A list of the most recent deficiencies for Royal of Cotuit. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-12 | 2024-01-19 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-12-05 | 2024-01-04 | N |
| 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. | Health | 2023-12-05 | 2024-01-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-05 | 2024-01-04 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-12-05 | 2023-12-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-12-05 | 2023-12-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-05 | 2023-12-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-05 | 2023-12-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-05 | 2023-12-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-05 | 2023-12-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-05 | 2023-12-29 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-12-12 | 2023-12-13 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-12-12 | 2023-12-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-16 | 2023-11-07 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-10-16 | 2023-11-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-11 | 2023-05-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-28 | 2022-10-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-07 | 2022-07-25 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-07 | 2022-07-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-03 | 2022-03-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-12 | 2021-11-11 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-06-08 | 2021-07-09 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-06-08 | 2021-07-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-06-08 | 2021-07-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-08 | 2021-07-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-08 | 2021-07-09 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-06-08 | 2021-07-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-08 | 2021-07-09 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-06-08 | 2021-07-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-08 | 2021-07-09 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-06-08 | 2021-07-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-08 | 2021-07-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-08 | 2021-07-09 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-06-08 | 2021-07-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-08 | 2021-07-09 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-05-29 | 2019-07-13 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-05-29 | 2019-07-13 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-05-29 | 2019-07-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-05-29 | 2019-07-13 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-05-29 | 2019-07-13 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-05-29 | 2019-07-13 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-05-29 | 2019-07-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-29 | 2019-07-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-04-24 | 2019-05-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-04-24 | 2019-05-30 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2019-04-24 | 2019-05-24 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-04-24 | 2019-05-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-24 | 2019-05-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-24 | 2019-05-24 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-04-24 | 2019-05-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-04-24 | 2019-05-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-04-24 | 2019-05-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-24 | 2019-05-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-24 | 2019-05-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-04-24 | 2019-05-24 | N |
