nurses on each unit for the 3pm-11pm shift and two CNAs on each unit for the 11pm-7am shift. However, due to call-ins and scheduling difficulties, there were instances where only one nurse or fewer CNAs than required were present, especially on the Popponessett Unit. The Administrator and DON acknowledged the staffing issues, which led to the deficiency in ensuring residents' well-being.
A resident did not receive 11 packages, including Christmas presents, in a timely manner due to the facility's failure to deliver them until after the holiday. The resident's family member, acting as the Healthcare Proxy, raised concerns about the legality of withholding packages. Interviews revealed a lack of communication and documentation, with the Business Office Manager citing staffing limitations as the reason for the delay.
The facility failed to report allegations of abuse and harassment for two residents. One resident had packages withheld until they cleaned their room, and the incident was not reported despite family concerns. Another resident alleged harassment by the Administrator for payment and eavesdropping, but the complaint was not reported as it was deemed unsubstantiated. The facility's policy requires immediate reporting of such incidents, which was not followed.
A resident reported that their packages were withheld over Christmas until items were removed from their room. Despite being informed of the issue, the facility's administrator did not investigate or document the complaint, and no grievance was filed. The facility's policy requires immediate investigation of such allegations, but this was not followed.
A resident with moderate cognitive impairment and missing dentures did not have a dental appointment scheduled despite multiple requests. The resident had signed consent for dental services, but the facility failed to act on the request. Management was responsible for scheduling, but the Unit Manager did not follow through, leaving the resident without necessary dental care.
A resident with multiple diagnoses developed new pressure injuries, and the Facility failed to document the wound care orders in the EMR and TAR as required. The nursing staff received and performed the treatments but did not transcribe the orders, leading to incomplete medical records.
Smoking Supplies Not Secured
Penalty
Summary
The facility failed to maintain a safe environment free of accident hazards for four independent smokers on the Popponesett Unit by not ensuring their smoking materials were stored securely. The facility policy stated that independent smokers must keep all lighting materials at the designated secure area, and tobacco products were to be stored in a box on each unit. Staff interviews confirmed that residents who smoke independently were expected to place cigarettes and lighters back into their lock boxes after smoking, but staff also acknowledged that some residents did not always do so and that monitoring was difficult because there were many independent smokers on the unit. Resident #6 had diagnoses including COPD and nicotine dependence and was cognitively intact with a BIMS score of 15. Although the resident had a smoking agreement and care plan instructions that all light materials were to be kept in designated secure storage, survey observations showed the resident’s lock box was sometimes empty or contained only cigarettes, while the resident was observed smoking independently and returning to the unit without placing smoking supplies back in the lock box. The resident also stated that he/she did not always remember to use the lock box and sometimes kept supplies in a bag on the bed. Resident #10 had diagnoses including tobacco use and emphysema and was cognitively intact with a BIMS score of 13. Survey observations repeatedly found the resident’s smoking lock box empty while the resident was observed independently smoking outside. The resident’s care plan stated that all lighters and cigarettes were to be turned into the nurse when not in use, but the observations showed the supplies were not consistently stored in the lock box. Resident #33 had diagnoses including tobacco use, weakness, and COPD and had moderate cognitive impairment with a BIMS score of 13. The resident stated that he/she had smoked for a long time and did not always put smoking supplies back in the lock box. Survey observations showed the resident leaving the smoking area with a lighter and cigarette from a jacket pocket, returning to the unit without placing supplies in the lock box, and at times removing all smoking supplies from the lock box and taking them to the room. Resident #33’s care plan stated that all lighting materials were to be kept in designated secure storage at the nurses’ station, but the observations showed the supplies were not consistently secured there.
