Royal Cape Cod Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Royal Cape Cod Nursing & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF760Apr 1, 2025

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose physicians' orders included the administration of Methadone (opioid, narcotic) 10 milligrams (mg) daily, the Facility failed to ensure he/she was free from a significant medication error, when on 02/25/25 nursing staff did not properly identify the resident's name or dosage on the medication bottle and administered another residents' methadone to him/her. As a result of Resident #1 being administered 110 mg of Methadone (not 10 mg as ordered), he/she was transferred to the Hospital Emergency Department (ED) for evaluation and required treatment for adverse side effects related to an overdose of Methadone. […]

• Actual harm, isolatedF689Aug 11, 2021

  Based on observations, record review, and interviews, the facility failed to provide an environment that was free from accident hazards for 3 Residents (#17, #22, and #49), out of a total sample of 17 residents, and for residents on 2 Units (Unit 3 and Unit 4), out of 3 Units. Specifically, the facility 1.) Failed to implement the plan of care for Resident (#17) who required a two person assist for bed positioning, resulting in a fall and the Resident sustaining fractures of the femur (long bone of leg) and tibia (lower leg); and 2.) Failed to secure medications left at the bedside of two Residents (#22, #49); 3.) Failed to secure a medication cart containing many potentially harmful items on 1 Unit (Unit 4- dementia unit), out of 4 Units; and 4.) Failed to lock the clean utility rooms… […]

• No harm, potential for more than minimal, widespreadF838Aug 11, 2021

  Based on documentation review and staff interview, the facility failed to accurately assess the resources needed to provide competent support and care for their resident population. Specifically, the facility failed to ensure the Facility Assessment tool was updated with accurate information to reflect the current licensed beds in service in the facility. Findings include: The Facility Assessment indicated that the facility has a total of 93 licensed beds. The breakdown by unit is as follows and totals 99 beds, and not 93 beds: -19 bed certified Dementia Unit -28 bed Long Term Care Unit -26 bed Short Term/Rehab/Long Term Care Unit -26 bed Secure Long Term Care Unit During an interview on 8/10/21 at 2:51 P.M., the Administrator said that the 19 bed Dementia Special Care Unit (DSCU) was… […]

• No harm, potential for more than minimal, patternF605Jan 20, 2026

  Based on record review and interview, the facility failed to ensure for two Residents (#34, #6), from a total sample of 18 residents, that each Resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the Residents' highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed for Residents #34 and #6 to ensure a gradual dose reduction (GDR) of psychotropic medication was attempted in an effort to discontinue these drugs, unless documented in the medical record by the prescriber as clinically contraindicated. […]

• No harm, potential for more than minimal, patternF686Jan 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure two Residents (#28 and #10), out of a total sample of 18 residents, received care and treatment to pressure areas in accordance with professional standards to promote healing. Specifically, the facility failed:1. For Resident #28, to implement treatments as indicated to pressure ulcers on the Resident's left medial buttocks; and 2. For Resident #10, to implement treatments as indicated to a pressure ulcer on the Resident's right medial buttocks.Findings include:Review of the facility's policy titled Pressure Injury Prevention and Management Policy, revised 5/2025, indicated, but was not limited to, the following:-Assessments of pressure injuries will be performed by a licensed nurse, and documented in th… […]