Royal Of Cotuit

F-F610

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 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. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48084

Residents Affected - Some Based 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. For Resident #29, to ensure a grievance was filed for missing clothing and was investigated through the grievance process with an adequate resolution.

Findings include:

Review of the facility's policy titled Resident Council Meetings, dated as last reviewed/revised [DATE REDACTED], 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.

-The designated liaison shall be responsible for providing assistance with facilitating successful group meetings and responding to written requests from the group.

-The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council.

Review of the facility's Complaint/Grievance Policy and Procedure, dated [DATE REDACTED], indicated but was not limited to the following:

-All residents and their responsible party will have a mechanism to voice grievances and complaints to the Grievance Official in order to facilitate communication and timely resolution of the matter.

-Voiced grievances (e.g. those about treatment, care, management of funds, lost clothing, or violation of rights) are not limited to a formal, written process and may include a resident's verbalized complaint to facility staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 -Staff shall complete a grievance form when a resident makes a verbal complaint, if not completed by the complainant. Level of Harm - Minimal harm or potential for actual harm -The Grievance Official, or designee in his/her absence, will review the grievance within ,d+[DATE REDACTED] hours.

Residents Affected - Some -The Grievance Official will complete the Grievance form to include date received, summary statement, steps taken to investigate, summary of findings, confirmation or no confirmation of grievance, corrective action taken or to be taken, and date written resolution was issued if requested.

-The Grievance Official or Social Service Department will review the findings with the resident/responsible party and provide written resolution if requested.

1. Review of the Resident Council minutes from [DATE REDACTED] through [DATE REDACTED] indicated but were not limited to the following:

[DATE REDACTED]

Concern: Laundry has gone missing.

[DATE REDACTED]

Concern: Laundry issue is still a major factor. While some of it has been found, most articles of clothing have gone missing.

[DATE REDACTED]

Concern: Resident's laundry has gone missing. While this is still an issue, some resident's laundry has been found.

[DATE REDACTED].

Concern: Some Resident's laundry has gone missing.

Status: This has been completely resolved. All articles of clothing have been returned.

The facility failed to file grievances on behalf of the residents for the missing laundry items in [DATE REDACTED], and [DATE REDACTED] through [DATE REDACTED].

On [DATE REDACTED] at 1:30 P.M., the Surveyor held a Resident Council Meeting with 11 residents in attendance.

During the meeting, the residents brought forth the following concerns:

-10 of 11 residents said they did not know what a grievance form was or how to file a grievance.

-4 of 11 residents said they have had a lot of laundry go missing and the facility doesn't do anything about it.

They do not resolve it, follow up with you, or reimburse you for the missing laundry. They said it's just gone.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 -They said sometimes they give you old unlabeled things, but they are not what was missing, they are donated or from someone that died . Level of Harm - Minimal harm or potential for actual harm -They said the laundry is terrible, they don't resolve any issues, your stuff is just gone.

Residents Affected - Some During an interview on [DATE REDACTED] at 2:06 P.M., the Activity Director said the Residents voice a lot of complaints about missing laundry. She said she will jot it down on a scrap of paper and look for things, but if she can't find it the Resident has to take it up with laundry. She said she does not log anything that is reported missing, does not file a grievance on the resident's behalf, fill out a missing item form or anything like that, and she never has. She said she thinks the Administrator deals with it and she thinks the facility pays for lost items but was unsure of the process.

During an interview on [DATE REDACTED] at 4:54 P.M., the Administrator said she did not know of specific things reported missing at Resident Council, but she would expect the Activity Director to fill out grievance forms and notify laundry of missing items. She said missing items are not always elevated to a grievance, but they should be, as it is part of the grievance process. She said if unable to find the missing item within 72 hours there should be a form filled out and it should be part of the grievance book. She said the Missing Item Forms are all part of the grievance book, and she did not have any for concerns that came from Resident Council.

2. Review of the Grievance Book from [DATE REDACTED] through [DATE REDACTED] indicated but was not limited to the following:

[DATE REDACTED] - 1 grievance on the log.

-[DATE REDACTED] indicated Missing Dentures, located in room. Form failed to indicate family was updated on resolution.

[DATE REDACTED] - 3 grievances on the log, but only 2 were in the book.

-[DATE REDACTED] indicated education would be done with staff, and the education record attached was dated [DATE REDACTED]. Form failed to indicate resident was updated on resolution.

[DATE REDACTED]- 6 grievances on the log.

-[DATE REDACTED] indicated missing clothing, family to bring in receipts for reimbursement. Resolution indicated receipts provided did not contain dates. It failed to indicate resident/family was reimbursed. Form failed to indicate resolution was discussed and acceptable to the resident/family.

-[DATE REDACTED] indicated phone was broken. Form failed to indicate resolution was discussed and acceptable to the resident/family.

-[DATE REDACTED] indicated phone was broken. Form failed to indicate resolution was discussed and acceptable to the resident/family.

[DATE REDACTED] - 1 grievance on the log.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 -[DATE REDACTED] indicated missing pants. Not found. Summary indicated education regarding labeling of clothing. Form failed to indicate resolution was discussed and acceptable to the resident/family. Level of Harm - Minimal harm or potential for actual harm [DATE REDACTED] - 2 grievances on the log. 3 forms in the book.