Failure to Coordinate PASRR Review After New Mental Health Diagnosis
Penalty
Summary
The facility failed to coordinate a PASRR assessment for one resident after a schizoaffective disorder diagnosis was added to the clinical record. The resident was admitted in January 2026 with diagnoses including history of falls, compression fractures, dementia, anxiety, and depression. Review of the MDS dated 2/10/26 showed a BIMS score of 11 out of 15, indicating moderate cognitive impairment, and no diagnosis of schizophrenia was documented at that time. A later MDS dated 2/18/26 listed schizophrenia, and the diagnosis list in the electronic medical record showed schizoaffective disorder was added on 2/13/26. During interview, the SW stated she oversees the PASARR process and that if a resident has a new diagnosis of schizoaffective disorder, she would alert the appropriate authority for a new PASRR II to be completed. She stated she was unaware of the new diagnosis and did not make the referral. The DON stated a level II PASARR screen should have been completed when the resident acquired the new diagnosis, and it was not done.
Failure to Care Plan Hearing Aid Use for Communication Deficit
Penalty
Summary
The facility failed to develop, implement, and individualize a comprehensive care plan for a resident with unspecified sensorineural hearing loss and a communication deficit related to hearing aid use. The resident was admitted in February 2026, had a BIMS score of 5 out of 15 on the 3/2/26 MDS, was highly impaired for hearing, used hearing aids, and was dependent on staff for daily living needs. The resident’s record showed that orientation was difficult to assess due to hearing impairment, and physician and nursing notes documented that the resident was hard of hearing and had bilateral hearing aids. During observation on 3/25/26, the resident was lying in bed yelling for the hearing aids, which were found on a charging device on a bedside table out of the resident’s line of sight. The resident stated the hearing aids were needed while awake to communicate with others. Review of the medical record showed no physician orders for the hearing aid devices and no comprehensive care plan addressing the communication impairment or hearing aid needs. Nursing staff, including the admitting nurse, a unit manager, and the DON, acknowledged that the resident did not have a care plan in place for the hearing impairment and hearing aids and described the omission as an oversight.
Failure to Follow Physician Orders and Document Psychiatric Diagnosis
Penalty
Summary
The facility failed to provide services that met professional standards of practice for two residents. One resident with end stage renal disease and dependence on renal dialysis had physician orders to maintain occlusive dressing supplies at the bedside every shift, but surveyors did not observe the supplies at the bedside on multiple occasions. The resident was cognitively intact with a BIMS score of 15 out of 15 and was receiving dialysis. Nursing staff documented that the supplies were present each shift, but the resident stated they were not kept at the bedside, and the unit manager and DON acknowledged that the occlusive dressing should have been at the bedside as ordered. For the second resident, the medical record did not contain supporting documentation for a diagnosis of schizoaffective disorder that was added after admission. The resident was admitted with diagnoses including history of falls, compression fractures, dementia, anxiety, and depression, and later records showed a diagnosis of schizophrenia/schizoaffective disorder added to the profile. The record did not show why the diagnosis was added, did not show that it was present on admission, and did not include supporting documentation from a historical provider. The unit manager stated the diagnosis had been added based on a verbal order from the physician, but also stated there was no documentation in the record supporting the diagnosis. The social worker said she did not know where the diagnosis came from, and the DON stated that a new diagnosis of schizoaffective disorder requires documentation in the medical record of specific behaviors. The comprehensive care plan also did not identify behavioral symptoms for the diagnosis.
