Royal of Cotuit

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and document review, the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) program for one Resident (#3), out of a total sample of 19 residents. Specifically, the facility failed to initiate a new PASRR Level II Assessment following the addition of a schizoaffective disorder diagnosis to the clinical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement and individualize a comprehensive care plan for one Resident (#4), out of a total sample of 19 residents. Specifically, the facility failed to ensure a comprehensive care plan related to Resident #4's use of hearing aids to support a communication deficit was developed and implemented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that met professional standards of practice for two Residents (#6 and #3), out of a total sample of 19 residents. Specifically, the facility failed to:1. Ensure Resident #6 had an occlusive dressing at bedside as ordered by the physician; and2. Ensure Resident #3, who had a diagnosis of schizoaffective disorder added after admission, had supporting documentation in the medical record.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to implement recommendations from the Occupational Therapy assessments for contracture management for one Resident (#32), out of a total sample of 19 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure a person-centered plan of care with individualized interventions for trauma-informed care was developed for one Resident (#5), out of a total sample of 19 residents. Specifically, the facility failed to assess and implement care plan interventions for Resident #5 with a history of post-traumatic stress disorder (PTSD) and a history of a traumatic event.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure medications with a shortened expiration date upon opening were properly labeled once opened, in one medication storage room out of two medication storage rooms observed.

Inspectors wroteBased on record review and interview, the facility failed to ensure two Residents (#7 and #12), out of a total sample of five residents reviewed for immunizations, were screened for eligibility to receive the recommended influenza vaccination, residents/residents' representatives were educated on the benefits and potential side effects of the vaccines, were offered and administered (if applicable) the seasonal vaccine in a timely manner, and appropriately documented in the Resident's medical record.

Inspectors wroteBased on record review and interview, the facility failed to ensure two Residents (#7 and #12), out of a total sample of five residents reviewed for immunizations, were screened for eligibility to receive the recommended COVID-19 vaccination, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, were offered and administered (if applicable) the vaccine in a timely manner, and appropriately documented in the Resident's medical record.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure a functional, safe, and clean environment. Specifically, the facility failed to ensure residents and/or staff properly disposed of cigarette butts in designated smoking receptacles.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who on 05/22/25, slid off the bed onto the floor during care, the Facility failed to ensure that nursing immediately notified the Physician that he/she had experienced a fall.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed as being at risk for falls, had physical limitations in both upper and lower extremities due to contractures, and was dependent on staff for mobility including bed mobility, the Facility failed to ensure they developed an individualized comprehensive plan of care that included the number of staff members required during care, to appropriately meet his/her care needs.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who on 5/22/25 sustained a fall, the Facility failed to ensure care and treatment provided by nursing met professional standards of practice. When after Nurse #1 was notified by Certified Nurse Aide (CNA) #1 that Resident #1 slid out of bed and was on the floor in his/her room, Nurse #1 instructed the CNA's to put Resident #1 back to bed. There was no supporting documentation including assessments or nurse progress notes in Resident #1's medical record related to the fall, no incident report, and the oncoming shift nurse and the Physician were also not notified of the fall. [...]

Inspectors wroteBased 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. Specifically, the facility failed to provide RN services on 1/11/25 and 1/12/25.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow the grievance process for resident concerns reported at Resident Council, to ensure all grievances filed were thoroughly investigated with a documented resolution, and for two Residents (#6 and #29), out of a total sample of 18 residents. Specifically, the facility failed: 1. To ensure concerns brought forth during Resident Council including multiple concerns for missing laundry had a grievance filed on their behalf and were investigated through the grievance process; 2. To ensure grievances filed by residents/resident representatives/family/friends were thoroughly investigated with a documented resolution; 3. For Resident #6, to initiate an investigation when his/her cell phone was determined to be missing, file a grievance for the missing cell phone, and follow the grievance process; and 4. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure one Resident (#64), out of a total sample of 18 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed to implement wound care orders per physician recommendations for a Stage I pressure injury (localized area of non-blanchable redness on intact skin, usually over a bony prominence) to the left medial knee.

Inspectors wroteBased on record review and interview, the facility failed to ensure sufficient staffing to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to have sufficient staffing on the weekends as indicated on the payroll-based journal (PBJ) report submitted to Centers for Medicare and Medicaid Services (CMS) for Fiscal Year (FY) Quarter 4, 2024.