Residents Affected - Some -[DATE REDACTED] indicated family reported resident drowsy and not answering the phone. Form failed to indicate resolution was discussed and acceptable to the resident/family.

-[DATE REDACTED] indicated concern with wounds. Form failed to indicate resolution was discussed and acceptable to

the resident/family.

-[DATE REDACTED] indicated crumbs in drawer. Form failed to indicate resolution was discussed and acceptable to the resident/family.

[DATE REDACTED] - No log. 4 grievances in the book.

-[DATE REDACTED] indicated food was thrown away in container. Summary indicated educate families on policy. Staff in-service attached. Form failed to indicate resolution was discussed and acceptable to the resident/family.

-[DATE REDACTED] indicated resident menu complaint. Form failed to indicate resolution was discussed and acceptable to the resident/family.

-[DATE REDACTED] indicated family complaint of menu. Form failed to indicate resolution was discussed and acceptable to the resident/family.

[DATE REDACTED] - No log. 1 grievance in the book.

-[DATE REDACTED] indicated a cell phone was missing. Form failed to indicate phone had been located or that resolution was discussed and acceptable to the resident/family.

[DATE REDACTED] - 3 grievances on the log.

-[DATE REDACTED] indicated a missing item reported by family. Form failed to indicate resolution was discussed and acceptable to the resident/family.

-[DATE REDACTED] indicated complaint of harassment. Form failed to indicate resolution was discussed and acceptable to the resident/family.

During an interview on [DATE REDACTED] at 4:54 P.M., the Administrator said they discuss grievances at morning meeting, they go to the Social Worker and then they come back to my office to note the resolution and sign off on it as completed. They all should have a resolution noted and be signed off as completed and they are not.

The surveyor reviewed a grievance form from the grievance book dated [DATE REDACTED] regarding a missing cell phone with the Administrator. The form failed to include a summary of the findings and failed to include a resolution.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 During an interview on [DATE REDACTED] at 4:54 P.M., the Administrator said she did not know the status of the grievance for the missing phone or if the family had been updated. Level of Harm - Minimal harm or potential for actual harm 3. Resident #6 was admitted to the facility in [DATE REDACTED].

Residents Affected - Some Review of the Minimum Data Set (MDS) assessment, dated [DATE REDACTED], indicated he/she scored 13 out of 15 on

the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact.

On [DATE REDACTED] at 1:30 P.M., the surveyor held a Resident Council Meeting with 11 residents in attendance.

During the meeting, Resident #6 said he/she has had multiple missing clothing items, and his/her cell phone has been missing for months and none of it has been addressed.

During an interview on [DATE REDACTED] at 2:00 P.M., Certified Nursing Assistant (CNA) #2 said Resident #6 had a cell phone since at least [DATE REDACTED] when she started working at the facility, but she has not seen it for a couple months. She said he/she was accusing us of stealing it, everyone knew about it, but we did not find it. Additionally, she said Resident #6 was vocal about it at first but, she has not heard much about it recently, and did not know the status of the investigation.

During an interview on [DATE REDACTED] at 3:45 P.M., Resident #6 said the cell phone has been missing for a couple months. He/she said the phone was on the bed but when he/she returned from the bathroom it was gone. Resident #6 said he/she told the nurse at the desk, but they didn't care. He/she said nothing ever came of it. Additionally, he/she said there were multiple missing undergarments and was told he/she could just buy new ones and was shrugged off when reporting two blouses that were missing around Thanksgiving. Resident #6 said, Things just disappear, so I don't have anything nice anymore and won't buy any new things.

During an interview on [DATE REDACTED] at 4:05 P.M., CNA #2 said laundry is missing a lot. She said they look for it and if they don't find it, it's reported to the Unit Manager and she handles it. She said she was not aware of anything currently missing for Resident #6.

During an interview on [DATE REDACTED] at 4:25 P.M., Unit Manager #1 said if something is reported missing, they do

an initial search and then fill out a Missing Item Form. She said they used to fill out the Grievance Form but now there is a Missing Item Form. She said it is all part of the grievance book, and the Administrator handles it. She said missing laundry is frequently a concern but was not aware of Resident #6 missing any laundry. Additionally, she said Resident #6's cell phone has been missing for a few months and did not know the status of the investigation. She said the Missing Item Form would have been filled out when it was deemed missing and then turned into the office. She said she does not keep a copy, nor follow up on the investigation

after the forms are turned in. Additionally, she said there were no progress notes indicating a search or resolution for the missing cell phone in the medical record.

During an interview on [DATE REDACTED] at 4:54 P.M., the Administrator said she did not know Resident #6 was missing clothing or a cell phone. She said missing items are not always elevated to a grievance, but they should be, as it is part of the grievance process. She said if unable to find the missing item (clothes) within 72 hours there should be a form filled out and it should be part of the grievance book. She said things like cell phones should be reported right away. The Administrator said the Missing Item Forms are all part of the grievance book, and she did not have any for Resident #6.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 41106

Level of Harm - Minimal harm or 4. Resident #29 was admitted to the facility in [DATE REDACTED]. potential for actual harm

Review of the MDS assessment, dated [DATE REDACTED], indicated Resident #29 scored 15 out of 15 on the BIMS Residents Affected - Some which indicated the Resident was cognitively intact.

