Royal of Cotuit

In the surveyor’s words

From the most serious findings on record at Royal of Cotuit, in the surveyor’s own words.

• Actual harm, isolatedF658Oct 16, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a diagnosis of Diabetes with long-term use of insulin, and had a Physician's order with parameters for medication administration by nursing in the event of low blood sugar, the Facility failed to ensure Resident #1 was provided nursing care and treatment in accordance with professional standards of practice, when on 10/01/23, he/she experienced a hypoglycemic (low blood sugar) episode and was found minimally responsive by nursing, however, nursing did not follow Physician's orders related to the treatment of a low blood sugar with Glucagon (hormone that increases blood sugar), and although Resident #1's Physician ordered that he/she be immediately transferred to the Hospital for evaluation,… […]

• Actual harm, isolatedF726Oct 16, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose diagnoses included Diabetes with long-term use of insulin, and was at risk for hypoglycemia (low blood sugar) for which he/she had Physician's orders in place with parameters specific to the administration of Glucagon (hormone that increases blood sugar), the Facility failed to ensure that nursing staff was competent and had the necessary skill set to appropriately care for residents in the event of a sudden change in condition. On 10/01/23, at approximately 8:00 A.M., Nurse #1 was notified by a Certified Nurse Aide (CNA) that Resident #1 was unresponsive, and after she assessed Resident #1, Nurse #1 determined he/she was experiencing a hypoglycemic (low blood sugar) episode. […]

• No harm, potential for more than minimal, widespreadF727Feb 7, 2025

  Based on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, with no nurse staffing waivers in place as required, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse Aides (CNA) that the RN was responsible for overseeing with the provision of resident care. […]

• No harm, potential for more than minimal, patternF689Mar 31, 2026

  Based on interview and record review, the facility failed to maintain a safe environment, free of accident hazards for four Residents (#6, #10, #33, #77), out of eight independent smokers on the Popponesett Unit. Specifically, the facility failed to ensure the Residents' smoking materials were stored securely. Findings include:Review of the facility's policy titled Smoking Policy and Procedure, undated, indicated but was not limited to the following: - It is the policy of [Corporate Name] to provide a safe environment for residents, staff and visitors through the enforcement of a smoking policy designed to reduce risks to residents who smoke tobacco products, reduce the risks of passive smoking for others and reduce the risk of fire. […]

• No harm, potential for more than minimal, patternF565Feb 7, 2025

  Based on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council were documented to ensure they were acted upon timely and included the facility response and rationale for response and to ensure residents were able to hold meetings without staff present unless they desired to invite staff. Findings include: Review of the facility's policy titled Resident Council Meetings, dated as last reviewed/revised [DATE], indicated but was not limited to the following: -The Activity Director shall be designated, if approved by the group, to serve as a liaison between the group and the facility's administration and any other staff members. […]