Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mayflower Place Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to properly label, date, and store food products in two nourishment kitchenettes, as observed by a surveyor. Items such as nectar thick juices and a bologna sandwich were either past their discard dates or lacked labeling, contrary to facility policy. Interviews with Food Service Directors revealed that dietary staff were responsible for these tasks, but the procedures were not followed, potentially risking foodborne illness.
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak, with improper testing procedures and inadequate PPE usage. Staff did not follow correct nasal swab procedures, lacked documentation for testing results, and were not required to wait for test results before starting shifts. Additionally, staff entered COVID-19 positive residents' rooms without required N95 respirators and eye protection, and signage was inaccurate, leading to confusion about necessary precautions.
A resident at high risk for falls experienced nine falls over six months, resulting in injuries and hospitalization, due to the facility's failure to consistently implement fall prevention measures. Observations showed the resident's call light was often out of reach, and purposeful rounding sheets were incomplete. Staff interviews revealed a lack of understanding and inconsistent implementation of the rounding program, leading to inadequate oversight and repeated falls.
The facility failed to implement its antibiotic stewardship program due to incomplete surveillance line listing reports. The policy requires documentation of antibiotic usage and outcomes, but reviews from June to August 2024 showed missing documentation of infection symptoms and onset dates, preventing verification of antibiotic initiation criteria. The Infection Preventionist acknowledged the lack of necessary documentation to ensure appropriate antibiotic prescribing and limit use, highlighting the need for improvement.
Two residents experienced uncomfortable room temperatures due to malfunctioning air conditioning units and poor communication among staff. One resident, who was cognitively intact, had a stuck AC valve, while another with severe cognitive impairment had a thermostat set at 90°F. Despite complaints, maintenance was not informed until surveyor intervention, revealing a breakdown in communication and failure to enter requests into the TELS system.
A resident reported being pushed roughly by a CNA while being assisted onto a bedpan, but the facility failed to complete the investigation and document the resolution of the grievance. The resident, who was cognitively intact and had a hip replacement, was not informed of the outcome, and the Director of Social Services admitted the investigation was incomplete.
A resident reported being roughly handled by a CNA, causing pain, but the facility failed to complete the investigation or report the incident to the state as required. The grievance form was incomplete, and the investigation did not adhere to the facility's abuse policy.
A resident reported being roughly handled by a CNA, causing pain, but the LTC facility failed to report the abuse allegation to the state agency within the required timeframe. The resident, who was cognitively intact, informed staff, but the grievance form lacked necessary documentation, and the incident was not recorded in the HCFRS.
A resident reported being roughly handled by a CNA, but the facility failed to conduct a thorough investigation as required by its abuse policy. The investigation lacked interviews with all relevant parties and did not provide a resolution to the grievance. Key documentation was incomplete, and the resident did not receive updates on the complaint's outcome.
A facility failed to develop and implement individualized care plans for a resident with multiple diagnoses, including heart failure and anxiety. Despite the comprehensive MDS assessment identifying several care areas needing attention, no care plans were documented in the resident's records. An MDS Nurse confirmed the absence of these plans, acknowledging they should have been developed following the MDS assessment.
The facility failed to follow physician orders and ensure timely diagnostic testing for two residents. One resident's lab tests were delayed by six weeks, while another resident's urine sample for a UTI was not collected for five days. The delays were acknowledged by the facility's staff, including the DON, and did not meet the expected standards of practice.
A facility failed to provide consistent Foley catheter care for a resident, leading to a deficiency. The resident, who had frequent UTIs and a history of catheter-related issues, did not have documented orders for catheter care. Observations showed urine with sediment, and staff interviews revealed inconsistent documentation and uncertainty about care procedures. The DON confirmed the lack of adherence to the facility's policy, contributing to the deficiency.
The facility failed to coordinate hospice services for three residents, resulting in incomplete medical records and lack of continuity of care. One resident's hospice binder lacked current certification and documentation of visits, while another's was missing a recertification statement and service schedule. A third resident's hospice service schedule was not provided, and the DON's expectations for documentation were unmet.