During an interview on [DATE REDACTED] at 9:09 A.M., Resident #29 said Laundry has lost over $600 worth of his/her clothes.

On [DATE REDACTED] at 3:50 P.M., the surveyor reviewed the Grievance book for 2024 and 2025 and found only one grievance filed on behalf of Resident #29 which included:

-Grievance filed [DATE REDACTED]

-Description of Complaint: Resident was missing a pair of pants not found, but all clothes will be labeled at

the front desk and distributed to residents.

-Summary Statement: Education was done for Resident and encouraged to send clothes to son's house, Salvation Army or throw out.

-Steps Taken to Investigate: All clothes that are mailed to patients will be labeled upon arrival.

-Summary of Findings (to include statement of whether grievance was confirmed or not confirmed: Patient has lost 50 lbs. (pounds) and will need to process old clothes that are too large and label all.

-Corrective Action Taken or To Be Taken: Lost clothing has reduced to 0 for this resident.

-Resolution Acceptable to Resident/Responsible person: The boxes yes or no were not checked and the date resolved was left blank. The Staff Development Coordinator (SDC) and Director of Nursing (DON) with Resident; he/she appears to accept the explanation.

No evidence of grievance was resolved.

During an interview on [DATE REDACTED] at 4:52 P.M., Resident #29 said he/she had a meeting with the Administrator about his/her missing clothing, and he/she was told to donate some clothes.

During an interview on [DATE REDACTED] at 11:00 A.M., the Administrator said Resident #29's clothes were going missing, but he/she has had nothing missing for the last three months. The Administrator said prior to that we could not keep an inventory because he/she was receiving packages three times a week. The surveyor reviewed the grievance filed [DATE REDACTED] with the Administrator who said she was not aware of any other missing clothes since the incident of the missing pants in [DATE REDACTED]. The Administrator said the grievance written for the pants is weak and there was no resolution for the missing pants. The Administrator said there were no other grievances filed for missing clothes for Residents #29.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 During an interview on [DATE REDACTED] at 9:09 A.M., Resident #29 said he/she just recently bought $300 worth of new clothes and is already missing a pink sweatshirt with the head of a cat and their paws on the front of it. Level of Harm - Minimal harm or Resident #29 said it has been missing for weeks. potential for actual harm

During an interview with the Director of Laundry and Laundry Staff #1 on [DATE REDACTED] at 12:45 P.M., Laundry Residents Affected - Some Staff #1 said she had been aware for weeks that Resident #29 was missing a pink sweatshirt with a cat's face and their paws on the front of it. Laundry Staff #1 said Resident #29 showed her a picture of the missing sweatshirt which he/she has been looking for and unable to find. Laundry Staff #1 showed the surveyor a picture of the missing sweatshirt on her phone. Laundry Staff #1 said if she can't find an item the resident is missing, then she reports it to the Activity Director. After that she does not know what will happen.

During a telephonic interview on [DATE REDACTED] at10:24 A.M., Family Member (FM) #1 (Resident #29's Health Care Proxy) said he has been in contact with the facility regarding at least ,d+[DATE REDACTED] pieces of missing clothing, but you (the surveyor) would have to speak directly to Resident #29 to find out how much clothing is missing. FM #1 said they have never been reimbursed for any of the missing clothing, and it is simple if they (the facility) just labelled the clothing there would not be a problem.

During an interview on [DATE REDACTED] at 2:55 P.M., the Activity Director said she was aware Resident #29 was missing the pink sweatshirt with a cat face on the front for a couple of months. She said she never filed a grievance for Resident #29, but she still looks for the sweatshirt.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm 41106

Residents Affected - Few Based 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.

Findings include:

Review of the facility's policy titled Abuse Policy, undated, indicated but was not limited to the following:

Policies and procedures regarding investigation and reporting of alleged violations of federal or state laws involving mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident's property.

-Such violations will also be reported to state agencies in accordance with existing state law.

-The facility will investigate each alleged violation thoroughly and report the results of the investigation to the Executive Director or his or her designee, as well as to state agencies as required by state and federal law.

-Protection:

-If the suspected perpetrator is an employee, the Executive Director shall place the employee on immediate investigatory suspension while completing the investigation.

Investigation of suspected resident abuse/ mistreatment/misappropriation/neglect/injury of unknown origin:

1. If a family member, resident, or staff reports an incident of abuse/mistreatment/neglect, it is to be reported to the Director of Nursing or manager immediately and an incident/accident report is to be completed.

2. The supervisor is to initiate the following steps:

-Send the initial report to the Department of Public Health via Virtual Gateway immediately but no later than two hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 1. Resident #29 was admitted to the facility in June 2020.

Level of Harm - Minimal harm or Review of the Minimum Data Set (MDS) assessment, dated 1/9/25, indicated Resident #29 scored 15 out of potential for actual harm 15 on the Brief Interview for Mental Status (BIMS), which indicated the Resident was cognitively intact.

Residents Affected - Few During an interview on 2/05/25 at 4:52 P.M., Resident #29 said he/she had a meeting with the Administrator about his/her missing clothing, and he/she was told to donate some clothes.