Failure to Implement OT Splinting Recommendation
Penalty
Summary
The facility failed to implement Occupational Therapy recommendations for contracture management for Resident #32, who was admitted with traumatic brain injury, swan neck deformity of the right fingers, and right ring finger trigger finger. The resident’s MDS assessment showed severe cognitive impairment. A hand specialist consultation noted right middle and right ring finger triggering, right finger swan neck deformity, a steroid shot in the right ring finger, and an OT referral for a figure eight splint for the right ring and middle fingers. OT evaluated the resident for new onset pain, decreased ROM, and decreased strength, and documented the need to fabricate a figure eight splint, establish a wearing schedule, and train caregivers on donning and doffing the splint to reduce pain and increase ROM of the right hand. The OT discharge summary documented that the resident was fitted for the figure eight splint and that nursing staff were trained on the orthotic wear schedule, which called for the splint to be worn in the morning before breakfast and removed at night before bed. However, the physician’s order summary for March 2026 showed no order for staff to don and doff the splint. During observations on 3/26/26 and 3/27/26, the resident was sitting in the dayroom without the splint on. Staff interviews showed CNA #1 was not aware staff were to apply the splint, Nurse #1 stated nurses would not know to apply it without an order, and multiple nursing and rehab staff acknowledged that the order was not obtained and follow-up was not completed after the OT recommendation was communicated.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to ensure a person-centered plan of care with individualized interventions for trauma-informed care was developed for one resident with a history of PTSD and a traumatic event. The facility’s Trauma Informed Care Policy stated that if a resident has a documented history of trauma or triggers on the assessment, the social worker and interdisciplinary team must immediately formulate a plan of care that includes specific triggers and coping support. Resident #5 was admitted with diagnoses including dementia and PTSD, and the MDS showed moderate cognitive impairment with a BIMS score of 8 out of 15. The resident’s Social Service admission and Cultural Assessment documented PTSD and a traumatic accident in adulthood, but the comprehensive care plan did not indicate a history of a traumatic life event or PTSD. During interviews, a CNA stated she was not aware of any resident on the unit with PTSD or related triggers or restrictions, and did not know whether Resident #5 required any specific care interventions. The Social Worker stated the trauma-informed assessment was used to identify trauma history and that identified information was put into the care plan for staff to see, but Resident #5 did not have a care plan specific to PTSD or the traumatic life event. The DON stated residents are assessed by social services on admission for trauma and that a care plan should be developed if they have PTSD or trigger for a traumatic experience, and acknowledged Resident #5 should have had a care plan in place.
Unlabeled Open Multi-Dose Tuberculin Vials
Penalty
Summary
The facility failed to ensure medications with a shortened expiration date upon opening were properly labeled after opening in one of two medication storage rooms observed. Review of the facility policy titled "Storage of Medications," revised 8/2020, stated that medications and biologicals are to be stored safely, securely, and properly, that certain medications such as multidose injectable vials require a shortened expiration date once opened, and that when the original seal of a manufacturer's container or vial is broken, the container or vial will be dated with a date-opened sticker and the date opened and new expiration date recorded. During observation on 3/26/26 at 10:30 A.M. in the medication storage room on Santuit Unit with Nurse #4, the surveyor found three bottles of Tuberculin multi-dose vials that were open and in use but had no opened date. In an interview later that day, Nurse #4 stated the bottles were open and in use and she did not know when they were opened, and said they should have been labeled with an opened date. During an interview on 3/30/26 at 4:14 P.M., the DON stated multi-dose vials have a shortened expiration date and should be labeled with the open and discard date upon opening to ensure they are not used after expiration.
Failure to Document and Provide Influenza Vaccination Process
Penalty
Summary
The facility failed to ensure that two residents reviewed for immunizations were screened for eligibility to receive the seasonal influenza vaccine, educated on the benefits and potential side effects, offered the vaccine in a timely manner, and properly documented in their medical records. The facility policy stated that residents without medical contraindications were to be offered influenza vaccine annually beginning no later than October 1, with education documented in the record and refusals recorded on the informed consent form. Resident #7 was admitted with diagnoses including type 2 diabetes and hypertension, and a guardian was appointed for decision-making. The resident's immunization consent showed the guardian had consented to annual influenza vaccination, but the medical record did not show that the 2025-2026 influenza vaccine was administered. The Infection Control Nurse stated the resident did not receive the vaccine and there was no documentation of education or refusal. Resident #12, admitted with heart disease, also had no documentation in the medical record showing education about the influenza vaccine, consent to receive it, or refusal for the 2025-2026 season. The Infection Control Nurse confirmed the resident did not receive the vaccine and that no such documentation existed, and the DON stated there should have been documentation of administration or refusal, along with consent and education for every resident.
