Royal Cape Cod Nursing & Rehabilitation Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to ensure a reasonable accommodation was made for two Residents (#66 and #81), out of 25 residents on the facility's Unit 4. Specifically, the facility failed to ensure the call system was accessible to the Residents to call for staff assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified of new wounds for one Resident (#28), out of a total sample of 18 residents. Specifically, for Resident #28, the facility failed to notify the physician of the discovery of two areas of deep tissue injury (pressure-induced damage to underlying tissues while the skin surface might remain intact; typically resulting from sustained pressure and/or shear forces, which disrupt blood flow and lead to tissue damage).

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of care were met for one Resident (#3), out of a total sample of 18 residents. Specifically, the facility failed to ensure there was a physician's order for the flushing (using a syringe to gently push sterile liquid into the catheter to clear blockages from mucous, blood clots, or debris, ensuring it drains urine properly) of a Foley catheter.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to ensure a treatment cart was locked when not in direct supervision of a licensed nurse on one of four units.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), whose Hospital Discharge Summary included a diagnosis of atrial fibrillation (irregular heartbeat) with an order for Xarelto (anticoagulant), the facility failed to ensure the Physician and Nurse Practitioner completed a review of his/her total program of care, including reviewing for accuracy Resident 1's medications, as a result he/she did not receive Xarelto for 13 days. [...]

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), whose Hospital Discharge Summary included a diagnosis of atrial fibrillation (irregular heart beat) with an order for Xarelto (anticoagulant), the Facility failed to ensure he/she was free from significant medication errors, when upon admission Resident #1's physician orders were not accurately reconciled and transcribed by nursing staff, he/she was not administered Xarelto for thirteen days, placing him/her at increased risk for adverse reactions. Findings Include:Review of the Facility's Policy titled, admission Assessment and Follow Up: Role of the Nurse, dated May 2023, indicated nursing would reconcile the list of medications from the medication history, admitting orders, and the discharge summary from the previous institution, according to established procedures. [...]

Inspectors wroteBased 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. Findings Include: Review of the Facility's Policy titled, Administering Medications, undated, indicated the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the pain medication was administered as ordered by the physician to adequately control pain for one Resident (#183) out of a sample of 19 residents.

Inspectors wroteBased on observations, interviews, and meal test trays for 1 of 2 units, the facility failed to provide residents with meals that were prepared and served in a manner that conserved flavor, were palatable, and served at safe and appetizing temperatures.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Maintain the main kitchen floor in a sanitary manner, specifically floor tile grout from build dirt and food particles, the walls free from food stains and the dish room floor (located in the main kitchen) from cracked, broken tiles, missing grout and incomplete tiling under the dish machine and sinks allow a build up of water and food particles. 2. [...]

Inspectors wroteBased on observations, interviews and records reviewed for one Resident (Resident #51) of 19 sampled residents, the facility failed to notify the Residents physician of a potential need to alter treatment. Specifically, for Resident #51, the facility failed to notify the physician of an unscheduled medication administration and failed to obtain physician guidance/orders per facility policy.

Inspectors wroteBased on policy review,observation, record review, and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for one Resident (#58), out of 18 sampled residents. Specifically, the facility failed to ensure: For Resident #58, a care plan was developed to address the Resident's use of a palm guard (a splint used to prevent fingers from digging in to the palm of the hand, to prevent skin damage and prevent further deformity).

Inspectors wroteBased on observation and staff interview, the facility failed to ensure that accident hazards were minimized for residents on the fourth-floor unit, specifically Resident #51, where staff failed to ensure medications were secure, attended to, and not accessible to residents.

Inspectors wroteBased on observations, interviews, and policy reviewed the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and only authorized personnel were permitted access. Specifically, the facility failed to: 1. Maintain locked medication and treatment carts on one of four units, and 2. Store medication according to manufacturers guidelines in one of two medication carts reviewed; and 3. Ensure only authorized personal had access to medication on one of four units