During a telephonic interview on 2/6/25 at 10:24 A.M., Family Member (FM) #1 (Resident #29's Health Care Proxy) said Resident #29 was upset and told him, he/she had 11 packages that were not delivered over Christmas until he/she got rid of stuff in his/her room. FM #1 said some of the packages contained Christmas presents for family members. FM #1 said he spoke with the woman in Activities and informed her that Resident #29's packages were not delivered, and it was illegal for them to withhold packages and cited Federal law chapter 8, section 1701 and 1702.

During an interview on 2/06/25 at 11:00 A.M., the surveyor informed the Administrator of FM #1's concern of packages being withheld until extra items in Resident #29's room were removed. The Administrator said FM #1 had expressed his concerns to her about Resident #29 not receiving some packages and he did cite the Federal law to her during a meeting in January about mail delivery. The Administrator said she did not keep any notes on the conversations with FM #1 and referred the surveyor to check the social service notes. The Administrator said she did not investigate why Resident #29's packages were held in the business office, and/or file a grievance.

During an interview on 2/06/25 at 11:18 A.M., the Front Desk Receptionist (FDR), with the Administrator present, said Resident #29 was complaining about packages not being delivered over Christmas. FDR said

she told the Business Office Manager (BOM) about the complaints and never heard any more about the complaint.

During an interview on 2/07/25 at 9:02 A.M., Social Worker (SW) #1 said she called FM #1 at the beginning of January and asked him to come in and pick up some of Resident #29's extra belongings the facility was storing. She said at that time FM #1 brought the concerns of Resident #29 not receiving his/her packages, and FM #1 said it violated federal law. SW #1 said she notified the Administrator, and they decided to have a meeting with FM #1. SW #1 said the care plan meeting took place on 1/15/25 and mail delivery concerns were discussed, and they reviewed Resident #29's purchase of clothing and extra clothes in the room. SW #1 said FM #1 brought up the Federal law of delivery of packages and FM #1 was assured Resident #29 would receive his/her packages going forward.

During an interview on 2/07/25 at 10:35 A.M., the Corporate Nurse said she was not aware of FM #1's complaint that Resident #29 did not receive packages over Christmas until items were removed from his/her room.

On 2/7/25 at 11:30 A.M., the surveyor reviewed Health Care Facility Reporting System (HCFRS) which from 12/24/2024 through 2/7/25 failed to indicate any incidents of alleged misappropriation of Resident #29's property was reported by the facility.

2. Resident #609 was admitted to the facility in March 2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Review of the MDS assessment, dated 12/19/24, indicated Resident #609 scored 15 out of 15 on the BIMS indicating he/she was cognitively intact. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/4/25 at 9:35 A.M., Resident #609 said he/she was just going to call the Department of Public Health (DPH) and file a complaint of harassment for payment and for ease dropping on his/her Residents Affected - Few private conversation he/she had with their spouse. Resident #609 said the Administrator continues to harass him/her for payment and he/she was told by his/her lawyer to pay what you can.

During an interview on 2/4/25 at 8:55 A.M., the Director of Nurses (DON) was notified of Resident #609's alleged complaints of harassment and ease dropping on a phone conversation against the Administrator.

The DON said she was aware of Resident #609's complaint of ease dropping but was not aware of the harassment for payment.

During an interview on 2/05/25 at 9:13 A.M., the Corporate Nurse said she was aware of the financial concerns relating to Resident #609, but she was not aware he/she made allegations of harassment yesterday.

During an interview on 2/05/25 at 9:26 A.M., the Administrator said she was made aware yesterday of Resident #609's complaint of harassment for non-payment against her. She said she is fully aware of Resident #609's current financial issues and last week she called the local police on Resident #609 after he/she received a 30-day discharge notice and then threatened her in the lobby. The Administrator said because she knows what is going on with Resident #609, she did not report the allegations of harassment to

the state as they were not substantiated.

During an interview on 2/05/25 at 2:01 P.M., Corporate Nurse said a complaint of harassment requires reporting and an investigation.

On 2/7/25 at 11:30 A.M., the surveyor reviewed HCFRS which from 2/4/25 through 2/7/25 failed to indicate any incidents of alleged harassment towards Resident #609 were reported by the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or 41106 potential for actual harm Based on interview and record review, the facility failed to investigate an allegation of misappropriation of Residents Affected - Few 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.

Findings include:

Review of the facility's policy titled Abuse Policy, undated, indicated but was not limited to the following:

-Policies and procedures regarding investigation and reporting of alleged violations of federal or state laws involving mistreatment, neglect, abuse, injuries of unknown source and misappropriation of residence property.

-Such violations will also be reported to state agencies in accordance with existing state law.

-The facility will investigate each alleged violation thoroughly and report the results of the investigation to the executive director or his or her designee, as well as to state agencies as required by state and federal law.

-Protection:

-If the suspected perpetrator is an employee, the executive director shall place the employee on immediate investigatory suspension while completing the investigation.

Investigation of suspected resident abuse/mistreatment/misappropriation/neglect/injury of unknown origin

1. If a family member resident or staff reports an incident of abuse/mistreatment neglect, it is to be reported to the director of nursing or manager immediately in an incident/accident report is to be completed.