Failure to Document COVID-19 Vaccine Education, Consent, and Refusal
Penalty
Summary
The facility failed to ensure that two residents were screened for eligibility to receive the recommended COVID-19 vaccination, educated on the benefits and potential side effects of the vaccine, offered the vaccine in a timely manner, and properly documented in the medical record. The facility policy titled COVID-19 Vaccine Policy-Massachusetts stated that before offering the vaccine, residents or their representatives were to receive education regarding the benefits and risks and potential side effects, and the medical record was to include documentation of the education provided, the resident’s acceptance or refusal, and each dose administered. Resident #7 was admitted with diagnoses including type 2 diabetes and hypertension, and a guardian was appointed in June 2021. Review of the medical record did not show documentation that the guardian was educated about the COVID-19 vaccine benefits and potential side effects or that the guardian consented to or refused vaccination. Resident #12 was admitted with a diagnosis including heart disease, and the medical record also lacked documentation that the resident was educated about the COVID-19 vaccine benefits and potential side effects or that the resident consented to or refused vaccination for the 2025-2026 season. The ICN stated that neither resident received the vaccine and that there was no documentation of education, consent, or refusal; the DON stated there should have been documentation of administration or refusal, along with consent and documented education for every resident.
Smoking Area Not Properly Maintained
Penalty
Summary
The facility failed to ensure a functional, safe, and clean environment in the designated smoking area because cigarette butts were not properly disposed of in the smoking receptacles. Surveyors observed two tall receptacles for cigarette butts with numerous cigarette butts scattered across the pavement, several cigarette butts in the mulch adjacent to the facility, and several cigarette butts accumulated underneath three chairs positioned along the outer perimeter of the smoking area. The same conditions were observed again on a subsequent observation the next day. Staff interviews showed that residents were independent smokers and no one was assigned to go outside with them. A CNA stated that CNAs were not assigned to clean up the area and that maintenance staff sometimes cleaned it. The Maintenance Director said he tried to clean the area one to two times a week, had placed a broom and dustpan outside for residents to sweep up after use, and did not have a cleaning schedule or anyone assigned to maintain the area. The DON said Maintenance was responsible for the smoking area and was not sure of a cleaning schedule or why the area had not been maintained. The Administrator said Maintenance and Activities would usually maintain the area and was not sure why it had not been maintained.
Failure to Notify Physician After Resident Fall
Penalty
Summary
A deficiency occurred when nursing staff failed to immediately notify the physician after a resident experienced a fall. The resident, who had multiple diagnoses including cerebral palsy, contractures, kyphosis, convulsions, periprosthetic fracture, atrial fibrillation, osteoarthritis, congestive heart failure, and hearing loss, was dependent on staff for activities of daily living and was identified as being at risk for falls. During morning care, a CNA was providing care alone, rolled the resident onto their side, and the resident's legs slid off the bed, resulting in the resident being lowered to the floor. The CNA notified a nurse, who found the resident on the floor, but the nurse did not notify the physician of the fall and did not complete an incident report. The nurse also failed to communicate the fall to the oncoming nurse during shift change, resulting in further lack of physician notification. The facility's policies required prompt physician notification for any falls or incidents, but there was no documentation in the medical record to support that this occurred. The DON confirmed the expectation that all nurses notify the physician of any falls or incidents, in accordance with facility policy.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified during a review of the nursing schedules from January 6, 2025, to February 6, 2025, which revealed that there was no RN coverage for the entire 24-hour periods on January 11 and January 12, 2025. The facility did not have any nurse staffing waivers in place to justify this lack of coverage, thereby placing all residents at risk of not having their clinical needs met. Interviews conducted with the facility's staff, including the Administrator, Scheduling Coordinator, and Director of Nurses, confirmed the absence of RN coverage on the specified dates. The Administrator acknowledged that there should be RN coverage for at least eight hours every day, and the Scheduling Coordinator explained that the RN scheduled for those days had called in, and they were unable to find a replacement. The Director of Nurses was unaware of the lack of RN coverage on those days, indicating a lapse in communication and oversight within the facility's staffing management.
