🔎 Royal Cape Cod Nursing And Rehabilitation Center
Inspection Results
Inspection Overview
Royal Cape Cod Nursing And Rehabilitation Center has been cited for a total of 64 deficiencies since we began saving each survey.
In Massachusetts, the average facility has **46.34 deficiencies** in our database. This profile shows the longer-term view.
Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.
Understanding Deficiency Severity (A-L Scale)
The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**
| Severity (Harm) | Scope (Widespread?) | Code Range |
|---|---|---|
| No Actual Harm | Isolated to Pattern | A - C |
| No Actual Harm | Widespread | D - F |
| **Actual Harm** | Isolated | G |
| **Actual Harm** | Pattern | H |
| **Actual Harm** | Widespread | I |
| **Immediate Jeopardy** | Isolated | J |
| **Immediate Jeopardy** | Pattern | K |
| **Immediate Jeopardy** | Widespread | L |
Detailed Deficiency List (Most Recent First)
Scope/Severity: G
Ensure that residents are free from significant medication errors.
Scope/Severity: D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Scope/Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: E
Provide safe, appropriate pain management for a resident who requires such services.
Scope/Severity: D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity: E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Scope/Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: D
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Perform COVID19 testing on residents and staff.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity: E
Ensure that residents are fully informed and understand their health status, care and treatments.
Scope/Severity: D
Keep residents' personal and medical records private and confidential.
Scope/Severity: E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Scope/Severity: E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: D
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Scope/Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Scope/Severity: D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Scope/Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: E
Perform COVID19 testing on residents and staff.
Scope/Severity: D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Scope/Severity: E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Scope/Severity: E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Scope/Severity: E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Scope/Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Assist a resident in gaining access to vision and hearing services.
Scope/Severity: G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Scope/Severity: D
Ensure that residents are free from significant medication errors.
Scope/Severity: E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Scope/Severity: F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Scope/Severity: F
Have a plan that describes the process for conducting QAPI and QAA activities.
Scope/Severity: F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Scope/Severity: F
Provide and implement an infection prevention and control program.
Scope/Severity: F
Implement a program that monitors antibiotic use.
Scope/Severity: D
Keep all essential equipment working safely.
Scope/Severity: E
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Scope/Severity: D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Scope/Severity: D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Scope/Severity: B
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Scope/Severity: B
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Scope/Severity: B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Provide activities to meet all resident's needs.
Scope/Severity: D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Scope/Severity: D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Scope/Severity: B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity: D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Scope/Severity: D
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: D
Have a program that investigates, controls and keeps infection from spreading.
Scope/Severity: E
Keep all essential equipment working safely.
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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**