2. The supervisor is to initiate the following steps:

Reporting:

-a. An employee who suspects an alleged violation shall immediately notify the executive director or his/her designee. The executive director shall also notify the appropriate state agency in accordance with state law.

b. The results of all investigations must be reported immediately to the Executive Director or his/her designee and to the appropriate state agencies as required by state law with initial reports submitted within two hours and follow up within (5) working days of the violation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Policy and procedure: investigation of suspected resident abuse/mistreatment/misappropriation/neglect/injury unknown origin: Level of Harm - Minimal harm or potential for actual harm 1. If a family member, resident or staff reports an incident of abuse/mistreatment/neglect, it is to be reported to the director of nursing services or manager immediately in an incident/accident report is to be completed. Residents Affected - Few 2. The supervisor is to initiate the following steps:

a. Immediate investigation into the alleged incident.

b. Interview staff member implicated. Get written statements.

c. Interview other staff members. Employees should document incident in written narrative.

d. Interview with resident or resident witnesses. Supervise it to document written statement from resident(s).

e. All statements should include date and time of alleged incident, and date of time statement was written.

f. Employee involved is to be sent home pending investigation.

g. Immediate notification to the Director of Nurses and Executive Director.

h. Send initial report to the Department of Public health via Virtual Gateway immediately but no more than two hours.

i. Notify the social worker who will interview the resident. Document in social service progress note.

j. Internal written reports are to be initiated during the shift the incident occurred, and complete it within 24 to 48 hours.

k. Final report to be submitted to the Department of Public health via Virtual Gateway within (5) business days of the initial report.

Resident #29 was admitted to the facility in June 2020.

Review of the Minimum Data Set (MDS) assessment, dated 1/9/25, indicated Resident #29 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the Resident was cognitively intact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 During a telephonic interview on 2/06/25 at 10:24 A.M., Family Member (FM) #1 (Resident #29's Health Care Proxy) said Resident #29 was upset and told him, he/she had 11 packages that were not delivered over Level of Harm - Minimal harm or Christmas until he/she got rid of stuff in his/her room. FM #1 said some of the packages contained Christmas potential for actual harm presents for family members. FM #1 said he spoke with the woman in Activities and informed her that Resident #29's packages were not delivered, and it was illegal for them to withhold packages and cited Residents Affected - Few Federal law chapter 8, section 1701 and 1702.

During an interview on 2/06/25 at 11:00 A.M., the surveyor informed the Administrator of FM #1's concern of packages being withheld until extra items in Resident #29's room were removed. The Administrator said FM #1 had expressed his concerns to her about Resident #29 not receiving some packages and he did cite the Federal law to her during a meeting in January about mail delivery. The Administrator said she did not keep any notes on the conversations with FM #1 and referred the surveyor to check the social service notes. The Administrator said she did not investigate why Resident #29's packages were held in the business office and/or file a grievance.

During an interview on 2/06/25 at 11:18 A.M., the Front Desk Receptionist (FDR), with the Administrator present, said Resident #29 was complaining about packages not being delivered over Christmas. The FDR said she told the Business Office Manager (BOM) about the complaints and never heard any more about the complaint.

During an interview on 2/07/25 at 9:02 A.M., Social Worker (SW) #1 said she called FM #1 at the beginning of January and asked him to come in and pick up some of Resident #29's extra belongings the facility was storing. She said at that time FM #1 brought the concerns of Resident #29 not receiving his/her packages, and FM #1 said it violated federal law. SW #1 said she notified the Administrator, and they decided to have a meeting with FM #1. SW #1 said the care plan meeting took place on 1/15/25 and mail delivery concerns were discussed, and they reviewed Resident #29's purchases of clothing and extra clothes in the room. SW #1 said FM #1 brought up the Federal law of delivery of packages and FM #1 was assured Resident #29 would receive his/her packages going forward.

The facility did not provide the surveyor with an investigation into FM #1's allegations of misappropriation of Resident #29's personal packages dating back to at least 1/15/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or 49425 potential for actual harm Based on interviews and record review, the facility failed to ensure one Resident (#64), out of a total sample Residents Affected - Some 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.

Findings include:

Review of the facility's policy titled Prevention of Pressure Ulcers/Injuries, dated as last revised May 2024, indicated but was not limited to the following:

-Identify any signs of developing pressure injuries (non-blanchable erythema)

-Inspect pressure points

-Evaluate, report and document potential changes in the skin

-Review the interventions and strategies for effectiveness

Review of the facility's policy titled Charting and Documentation, dated as last revised May 2023, indicated but was not limited to the following:

-All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, should be documented in the resident's medical record.

-The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care

-The following information is to be documented in the resident medical record:

-Objective observations

-Treatments or services performed

-Progress toward or changes in the care plan goals and objectives

-Documentation of procedures and treatments will include care-specific details

Review of the facility's policy titled Skin Integrity Management, undated, indicated but was not limited to the following:

-Residents with actual skin breakdown are identified, assessed, and provided treatment according to standards of practice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 -Refer to wound MD/wound clinic as appropriate.

Level of Harm - Minimal harm or -Implement wound care modalities potential for actual harm

Review of the Wound Clinic Services Agreement, dated January 2024, indicated but was not limited to the Residents Affected - Some following:

Facility Responsibilities:

-Provide a dedicated nurse to round and communicate with the Provider.

-Inform the resident's primary care provider of Provider's recommendation within 24 hours.

