Cycle 1
Health 2025-01-30 · Fire 2025-01-30
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Buzzards Bay, MA
Royal Cape Cod Nursing & Rehabilitation Center
4-star overall rating with 4-star inspections with $9,004 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
8 Lewis Point Road, Buzzards Bay, MA
(508) 759-5752
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Royal Health Group
Operator or chain grouping
Approved since
1991-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.60
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.84
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.94
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.17
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,013
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9998
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.34
Baseline 21.42% · Performance 20.34% · Measure score 2.34 · Achievement 2.34 · Improvement 1.95
Healthcare-associated infections
8.82
Baseline 7.93% · Performance 5.20% · Measure score 8.82 · Achievement 8.82 · Improvement 8.81
Total nurse turnover
6.03
Baseline 42.19% · Performance 39.02% · Measure score 6.03 · Achievement 6.03 · Improvement 1.32
Adjusted total nurse staffing
1.37
Baseline 3.62 hours · Performance 3.47 hours · Measure score 1.37 · Achievement 1.37 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.02% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 173 · Observed rate 8.67% · Lower 95% interval 6.92% |
| Discharge to community | 73.52% |
50.57%
22.9 pts better
|
Better than the National Rate · Eligible stays 161 · Observed rate 69.57% · Lower 95% interval 66.72% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 144 · Denominator 144 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 144 |
| Discharge self-care score | 28.18% |
53.69%
25.5 pts worse
|
Numerator 31 · Denominator 110 |
| Discharge mobility score | 14.55% |
50.94%
36.4 pts worse
|
Numerator 16 · Denominator 110 |
| Pressure ulcers or injuries, new or worsened | 2.08% |
2.29%
0.2 pts better
|
Numerator 3 · Denominator 144 · Adjusted rate 2.11% |
| Healthcare-associated infections requiring hospitalization | 5.2% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 139 · Observed rate 2.16% · Lower 95% interval 3.06% |
| Staff COVID-19 vaccination coverage | 2.06% |
8.2%
6.1 pts worse
|
Numerator 2 · Denominator 97 |
| Staff flu vaccination coverage | 32.69% |
42%
9.3 pts worse
|
Numerator 34 · Denominator 104 |
| Discharge function score | 28.18% |
56.45%
28.3 pts worse
|
Numerator 31 · Denominator 110 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 96.05% |
96.28%
0.2 pts worse
|
Numerator 73 · Denominator 76 |
| Resident COVID-19 vaccinations up to date | 10.39% |
25.2%
14.8 pts worse
|
Numerator 8 · Denominator 77 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.9
0.3 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.5 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
92.2%
7.5 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
94.8%
3.9 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.5%
0.4 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.7% · Q3 2.7% · Q4 4.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 34.5% |
12.0%
22.5 pts worse
|
11.4%
23.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 50.0% · Q3 31.0% · Q4 26.2% · 4Q avg 34.5% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
5.2%
3.3 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 5.5% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.0% |
19.2%
12.8 pts worse
|
19.6%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 35.2% · Q3 29.3% · Q4 26.8% · 4Q avg 32.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.2% |
22.5%
0.3 pts better
|
16.7%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 20.9% · Q3 20.8% · Q4 23.9% · 4Q avg 22.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.2% |
17.7%
1.5 pts better
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 16.9% · Q3 13.9% · Q4 8.8% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.4% |
17.6%
3.2 pts better
|
14.9%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 13.5% · Q3 17.9% · Q4 9.3% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
2.0%
0.1 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 2.7% · Q4 1.4% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.9% |
21.7%
8.2 pts worse
|
19.8%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 27.3% · Q3 33.4% · Q4 29.4% · 4Q avg 29.9% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
4.6%
1.9 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.3% · Q3 3.8% · Q4 4.1% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.8% |
77.1%
14.7 pts better
|
81.7%
10.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.2% · Q2 94.6% · Q3 90.8% · Q4 87.6% · 4Q avg 91.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
11.8%
2.6 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 9.4% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.3%
0.7 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.6% · Q3 2.9% · Q4 1.3% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.0% |
77.7%
10.3 pts better
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
25.8%
1.9 pts better
|
23.9%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 21.6% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-21 · Fire 2023-11-21
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-08-11 · Fire 2021-08-11
15 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-30
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-02-14
F · Potential for more than minimal harm
2025-01-30
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-02-14
F · Potential for more than minimal harm
2025-01-30
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-02-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-15
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-07-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-15
G · Actual harm
2025-04-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-10
E · Potential for more than minimal harm
2023-11-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-11-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-11-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-21
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-12-08
G · Actual harm
2021-08-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-08-13
F · Potential for more than minimal harm
2021-08-11
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2021-09-08
E · Potential for more than minimal harm
2021-08-11
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2021-09-09
E · Potential for more than minimal harm
2021-08-11
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-08-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-10-06
E · Potential for more than minimal harm
2021-08-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-08-22
E · Potential for more than minimal harm
2021-08-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-09-09
E · Potential for more than minimal harm
2021-08-11
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2021-09-08
E · Potential for more than minimal harm
2021-08-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-08-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-08-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-08-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2021-08-14
D · Potential for more than minimal harm
2021-08-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-09-02
D · Potential for more than minimal harm
2021-08-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-08-11
F849 · Administration Deficiencies
Health
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.
Corrected 2021-08-13
Penalties and ownership
What sits behind the stars
$9,004
2025-04-01
Fine
Fine · fine $9,004
Fine
Ownership
Mamary, James
5% Or Greater Direct Ownership Interest · Individual
Mamary, James
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Bourne Manor Extended Care Facility
Bourne, MA
1-star overall rating with 2-star inspections with $48,575 in total fines with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Cape Heritage Rehabilitation & Health Care Center
Sandwich, MA
2-star overall rating with 2-star inspections with 6 recent health deficiencies
#3
Tremont Rehabilitation & Skilled Care Center
Wareham, MA
3-star overall rating with 3-star inspections with $285,936 in total fines with 7 recent health deficiencies
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