Failure to Address Resident Grievances and Respect Meeting Rights
Penalty
Summary
The facility failed to ensure that grievances and concerns raised by the Resident Council were properly documented and addressed in a timely manner. The facility's policy required that grievances, whether verbal or written, be documented and acted upon, but this was not consistently done. The Resident Council meetings revealed ongoing issues with missing laundry and lack of communication between residents and Certified Nursing Assistants (CNAs), yet these concerns were not formally documented as grievances, nor were they resolved effectively. The Activity Director, who was responsible for facilitating these meetings, did not log missing items or file grievances on behalf of the residents, leaving many issues unaddressed. Additionally, the facility did not respect the residents' right to hold meetings without staff presence unless explicitly invited. Residents expressed discomfort with staff attending meetings uninvited, as it inhibited open discussion of their concerns. Despite the Ombudsman's reminders that staff should only attend if invited, staff presence was a regular occurrence, which discouraged residents from voicing their issues. This lack of adherence to the residents' rights further contributed to the unresolved grievances. Interviews with the Activity Director and the Administrator revealed a lack of clarity and communication regarding the grievance process. The Activity Director assumed the Administrator handled grievances, while the Administrator expected the Activity Director to document and escalate issues. This miscommunication resulted in missing items and other concerns not being properly addressed or resolved, as evidenced by the absence of grievance forms in the facility's records. The ongoing issues with missing laundry and inadequate communication were not effectively managed, leading to resident dissatisfaction and a failure to uphold their rights.
Failure to Follow Grievance Process for Missing Items
Penalty
Summary
The facility failed to adhere to its grievance process, particularly in addressing concerns raised during Resident Council meetings and individual grievances filed by residents. Multiple residents reported issues with missing laundry, yet the facility did not file grievances on their behalf or investigate these concerns through the established grievance process. The Activity Director admitted to not logging or filing grievances for missing items, instead leaving the responsibility to the residents to address the issue with the laundry department. The Administrator was unaware of specific missing items reported during Resident Council meetings and acknowledged that missing items should be elevated to grievances, which was not done. Resident #6 experienced the loss of a cell phone and multiple clothing items, which were not addressed through the grievance process. Despite being cognitively intact, Resident #6 reported the missing items to staff, but no investigation or resolution was documented. Interviews with staff revealed a lack of follow-up on the missing items, and the Administrator was not aware of the missing cell phone or clothing, indicating a breakdown in communication and procedure. Resident #29 also faced issues with missing clothing, valued at over $600, which were not properly addressed through the grievance process. Although a grievance was filed for a missing pair of pants, the resolution was incomplete, and no further grievances were documented despite ongoing issues. The resident and their family reported continued losses, and staff were aware of specific missing items, yet no formal grievances were filed or resolved. The Administrator acknowledged the inadequacy of the grievance process and the lack of resolution for Resident #29's missing items.
Failure to Implement Wound Care Orders for Pressure Injury
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with a Stage I pressure injury on the left medial knee, as per physician recommendations. The resident, who was admitted with diagnoses including type II diabetes, severe protein calorie malnutrition, and pressure ulcers, was mildly cognitively impaired and dependent on staff for bed mobility. The comprehensive care plan indicated the need for treatment of the pressure ulcer, but the facility did not implement the physician's order to apply skin prep daily to the affected area. The Wound Evaluation and Management Summary documented the need for skin prep treatment, but the Physician's Orders/Treatment Administration Record for January and February 2025 did not reflect this order. Interviews with staff revealed that the wound physician's recommendations were communicated verbally and electronically, but the order for skin prep was never transcribed or implemented. The Assistant Director of Nursing (ADON) acknowledged the oversight and noted that the resident had multiple open areas, which may have contributed to the error. The Director of Nursing (DON) stated that her expectation was for nurses to transcribe and implement treatment orders on the day they are received. However, the order for skin prep was not executed, leading to a deficiency in the care provided to the resident. This oversight resulted in the progression of the pressure injury from Stage I to Stage II, as documented in subsequent wound evaluations.