-Discuss recommendations/wound care plan with the Provider on the day of rounds.

Resident #64 was admitted to the facility in December 2023 with diagnoses including type II diabetes, severe protein calorie malnutrition, and pressure ulcers.

Review of the Minimum Data Set (MDS) assessment, dated 1/15/25, indicated Resident #64 was mildly cognitively impaired as evidenced by a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS). Additionally, Resident #64 had skin treatments and was dependent on staff for bed mobility.

Review of the comprehensive care plan indicated but was not limited to the following:

-Resident has a stage 1 pressure ulcer of the left medial knee related to immobility (1/16/25)

-Administer treatments as ordered and monitor for effectiveness (1/16/25)

Review of the medical record indicated Resident #64 was followed by a Wound Care Physician at the facility.

Review of the Wound Evaluation and Management Summary, dated 1/15/25, indicated but was not limited to

the following:

-Stage 1 Pressure Wound of the Left Medial Knee measured 1.0 x 1.0 x not measurable centimeters (cm)

-Dressing treatment plan: Skin prep once daily for 30 days.

-Additional wound detail: This is a stage 1 pressure injury at the site of prior stage 2 wound

-Pillow between knees

-Additional information: The patient is resistant to repositioning and using a pillow between her knees

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Review of the skin/wound note, dated 1/16/25, written by the Assistant Director of Nursing (ADON), indicated Resident #64 was seen by wound physician and an order was received to apply skin prep to the stage 1 Level of Harm - Minimal harm or pressure injury on the left medial knee daily. potential for actual harm

Review of the January and February 2025 Physician's Orders/Treatment Administration Record (TAR) failed Residents Affected - Some to indicate an order was implemented to apply skin prep to the stage 1 pressure injury of the left medial knee.

Review of the Wound Evaluation and Management Summary, dated 1/21/25, indicated but was not limited to

the following:

-Stage 1 Pressure Wound of the Left Medial Knee measured 1.0 x 1.0 x not measurable cm

-Dressing treatment plan: Skin prep once daily for 30 days.

-Pillow between knees

-Additional information: The patient is resistant to repositioning and using a pillow between her knees

Review of the skin/wound note, dated 1/22/25, written by the ADON, indicated Resident #64 was seen by wound physician and to continue previously ordered treatment to the stage 1 pressure injury of the left medial knee.

Review of the January and February 2025 Physician's Orders/TAR failed to indicate an order was implemented to apply skin prep to the stage 1 pressure injury of the left medial knee.

Review of the Wound Evaluation and Management Summary, dated 2/4/25, indicated but was not limited to

the following:

-Stage 2 Pressure Wound of the Left Medial Knee measured 0.8 x 0.9 x 0.02 cm

-Dressing treatment plan: gauze island with border apply every two days for 30 days

-Discontinue skin prep

-Pillow between knees

-Additional information: The patient is resistant to repositioning and using a pillow between her knees

Review of the skin/wound note dated 2/5/25, written by Unit Manager (UM) #1, indicated Resident #64 was seen by wound physician and an order was received to cleanse area with normal saline, cover with bordered gauze island dressing, change every two days to the stage II pressure injury of the left medial knee.

Review of the February 2025 Physician's Orders/TAR indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 -Left medial knee: Wash with normal saline, pat dry. Apply gauze island with border every other day for wound healing. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/6/25 at 10:09 A.M., UM #1 said she just started completing wound rounds on her unit with the wound physician this week. She said the wound physician communicates his recommendations Residents Affected - Some verbally and then sends them over to the facility electronically the same day. UM #1 said she then notifies

the medical director of the recommendations and documents the information in a nursing note. UM #1 said Resident #64's treatment was updated to apply a dressing for protection of the area and she implemented

the new order yesterday. She said there was no other treatment order in place to the area, only to encourage

a pillow between the knees.

During an interview on 2/6/25 at 10:25 A.M., Nurse #1 said she provides care to Resident #64 on a consistent basis. She said Resident #64 did not have an order to apply skin prep to the left medial knee. Nurse #1 said she would place a pillow between the Resident's knees and encourage him/her to keep it in place.

During an interview on 2/6/25 at 1:49 P.M., ADON said she completed rounds with the wound physician until last week. She said she would remove the dressings, and the wound physician would take measurements of

the areas and give her recommendations verbally. She said she would document his verbal recommendations on a rounding sheet which included current treatment orders. The ADON said the wound evaluations are then sent over electronically to the medical record system. She then implements the orders, and documents it in a nursing note. She said the medical director defers treatment plans to the wound physician. The ADON and the surveyor reviewed Resident #64's wound evaluations, dated 1/15/25 and 1/22/25, nursing progress notes, and physician's orders in the medical record. She said Resident #64 was supposed to have an order to apply skin prep to the left medial knee, and documented it in her nursing note, however it was never put into place. The ADON said the Resident has an abundance of open areas, and it must have been an oversight. The ADON said she was going to notify the physician of the error.

During an interview on 2/6/25 at 2:12 P.M., the Director of Nursing (DON) said her expectations are for the nurse who is completing rounds with the wound physician to transcribe and implement all the treatment orders on the day they are received. She said the order was never implemented as it should have been.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 48084

Residents Affected - Some Based 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.

