Cycle 1
Health 2024-09-17 · Fire 2024-09-17
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Falmouth, MA
Royal Nursing Center, LLC
3-star overall rating with 3-star inspections with $8,278 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
359 Jones Rd, Falmouth, MA
(774) 345-0220
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
121
Certified beds
Average residents
98
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Royal Health Group
Operator or chain grouping
Approved since
1990-07-01
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
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.69
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.37
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,344
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9857
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.11
Baseline 17.06% · Performance 20.45% · Measure score 2.11 · Achievement 2.11 · Improvement 0
Healthcare-associated infections
0.85
Baseline 8.11% · Performance 7.68% · Measure score 0.85 · Achievement 0.50 · Improvement 0.85
Total nurse turnover
9.03
Baseline 43.75% · Performance 26.76% · Measure score 9.03 · Achievement 9.03 · Improvement 8.49
Adjusted total nurse staffing
0
Baseline 3.46 hours · Performance 3.15 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.53% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 279 · Observed rate 11.47% · Lower 95% interval 9.04% |
| Discharge to community | 71.33% |
50.57%
20.8 pts better
|
Better than the National Rate · Eligible stays 272 · Observed rate 65.44% · Lower 95% interval 65.17% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.49% |
95.27%
4.2 pts better
|
Numerator 194 · Denominator 195 |
| Falls with major injury | 1.03% |
0.77%
0.3 pts worse
|
Numerator 2 · Denominator 195 |
| Discharge self-care score | 45.45% |
53.69%
8.2 pts worse
|
Numerator 65 · Denominator 143 |
| Discharge mobility score | 57.34% |
50.94%
6.4 pts better
|
Numerator 82 · Denominator 143 |
| Pressure ulcers or injuries, new or worsened | 2.06% |
2.29%
0.2 pts better
|
Numerator 4 · Denominator 194 · Adjusted rate 2.06% |
| Healthcare-associated infections requiring hospitalization | 7.68% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 201 · Observed rate 7.96% · Lower 95% interval 5.27% |
| Staff COVID-19 vaccination coverage | 7.69% |
8.2%
0.5 pts worse
|
Numerator 7 · Denominator 91 |
| Staff flu vaccination coverage | 57.69% |
42%
15.7 pts better
|
Numerator 75 · Denominator 130 |
| Discharge function score | 54.55% |
56.45%
1.9 pts worse
|
Numerator 78 · Denominator 143 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 41 · Denominator 41 |
| Transfer of health information to patient | 96.49% |
96.28%
0.2 pts better
|
Numerator 110 · Denominator 114 |
| Resident COVID-19 vaccinations up to date | 33.96% |
25.2%
8.8 pts better
|
Numerator 36 · Denominator 106 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.9
About the same
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
92.2%
6.9 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 100.0% · Q4 97.5% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.8%
5.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
3.5%
2.2 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.9% · Q3 5.1% · Q4 3.8% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 31.2% |
12.0%
19.2 pts worse
|
11.4%
19.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 38.0% · Q3 33.3% · Q4 23.7% · 4Q avg 31.2% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
5.2%
1.6 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 5.9% · Q3 3.3% · Q4 1.7% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.6% |
19.2%
11.6 pts better
|
19.6%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 7.1% · Q3 5.0% · Q4 8.1% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.8% |
22.5%
3.7 pts better
|
16.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 17.6% · Q3 19.6% · Q4 18.5% · 4Q avg 18.8% · 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 | 16.0% |
17.7%
1.7 pts better
|
16.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 15.8% · Q3 21.2% · Q4 11.3% · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
17.6%
4.3 pts better
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 22.1% · Q3 13.6% · Q4 6.7% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.0%
0.2 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
2.0%
1.4 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.7% · Q3 3.8% · Q4 2.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.3% |
21.7%
3.4 pts better
|
19.8%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 17.2% · Q3 19.1% · Q4 15.8% · 4Q avg 18.3% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.6%
About the same
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 5.8% · Q3 4.1% · Q4 6.8% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.3% |
77.1%
8.2 pts better
|
81.7%
3.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.8% · Q2 89.2% · Q3 82.2% · Q4 80.1% · 4Q avg 85.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
11.8%
1.3 pts better
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 10.3% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.3%
1.1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.6% |
77.7%
14.9 pts better
|
79.7%
12.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
25.8%
6.3 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 17.7% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-08 · Fire 2023-06-08
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2020-03-05 · Fire 2020-03-05
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-17
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-08
E · Potential for more than minimal harm
2023-06-08
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-06-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-06-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-07
F · Potential for more than minimal harm
2020-03-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-11-03
E · Potential for more than minimal harm
2020-03-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-12-17
E · Potential for more than minimal harm
2020-03-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-11-13
E · Potential for more than minimal harm
2020-03-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-12-17
D · Potential for more than minimal harm
2020-03-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-11-04
D · Potential for more than minimal harm
2020-03-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-11-13
D · Potential for more than minimal harm
2020-03-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-12-17
D · Potential for more than minimal harm
2020-03-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-12-17
D · Potential for more than minimal harm
2020-03-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-11-04
C · Minimal harm
2020-03-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-12-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-10
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-09-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-09-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-19
G · Actual harm
2025-04-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-01
D · Potential for more than minimal harm
2024-09-17
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-17
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 2024-10-11
D · Potential for more than minimal harm
2024-09-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-11
E · Potential for more than minimal harm
2023-06-08
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-06-08
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-06-08
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-06-08
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-06-08
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-06-08
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 2023-06-20
D · Potential for more than minimal harm
2023-06-08
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-08
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-06-08
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 2023-06-20
B · Minimal harm
2023-06-08
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-06-20
F · Potential for more than minimal harm
2020-03-05
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 2020-10-02
E · Potential for more than minimal harm
2020-03-05
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2020-10-02
E · Potential for more than minimal harm
2020-03-05
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 2020-10-02
D · Potential for more than minimal harm
2020-03-05
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 2020-10-02
D · Potential for more than minimal harm
2020-03-05
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 2020-10-02
D · Potential for more than minimal harm
2020-03-05
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2020-10-02
D · Potential for more than minimal harm
2020-03-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-10-02
D · Potential for more than minimal harm
2020-03-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-10-02
D · Potential for more than minimal harm
2020-03-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2020-10-02
D · Potential for more than minimal harm
2020-03-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-10-02
D · Potential for more than minimal harm
2020-03-05
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2020-10-02
D · Potential for more than minimal harm
2020-03-05
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2020-10-02
D · Potential for more than minimal harm
2020-03-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2020-10-02
Penalties and ownership
What sits behind the stars
$8,278
2025-04-08
Fine
Fine · fine $8,278
Fine
Ownership
Mamary, James
5% Or Greater Direct Ownership Interest · Individual
Mamary, James
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Jml Care Center Inc
Falmouth, MA
2-star overall rating with 3-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Royal Megansett Nursing & Rehabilitation
N Falmouth, MA
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Royal Of Cotuit
Mashpee, MA
2-star overall rating with 2-star inspections with $7,901 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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