Facility Fails to Maintain Adequate Staffing Levels on Weekends
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, particularly on weekends, as evidenced by the Payroll-Based Journal (PBJ) report submitted to CMS for Fiscal Year Quarter 4, 2024. The report highlighted excessively low weekend staffing, which triggered a need for follow-up during the survey. The facility's Healthcare Facility Assessment (FA) did not reflect updated staffing patterns, and the as-worked staffing schedules and time sheets showed that the number of licensed nurses and nurse aides was below the required levels on multiple dates. Interviews with the Director of Nursing (DON) and the Staffing Coordinator revealed that the facility's staffing pattern for the 3pm-11pm shift should include two nurses on each unit, and the 11pm-7am shift should have two CNAs on each unit. However, due to call-ins and scheduling difficulties, there were instances where only one nurse or fewer CNAs than required were present, particularly on the Popponessett Unit. The Staffing Coordinator mentioned that the 7pm-11pm shift was particularly challenging to cover, and there were occasions when the weekend nurse was left alone after 7pm. The Administrator acknowledged that the staffing pattern did not carry over to the updated FA and confirmed that the facility should have maintained the staffing levels as previously noted. The DON, who was not employed during the time of the deficiency, stated that there should never be just one CNA on each unit, and someone should have been mandated to stay to cover the shifts. The report indicates that the facility's failure to maintain adequate staffing levels, particularly during weekends and specific shifts, led to the deficiency in ensuring residents' well-being.
Failure to Ensure Timely Delivery of Packages
Penalty
Summary
The facility failed to ensure timely delivery of packages to Resident #29, who was cognitively intact and had a Healthcare Proxy invoked. The issue arose when 11 packages, including Christmas presents, were not delivered to the resident until after the holiday. The delay was reportedly due to the need to clear out extra belongings from the resident's room. The resident's family member, acting as the Healthcare Proxy, raised concerns about the legality of withholding packages, citing federal law. Interviews with facility staff revealed a lack of communication and documentation regarding the withheld packages. The Administrator did not investigate the issue or file a grievance, and the Business Office Manager admitted to holding packages due to staffing limitations during the holiday season. Despite the family member's complaints, the facility did not adequately address the delay in package delivery, leading to the deficiency noted in the report.
Failure to Report Allegations of Abuse and Harassment
Penalty
Summary
The facility failed to report allegations of abuse within the State mandated time frame for two residents. For the first resident, an allegation of misappropriation of property was not reported. The resident, who was cognitively intact, had packages withheld until they cleaned out their room. The resident's family member, acting as a health care proxy, raised concerns about the legality of withholding packages, citing federal law. Despite these concerns being communicated to the Administrator and other staff, no investigation was conducted, and the incident was not reported to the State Survey Agency. For the second resident, an allegation of harassment by the Administrator was not reported. The resident, also cognitively intact, expressed intentions to file a complaint with the Department of Public Health due to harassment for payment and eavesdropping on a private conversation. The Director of Nurses was aware of the eavesdropping complaint but not the harassment for payment. The Administrator acknowledged the harassment complaint but did not report it, believing it was unsubstantiated. The Corporate Nurse later confirmed that such complaints require reporting and investigation, yet no report was made to the state. The facility's policy mandates immediate reporting of such incidents to the Department of Public Health, but this was not adhered to in both cases. The Health Care Facility Reporting System review confirmed that no incidents of alleged misappropriation or harassment were reported for the specified periods. This failure to report and investigate allegations of abuse and harassment constitutes a deficiency in the facility's compliance with state and federal regulations.