Findings include:

Review of the PBJ Staffing Data Report, CASPER Report 1705D FY Quarter 4, 2024 (July 1 - September 30) indicated the following:

This Staffing Data Report identifies areas of concern that will be triggered (e.g., requires follow-up during the survey).

-Excessively Low Weekend Staffing - Triggered = Submitted Weekend Staffing data is excessively low.

Review of the facility's healthcare Facility Assessment (FA), revised 1/7/2025, indicated the following:

Part 1: Resident Profile

-Number of residents you are licensed to provide care for - 98

-Average daily census: 88-92

Staffing Plan

3.2 Total Number Needed or Average or Range of Staff:

- Licensed nurses (LN) providing direct care: 1:x LN ratio Days and Evenings.

- Direct Care Staff (Nurse Aides): 1:x ratio

The facility failed to indicate updated staffing patterns on the FA.

Review of the facility's previous healthcare FA, revised 10/6/2023, last reviewed 10/29/2024, indicated the following:

Part 1: Resident Profile

-Number of residents you are licensed to provide care for - 99

-Average daily census (ADC): 85-92

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 -Current ADC: 72

Level of Harm - Minimal harm or Staffing Plan potential for actual harm 3.2 Total Number Needed or Average or Range of Staff: Residents Affected - Some - Licensed nurses (LN) providing direct care:

RN or Unit Manager 1 for each unit (2 units Monday-Friday)

Staff Nurse: 2 for each unit per shift; 1 on 11pm -7am.

- Direct Care Staff (Nurse Aides-CNA): Nights 2 per unit.

Review of the as worked staffing schedules and time sheets provided by the Scheduling Coordinator for licensed nurses and nurse aides during FY Quarter 4, 2024, indicated the total number of LN and nurse aides was below the needed or average range, per the FA, for the following dates:

7/6/24

-Total Census 74

-7pm-11pm one nurse on Popponessett Unit (one less than the minimum required)

7/13/24

Total Census 74

-7pm-11pm one nurse on Popponessett Unit (one less than the minimum required)

7/14/24

Total Census 74

-11pm-7am three total CNAs (one less than the minimum required)

7/20/24

Total Census 78

-7pm-11pm one nurse on Popponessett Unit (one less than the minimum required)

7/21/24

Total Census 79

-7pm-11pm one nurse on Popponessett Unit (one less than the minimum required)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 7/27/24

Level of Harm - Minimal harm or Total Census 78 potential for actual harm -7pm-11pm one nurse on Popponessett Unit (one less than the minimum required) Residents Affected - Some -11pm-7am three total CNAs (one less than the minimum required)

7/28/24

Total Census 80

-7pm-11pm one nurse on Popponessett Unit (one less than the minimum required)

8/2/24

Total Census 76

-11pm-7am two total CNAs (two less than the minimum required)

8/10/24

Total Census 75

-11pm-7am two total CNAs (two less than the minimum required)

-7pm-11pm one nurse on Popponessett Unit (one less than the minimum required)

8/11/24

Total Census 74

-7pm-11pm one nurse on Popponessett Unit (one less than the minimum required)

8/17/24

Total Census 83

-7pm-11pm one nurse on Popponessett Unit (one less than the minimum required)

8/18/24

Total Census 81

-11pm-7am three total CNAs (one less than the minimum required)

8/24/24

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Total Census 87

Level of Harm - Minimal harm or -11pm-7am one CNA with one trainee (three less than the minimum required) potential for actual harm 8/25/24 Residents Affected - Some Total Census 87

-7pm-11pm one nurse on Popponessett Unit (one less than the minimum required)

8/28/24

Total Census 89

-11pm-7am three total CNAs (one less than the minimum required)

8/31/24

Total Census 89

-11pm-7am two total CNAs (two less than the minimum required)

-7pm-11pm one nurse on Popponessett Unit (one less than the minimum required)

9/1/24

Total Census 90

-7pm-11pm one nurse on Popponessett Unit (one less than the minimum required)

9/7/24

Total Census 84

-7pm-11pm one nurse on Popponessett Unit (one less than the minimum required)

9/22/24

Total Census 83

-7pm-11pm one nurse on Popponessett Unit (one less than the minimum required)

9/28/24

Total Census 83

-7pm-11pm one nurse on Popponessett Unit (one less than the minimum required)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 9/30/24

Level of Harm - Minimal harm or Total Census 83 potential for actual harm -11pm-7am three total CNAs (one less than the minimum required) Residents Affected - Some

During an interview on 2/6/25 at 2:00 P.M., the Director of Nurse (DON) said with a Census of 70-80 our staffing pattern on the 3pm-11pm shift would be 2 nurses on each unit and on 11pm-7am shift the staffing pattern would be 2 CNAs on each unit.

