ROYAL Cotuit Nursing and Rehabilitation Center

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Name

  CMS lists a new name for this home. It was ROYAL OF COTUIT.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

CMS lists this as a standard inspection.

• Citation F0689. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 4, 2026.

• Citation F0644. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  CMS lists it as corrected on May 4, 2026.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on May 4, 2026.

  CMS has cited this home for F0656 3 times since 2023.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on May 4, 2026.

  CMS has cited this home for F0658 4 times since 2023.

• Citation F0688. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

  CMS lists it as corrected on May 4, 2026.

• Citation F0699. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care or services that was trauma informed and/or culturally competent.

  CMS lists it as corrected on May 4, 2026.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 4, 2026.

  CMS has cited this home for F0761 2 times since 2023.

• Citation F0883. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement policies and procedures for flu and pneumonia vaccinations.

  CMS lists it as corrected on May 4, 2026.

• Citation F0887. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

  CMS lists it as corrected on May 4, 2026.

• Citation F0921. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS lists it as corrected on May 4, 2026.

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CMS lists this as a standard inspection.

• Citation E0036. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish emergency prep training and testing.

  CMS lists it as corrected on May 15, 2026.

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• Fire safety citation

  CMS removed citation K0222 from the fire safety inspection on February 14, 2025.

• Fire safety citation

  CMS removed citation K0311 from the fire safety inspection on February 14, 2025.

• Fire safety citation

  CMS removed citation K0324 from the fire safety inspection on February 14, 2025.

• Fire safety citation

  CMS removed citation K0345 from the fire safety inspection on February 14, 2025.

• Fire safety citation

  CMS removed citation K0918 from the fire safety inspection on February 14, 2025.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on August 3, 2025.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on August 3, 2025.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on August 3, 2025.

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• Fine

  CMS changed the fine from October 16, 2023 from $12,155 to $7,901.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a standard inspection.

• Citation F0727. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on March 14, 2025.

• Citation F0565. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to organize and participate in resident/family groups in the facility.

  CMS lists it as corrected on March 7, 2025.

  CMS has cited this home for F0565 2 times since 2023.

• Citation F0585. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on March 7, 2025.

  CMS has cited this home for F0585 2 times since 2023.

• Citation F0686. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on March 7, 2025.

• Citation F0725. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on March 14, 2025.

• Citation F0576. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure residents have reasonable access to and privacy in their use of communication methods.

  CMS lists it as corrected on March 7, 2025.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on March 14, 2025.

  CMS has cited this home for F0609 2 times since 2023.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on March 7, 2025.

• Citation F0790. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide routine and 24-hour emergency dental care for each resident.

  CMS lists it as corrected on March 14, 2025.

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CMS lists this as a standard inspection.

• Citation E0009. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Include a process for Emergency Preparedness collaboration.

  CMS lists it as corrected on February 16, 2025.

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• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on June 22, 2024.

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• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a standard inspection.

• Citation F0561. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  CMS lists it as corrected on December 29, 2023.

• Citation F0565. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to organize and participate in resident/family groups in the facility.

  CMS lists it as corrected on January 4, 2024.

• Citation F0583. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Keep residents' personal and medical records private and confidential.

  CMS lists it as corrected on December 29, 2023.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on January 4, 2024.

• Citation F0585. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 4, 2024.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on December 29, 2023.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on December 29, 2023.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on December 29, 2023.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on December 29, 2023.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on December 29, 2023.

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CMS lists this as a standard inspection.

• Citation E0025. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Create arrangements with other facilities to receive patients.

  CMS lists it as corrected on December 13, 2023.

• Citation E0030. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: List the names and contact information of those in the facility.

  CMS lists it as corrected on December 13, 2023.

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CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

52 of 341 Massachusetts homes (15%) got a citation at the actual harm level in 2023.

• Citation F0658. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on November 7, 2023.

• Citation F0726. Severity G: actual harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on November 7, 2023.

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