Cycle 1
Health 2025-02-07 · Fire 2025-02-07
12 health deficiencies
Top issue: Resident Rights (4 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Mashpee, MA
Royal Of Cotuit
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
161 Falmouth Road, Mashpee, MA
(508) 477-2490
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Royal Health Group
Operator or chain grouping
Approved since
1995-08-23
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
0.63
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
2.02
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.47
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
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.17
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,765
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.20% · Performance 22.08% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.57% · Performance 8.46% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.74
Baseline 47.69% · Performance 48.39% · Measure score 3.74 · Achievement 3.74 · Improvement 0
Adjusted total nurse staffing
0.50
Baseline 3.11 hours · Performance 3.22 hours · Measure score 0.50 · Achievement 0.50 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.64% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 264 · Observed rate 11.36% · Lower 95% interval 8.51% |
| Discharge to community | 59.48% |
50.57%
8.9 pts better
|
Better than the National Rate · Eligible stays 272 · Observed rate 54.41% · Lower 95% interval 53.25% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 91.81% |
95.27%
3.5 pts worse
|
Numerator 157 · Denominator 171 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 171 |
| Discharge self-care score | 63.46% |
53.69%
9.8 pts better
|
Numerator 66 · Denominator 104 |
| Discharge mobility score | 53.85% |
50.94%
2.9 pts better
|
Numerator 56 · Denominator 104 |
| Pressure ulcers or injuries, new or worsened | 4.12% |
2.29%
1.8 pts worse
|
Numerator 7 · Denominator 170 · Adjusted rate 4.19% |
| Healthcare-associated infections requiring hospitalization | 8.46% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 164 · Observed rate 9.15% · Lower 95% interval 5.43% |
| Staff COVID-19 vaccination coverage | 4.92% |
8.2%
3.3 pts worse
|
Numerator 3 · Denominator 61 |
| Staff flu vaccination coverage | 27.54% |
42%
14.5 pts worse
|
Numerator 19 · Denominator 69 |
| Discharge function score | 56.73% |
56.45%
0.3 pts better
|
Numerator 59 · Denominator 104 |
| Transfer of health information to provider | 95.92% |
95.95%
About the same
|
Numerator 47 · Denominator 49 |
| Transfer of health information to patient | 97.62% |
96.28%
1.3 pts better
|
Numerator 82 · Denominator 84 |
| Resident COVID-19 vaccinations up to date | 20.83% |
25.2%
4.4 pts worse
|
Numerator 20 · Denominator 96 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.9
1 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
1.5
1.8 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.8% |
92.2%
7.4 pts worse
|
93.4%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.0% · Q2 83.1% · Q3 80.0% · Q4 95.2% · 4Q avg 84.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.5% |
94.8%
9.3 pts worse
|
95.5%
10 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.2% |
3.5%
5.7 pts worse
|
3.3%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 6.2% · Q3 11.7% · Q4 12.9% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.0% |
12.0%
About the same
|
11.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 16.4% · Q3 9.3% · Q4 3.6% · 4Q avg 12.0% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
5.2%
1.9 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 4.3% · Q3 4.3% · Q4 11.1% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
19.2%
3.8 pts better
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 18.8% · Q3 14.3% · Q4 12.2% · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.7% |
22.5%
0.8 pts better
|
16.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 21.6% · Q3 26.3% · Q4 20.5% · 4Q avg 21.7% · 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 | 19.9% |
17.7%
2.2 pts worse
|
16.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 28.3% · Q3 7.6% · Q4 18.1% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.4% |
17.6%
7.8 pts worse
|
14.9%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 23.4% · Q3 21.3% · Q4 25.5% · 4Q avg 25.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.0%
0.3 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.5% |
2.0%
3.5 pts worse
|
1.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 4.8% · Q3 7.0% · Q4 5.2% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.4% |
21.7%
8.7 pts worse
|
19.8%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 28.5% · Q3 35.7% · Q4 30.5% · 4Q avg 30.4% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.6%
0.7 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.5% · Q3 3.2% · Q4 2.8% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.4% |
77.1%
5.7 pts worse
|
81.7%
10.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 61.8% · Q2 73.0% · Q3 75.7% · Q4 77.1% · 4Q avg 71.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.8% |
11.8%
4 pts worse
|
12.0%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 17.0% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.3%
1 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.1% · Q3 3.0% · Q4 1.8% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.5% |
77.7%
13.2 pts worse
|
79.7%
15.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
25.8%
1 pts better
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 25.9% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-05 · Fire 2023-12-05
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2021-06-08 · Fire 2021-06-08
17 health deficiencies
Top issue: Resident Assessment and Care Planning (5 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
2025-02-07
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-02-16
C · Minimal harm
2023-12-05
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-12-13
C · Minimal harm
2023-12-05
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-12-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-15
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 2025-08-03
D · Potential for more than minimal harm
2025-07-15
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 2025-08-03
D · Potential for more than minimal harm
2025-07-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-08-03
F · Potential for more than minimal harm
2025-02-07
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-03-14
E · Potential for more than minimal harm
2025-02-07
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-02-07
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 2025-03-07
E · Potential for more than minimal harm
2025-02-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-02-07
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-07
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-07
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 2025-03-14
D · Potential for more than minimal harm
2025-02-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-07
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-03-14
D · Potential for more than minimal harm
2024-05-29
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 2024-06-22
E · Potential for more than minimal harm
2023-12-05
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-12-29
E · Potential for more than minimal harm
2023-12-05
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-12-05
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-12-29
E · Potential for more than minimal harm
2023-12-05
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 2024-01-04
D · Potential for more than minimal harm
2023-12-05
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 2024-01-04
D · Potential for more than minimal harm
2023-12-05
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 2023-12-29
D · Potential for more than minimal harm
2023-12-05
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 2023-12-29
D · Potential for more than minimal harm
2023-12-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-05
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 2023-12-29
D · Potential for more than minimal harm
2023-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-29
G · Actual harm
2023-10-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-07
G · Actual harm
2023-10-16
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-04-11
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 2023-05-12
E · Potential for more than minimal harm
2021-06-08
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 2021-07-09
E · Potential for more than minimal harm
2021-06-08
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-07-09
E · Potential for more than minimal harm
2021-06-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-09
D · Potential for more than minimal harm
2021-06-08
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2021-07-09
D · Potential for more than minimal harm
2021-06-08
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-07-09
D · Potential for more than minimal harm
2021-06-08
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 2021-07-09
D · Potential for more than minimal harm
2021-06-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-07-09
D · Potential for more than minimal harm
2021-06-08
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 2021-07-09
D · Potential for more than minimal harm
2021-06-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-07-09
D · Potential for more than minimal harm
2021-06-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-07-09
D · Potential for more than minimal harm
2021-06-08
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2021-07-09
D · Potential for more than minimal harm
2021-06-08
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 2021-07-09
D · Potential for more than minimal harm
2021-06-08
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 2021-07-09
D · Potential for more than minimal harm
2021-06-08
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 2021-07-09
Penalties and ownership
What sits behind the stars
$7,901
2023-10-16
Fine
Fine · fine $7,901
Fine
Ownership
Mamary, James
5% Or Greater Direct Ownership Interest · Individual
Batilo, Maria
Contracted Managing Employee · Individual
Reid, Paula
Operational/Managerial Control · Individual
Weeks, Shauna
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Cape Regency Rehabilitation & Health Care Center
Centerville, MA
1-star overall rating with 2-star inspections with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Pavilion , The
Hyannis, MA
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
#3
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
Jump out