During an interview on 2/7/25 at 11:33 A.M., the Staffing Coordinator said on a typical day we staff 2 nurses

on each unit on the 3pm-11pm shift and 2 CNAs on each unit on the 11pm-7am shift. She said if the census is lower than 70 then they will adjust. She said if there is a call out that can't be covered someone will stay late and/or come in early to cover the shift. She said occasionally there are only 3 CNAs on at night due to call ins and one will float to the other unit to help. She said it's not ideal, but it happens sometimes. She said there should never be one CNA on each unit and did not know how that happened. She said there were a lot of call ins during this time frame which made the schedule difficult to manage. Additionally, she said there is still a hole in the nursing schedule and the 7pm-11pm shift is hard to cover. She said it never used to be like that, but it has been for a while. She said she has been able to cover it more often than during the time frame reviewed. She said sometimes someone will stay until 9:30/10:00pm and leave when it's quiet, but not always, and not on these days, it appears both nurses left between 7pm and 7:30pm on these days. She said the weekend nurse working 7pm-7am was alone after 7pm. She said she tries to schedule a desk nurse to cover it, but she cannot always do that or sometimes the on-call nurse will come in, but during this time frame the previous DON would not even answer the phone.

During an interview on 2/7/25 at 4:40 P.M., the Administrator said she was unsure why the staffing pattern did not carry over to the updated FA. She said the staffing pattern is the same as previously noted, 2 staff nurses on each unit for 3pm-11pm shift and there should be 2 CNAs on each unit on the 11pm-7am shift for

the census that we have, if the census drops then we would adjust staffing accordingly. She said occasionally due to call out there may only be 3 CNAs in the building on 11pm-7am shift and they would have to help each other, but there should never just be one on each unit.

During an interview on 2/7/25 at 4:50 P.M., the DON said if there is a hole in the schedule due to call ins generally, they would piece it together by having one nurse stay late and one come in early. She was unable to speak to FY Quarter 4 as she was not employed by the facility at that time. Additionally, she said there should never be just one CNA on each unit, someone should have been mandated to stay.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis. Level of Harm - Minimal harm or potential for actual harm 48084

Residents Affected - Many 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. Specifically, the facility failed to provide RN services on 1/11/25 and 1/12/25.

Findings include:

Review of the facility's policy titled Staffing, undated, indicated but was not limited to the following:

-Facility maintains adequate staffing on each shift to ensure that our residents' needs and services are met based on Facility Assessment. Licensed nursing staff are available to provide and monitor the delivery of care services.

Review of the as worked nursing schedules for 1/6/25 through 2/6/25 indicated but was not limited to the following:

-Saturday, 1/11/25, there was no RN coverage for the 24-hour period.

-Sunday, 1/12/25, there was no RN coverage for the 24-hour period.

During Entrance Conference on 2/4/25 at 9:02 A.M., the Administrator said the facility did not have any nurse staffing waivers.

During an interview on 2/6/25 at 2:00 P.M., the Administrator said there should be RN coverage for at least 8 hours every day.

During an interview on 2/7/25 at 11:33 A.M., the Scheduling Coordinator said there should be an RN working every day and on 1/11/25 and 1/12/25 the RN called in and we must not have been able to get another one, because we did not have RN coverage on either of those days.

During an interview on 2/7/25 at 4:50 P.M., the Director of Nurses said there should be RN coverage for at least 8 hours every day and she was not aware on 1/11/25 or 11/12/25 the facility did not have RN coverage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 Provide routine and 24-hour emergency dental care for each resident.

Level of Harm - Minimal harm or 28450 potential for actual harm Based on observation, record review, and interview, the facility failed to provide dental services for one Residents Affected - Few 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.

Findings include:

Review of the facility's policy titled [Facility Corporation] Dental Services, dated May 2023, indicated but was not limited to:

Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.

- If dentures are damaged or lost, Residents will be referred for dental services within three days.

- If the referral is not made within three days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services; and the reason for delay.

Resident #44 was admitted to the facility in November 2023 with diagnoses including chronic obstructive pulmonary disease, dysphagia, and vitamin B12 deficiency anemia.

Review of the Minimum Data Set (MDS), assessment, dated 11/12/24, indicated Resident #44 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) exam indicating moderate cognitive impairment. The MDS further indicated Resident # 44 requires supervision to clean, insert and remove dentures into and from

the mouth.

During an interview on 2/4/25 at 2:30 P.M., Resident #44 said his/her dentures were missing; they were no longer in the container on their bedside table. Resident #44 said a dental appointment needed to be scheduled.

Review of the Health Drive Request for Service Form, dated 11/8/23, indicated Resident #44 had signed consent for dental services.

Further review of the medical record failed to indicate that Resident #44 had a scheduled dental appointment to replace the missing dentures as requested.

During an interview on 02/06/25 at 03:11 P.M., Resident #44 said he/she needed an appointment to replace his/her lost dentures. The Resident said he/she spoke to the Unit Manager about it approximately three weeks ago, but she never got back to him/her.

During an interview on 02/07/25 at 02:13 P.M., Nurse #1 said management is responsible for scheduling appointments for the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 31 225689 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225689 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Royal of Cotuit 161 Falmouth Road Mashpee, MA 02649

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 During an interview on 02/07/25 at 02:23 P.M., Resident #44 said he/she had spoken to Unit Manager #1 about scheduling the dental appointment, but she had not given him/her a date yet. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/07/25 at 02:25 P.M., Unit Manager #1 said approximately three weeks ago Resident #44 requested to schedule a dental appointment. Unit Manager #1 said she did not make the Residents Affected - Few appointment in accordance with the resident's request.

On 2/7/25 at 3:27 P.M., the surveyor made the Administrator and the Director of Nurses aware of this incident as neither knew that Resident #44's dentures were missing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 31 225689