CAPE COD POST ACUTE CARE

Performance Report

ADMINISTRATION

RESULTS
Standard Survey - 31 of 39 Met Complaint Investigation Deficiencies - 1 Score after Adjustment for Scope and Severity : 30

This nursing facility met 31 out of the 39 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 1 . The facility's score after adjustment for scope and severity is 30. The statewide average facility score was 36.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
05/08/2025 E (F 658)
The services provided or arranged by the facility as outlined by the comprehensive care plan must meet professional standards of quality. (F 658)
Deficiency #2
08/24/2022 F (F 725 )
The facility must have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services that assure resident safety and attain or maintain the highest practical well-being of residents. Sufficient numbers of licensed nurses and other nursing personnel including but not limited to nurse aides must be provided on a 24-hour basis with a licensed nurse as charge nurse on each tour of duty. (F 725 )
Deficiency #3
08/24/2022 F (F 726)
The facility must have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services that assure resident safety and attain or maintain the highest practical well-being of residents. The facility must ensure nursing staff and nurse aides have the competencies necessary to care for each resident's need. (F 726)
Deficiency #4
05/08/2025 E (F 880 )
The facility must establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Identified incidents of infection and corrective measures must be recorded and the infection control program must be reviewed yearly and updated as necessary. (F 880 )

NURSING

RESULTS
Standard Survey - 21 of 33 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 2

This nursing facility met 21 out of the 33 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 2. The statewide average facility score was 27.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
08/24/2022 D (F 675)
The facility ensures that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. (F 675) and/or; The facility ensures that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices (F 684) and/or; The facility ensures that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (F 697) and/or; The facility ensures that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (F 698) and/or; Resident who displays or are diagnosed with dementia, receive the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. (F 744)
Deficiency #2
05/08/2025 D (F 675)
The facility ensures that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. (F 675) and/or; The facility ensures that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices (F 684) and/or; The facility ensures that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (F 697) and/or; The facility ensures that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (F 698) and/or; Resident who displays or are diagnosed with dementia, receive the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. (F 744)
Deficiency #3
03/19/2024 D (F 675)
The facility ensures that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. (F 675) and/or; The facility ensures that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices (F 684) and/or; The facility ensures that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (F 697) and/or; The facility ensures that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (F 698) and/or; Resident who displays or are diagnosed with dementia, receive the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. (F 744)
Deficiency #4
03/19/2024 D (F 688)
The facility ensures that; residents who enter the facility without limited range of motion do not experience reduction in range of motion unless the resident?s clinical condition demonstrates that a reduction in range of motion is unavoidable; residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion; residents with limited mobility receive appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. (F 688)
Deficiency #5
03/19/2024 D (F 690 )
The facility ensures that residents continent of bladder and bowel on admission receive services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. The facility ensures residents incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible, specifically not catheterizing residents incontinent of urine who enter the facility without an indwelling catheter and assessing residents who enter with an indwelling catheter for removal of the catheter as soon as possible. (F 690 )

RESIDENT RIGHTS

RESULTS
Standard Survey - 22 of 27 Met Complaint Investigation Deficiencies - 1 Score after Adjustment for Scope and Severity : 17

This nursing facility met 22 out of the 27 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 1 . The facility's score after adjustment for scope and severity is 17. The statewide average facility score was 24.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
04/29/2025 D (F 583)
The facility observes resident rights to personal privacy, including personal and medical records, accommodations, medical treatment, all communications, deliveries, personal care, visits, and meetings of family and resident groups and respects residents? right to refuse the release of personal and medical records when allowed by state and federal law. (F 583) and/or; The facility maintains medical records containing required information on each resident that are complete, accurately documented, readily accessible and Systematically organized; ensures all identifiable resident records remain confidential and does not release identifiable resident information unless permitted to do so; safeguards medical record information against loss, destruction, or unauthorized use; and retains the medical records for the specified amount of time. ( F 842)
Deficiency #2
03/19/2024 D (F 604 )
The facility ensures that residents are free from physical or chemical restraints used for purposes other than to treat the resident's medical symptoms. (F 604 )
Deficiency #3
03/19/2024 E (F 550 )
The facility treats each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident?s individuality; provide equal access to quality care regardless of diagnosis, severity of condition, or payment source; and ensures that residents can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. (F 550 )
Deficiency #4
03/19/2024 F (F 679 )
The facility provides, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. (F 679 )

KITCHEN/FOOD SERVICES

RESULTS
Standard Survey - 6 of 12 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 6

This nursing facility met 6 out of the 12 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 6. The statewide average facility score was 11.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
08/24/2022 E (F 804 )
The facility provides each resident food prepared by methods that conserve nutritive value, flavor, and appearance and is palatable, attractive and at a safe and appetizing temperature. (F 804 )
Deficiency #2
03/19/2024 D (F 806 )
The facility provides each resident food that accommodates resident allergies, intolerances, and preferences; and appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice. (F 806 ) and/or; The facility provides each resident drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration. (F 807 )
Deficiency #3
05/08/2025 D (F 812 )
The facility procures food from sources approved or considered satisfactory by federal state or local authorities and stores, prepares, distributes and serves food in accordance with professional standards for food service safety. (F 812 ) and/or; The facility has a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. (F 813 )

ENVIRONMENT

RESULTS
Standard Survey - 19 of 21 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 13

This nursing facility met 19 out of the 21 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 13. The statewide average facility score was 18.