Failure to Investigate Alleged Misappropriation of Resident's Packages
Penalty
Summary
The facility failed to investigate an allegation of misappropriation of personal property for a resident, who reported that their packages were not delivered over Christmas until items were removed from their room. The resident, who was cognitively intact, expressed their concerns to a family member, who then reported the issue to the facility's activities staff and cited federal law regarding mail delivery. Despite these reports, the facility did not initiate an investigation into the alleged misappropriation of the resident's packages. Interviews with facility staff revealed that the administrator was aware of the family member's concerns but did not document the conversations or investigate the matter further. The front desk receptionist confirmed that the resident had complained about the undelivered packages, and the business office manager was informed, but no further action was taken. The social worker also acknowledged the family member's concerns during a care plan meeting, where mail delivery issues were discussed, but no formal investigation was conducted. The facility's policy requires immediate investigation and reporting of alleged violations, including misappropriation of resident property, to the director of nursing or manager. However, in this case, the facility did not follow its policy, as no investigation was conducted, and no grievance was filed regarding the resident's missing packages. The lack of action and documentation indicates a failure to adhere to the facility's procedures for handling such allegations.
Failure to Schedule Dental Appointment for Missing Dentures
Penalty
Summary
The facility failed to provide necessary dental services for a resident who required new dentures. The resident, who was admitted with chronic obstructive pulmonary disease, dysphagia, and vitamin B12 deficiency anemia, reported that their dentures were missing and requested a dental appointment. Despite signing a consent for dental services, the medical record did not show any scheduled appointment to replace the missing dentures. The resident, who had moderate cognitive impairment, expressed the need for a dental appointment multiple times over a period of weeks. Interviews revealed that the resident had communicated the need for a dental appointment to the Unit Manager, who acknowledged the request but did not follow through with scheduling the appointment. The responsibility for scheduling appointments was confirmed to lie with management, yet the necessary action was not taken. The issue was brought to the attention of the Administrator and the Director of Nurses, who were previously unaware of the missing dentures and the lack of a scheduled appointment.
Failure to Document Wound Care Orders
Penalty
Summary
The Facility failed to maintain a complete and accurate medical record for a resident who had new physician orders for wound care treatment. Specifically, the nursing staff did not transcribe the wound care orders obtained on two consecutive days onto the resident's Treatment Administration Record (TAR). This failure was identified during a review of the resident's medical records and interviews with the nursing staff involved in the resident's care. The resident, who had multiple diagnoses including dementia, chronic obstructive pulmonary disease, and chronic kidney disease, developed new pressure injuries on various parts of their feet. The nursing staff assessed the wounds and received treatment orders from a Nurse Practitioner and a Hospice Nurse. However, these orders were not properly documented in the resident's Electronic Medical Record (EMR) or the TAR, as required by the Facility's policies on skin integrity management, medication and treatment order administration, and charting and documentation. Interviews with the nursing staff revealed that the orders were verbally communicated and treatments were performed, but the necessary documentation was not completed. The Director of Nurses confirmed that it was the Facility's expectation for nursing staff to write and transcribe telephone orders for wound treatments into the EMR, which did not occur in this case. This lapse in documentation led to the deficiency noted in the report.
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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 Mashpee
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 | 6.7 mi | ★★★★★ | 0 | 0 |
| Pavilion , The | 7.9 mi | ★★★★★ | 0 | 0 |
| Royal Megansett Nursing & Rehabilitation | 8.2 mi | ★★★★★ | 0 | 0 |
| Royal Nursing Center, Llc | 8.5 mi | ★★★★★ | 19 | 0 |
| Jml Care Center Inc | 9.2 mi | ★★★★★ | 0 | 0 |
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