Inspectors wroteBased on interviews and documentation review, the facility failed to ensure packages were delivered in a timely manner to one Resident (#29), out of a total sample of 18 residents.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse within the State mandated time frame for two Residents (#29 and #609), in a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #29, ensure an allegation of misappropriation of resident property by staff of withholding packages until the Resident cleaned out his/her room was reported to the State Survey Agency; and 2. For Resident #609, ensure an allegation of harassment by the Administrator was reported to the State Survey Agency.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of misappropriation of personal property for one Resident (#29), in a total sample of 18 residents. Specifically, the facility failed to investigate Resident #29's allegation that his/her packages were not delivered over Christmas until his/her room had items removed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide dental services for one Resident (44), out of a total sample of 18 residents. Specifically, the facility failed to schedule a dental appointment for new dentures as requested by the Resident.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had new physicians orders for wound care treatment to newly developed pressure injuries, the Facility failed to ensure they maintained a complete and accurate medical record when nursing failed to transcribe wound care orders that were obtained on 04/29/24 and 04/30/24, onto his/her Treatment Administration Record (TAR).

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to follow their policy and assess a smoker for safety to smoke with staff and provide smoking times when family was not available for one Resident (#16), out of a total sample of 20 residents.

Inspectors wroteBased on policy review, review of Resident Council Minutes, and resident and staff interviews, the facility failed to ensure that staff addressed and promptly resolved repeated grievances brought forward during Resident Council Meetings held from 5/22/23 through 10/31/23.

Inspectors wroteBased on observation and interviews, the facility failed to ensure residents' rights to personal privacy and confidentiality was promoted and protected for five Residents (#13, #273, #38, #274, and #23), from a total sample of 20 residents. Specifically, the facility failed to ensure: 1. For Resident #13, personal privacy of his/her own physical body was maintained during a medical examination; 2. For Resident #273, personal privacy of his/her own physical body was maintained during a medical examination. 3. For Residents #38, privacy was provided during psychotherapy sessions conducted by the facility's consultant psychotherapist in the Resident's room; 4. For Resident #274, privacy was provided during psychotherapy sessions conducted by the facility's consultant psychotherapist in the Resident's room; and 5. [...]

Inspectors wroteBased on observation, policy review, 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. Ensure food was stored, labeled, and dated in one of two kitchenette refrigerators observed; 2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene and prevent cross contamination. In addition, ensure the use of gloves was limited to a single use task; and 3. Maintain a professional routine service contract for the juice dispensing machine and identify and replace enclosed tubing that has become discolored to avoid contamination of the juice.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to follow their policy and track grievances through the conclusion, lead investigations, and review findings with the resident/responsible person for one Resident (#57), out of a total sample size of 20 residents.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#57), out of a total sample of 20 residents. Specifically, the facility failed to report the alleged misappropriation of $120 to the state agency within two hours on 2/22/23.

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to ensure an individualized plan of care was followed for Resident #16, in a total sample of 20 residents. Specifically, the facility failed to ensure a care plan for smoking preferences and times was developed.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for three Residents (#38, #44, and #23), out of a total sample of 20 residents. Specifically, the facility failed to ensure: 1. For Resident #44, the Resident's pacemaker was monitored and evaluated as per the facility policy and standards of practice; 2. For Resident #38, a. the Resident's pacemaker was monitored and evaluated as per the facility policy and standards of practice, and b. a physician's order was obtained for the provision of psychotherapy services; and 3. For Resident #23, a physician's order was obtained for the provision of psychotherapy services.

Inspectors wroteBased on observation, interview, policy review, and manufacturer's guidelines, the facility failed to store and label medication according to facility policy. Specifically, the facility failed: 1. For 1 of 2 medication carts observed, to ensure all medications were labeled when opened; and 2. For Resident #52, to ensure all drugs and biologicals were stored in locked compartments when not in use.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to adhere to infection control practices reducing potential transmission of infection by ensuring that the appropriate hand hygiene was preformed and personal protective equipment (PPE) was worn by staff when providing care for residents on Transmission-Based Precautions (TBP, used for patients who may be infected or colonized with certain infectious agents requiring additional precautions to prevent the spread of infection).

Inspectors wroteBased 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, 911 was not contacted by facility staff until an hour and a half after his/her hypoglycemic episode [...]

Inspectors wroteBased 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. [...]