A facility failed to ensure accurate MDS assessments for a resident with major depressive disorder and chronic congestive heart failure. The MDS assessments incorrectly indicated the resident received Hospice services, despite no supporting documentation or physician's orders. An MDS nurse confirmed the error during an interview.
A resident at high risk for falls, with a care plan requiring a floor mat for safety, fell and was injured because the mat was not in place. Despite being agitated and restless, staff did not follow the care plan, leading to the incident. The DON confirmed the mat was a required safety intervention.
Improper Food Storage and Labeling in Facility Kitchenettes
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, specifically in the labeling, dating, and storage of food products in two nourishment kitchenettes. Observations by the surveyor revealed multiple instances of improperly labeled or unlabeled food items, including nectar thick lemon water, orange juice, cranberry juice, and apple juice, as well as a bologna and cheese sandwich and a can of Wild Cherry Pepsi. These items were either past their manufacturer-recommended discard dates or lacked any labeling to indicate the resident's name and the date of storage, contrary to the facility's policy. Interviews with the Food Service Directors (FSD) indicated that dietary staff were responsible for stocking and cleaning the nourishment kitchenettes, including the removal of expired products. FSD #1 confirmed that all items should be labeled with a resident's name and date and that items brought in by visitors should be discarded within 48 hours. Despite these protocols, the surveyor's findings highlighted a failure in the implementation of these procedures, potentially exposing residents to the risk of foodborne illness.
Inadequate Infection Control and Testing Procedures During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak, as evidenced by improper testing procedures and inadequate use of personal protective equipment (PPE). The facility did not ensure that staff members conducted COVID-19 testing in accordance with the Massachusetts Department of Public Health (DPH) guidelines and the manufacturer's instructions for the BinaxNOW antigen test. Specifically, staff members were observed not following the correct nasal swab procedure, and there was a lack of documentation for testing results. Additionally, staff were not required to wait for test results before starting their shifts, and there was no oversight to ensure compliance with testing protocols. The facility also failed to implement appropriate PPE usage for staff caring for COVID-19 positive residents. Observations revealed that staff entered rooms of COVID-19 positive residents without wearing the required N95 respirators and eye protection, despite the availability of PPE outside the rooms. The signage outside resident rooms was inaccurate, leading to confusion among staff about the necessary precautions. This resulted in staff not adhering to the required infection control measures, such as wearing full PPE when entering rooms of COVID-19 positive residents. Furthermore, the facility's documentation and communication regarding testing and PPE protocols were inadequate. The Infection Preventionist admitted to the lack of documentation for staff testing, both at home and in the facility, and acknowledged the confusion among staff regarding PPE requirements. The facility's policies and procedures were not effectively communicated or enforced, contributing to the deficiencies observed during the survey.
Inadequate Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to consistently implement approaches to prevent falls and provide adequate oversight for a resident who was considered a fall risk. This resident experienced nine falls over a six-month period, resulting in three injuries, including one hospitalization. The facility's policy on incidents and falls, as well as purposeful rounding, was not effectively followed, leading to repeated falls and injuries for the resident. The resident, admitted in September 2023, had multiple diagnoses including cerebrovascular disease, ataxia, polyneuropathy, and restlessness. The resident's Minimum Data Set assessment indicated moderately impaired cognition and a high risk for falls. Despite this, the facility did not consistently implement interventions such as ensuring the call light was within reach, conducting purposeful rounding, and maintaining fall mats on both sides of the bed. Observations revealed that the resident's call light was often out of reach, and the purposeful rounding sheets were incomplete or missing. Interviews with staff indicated a lack of understanding and inconsistent implementation of the purposeful rounding program. The facility's process for investigating falls and updating care plans with new interventions was not effectively executed. Duplicate interventions were noted, and some falls lacked proper investigation and documentation. The Unit Manager and Director of Nursing acknowledged the deficiencies in implementing fall prevention measures and the need for improvement in the process.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, as evidenced by incomplete surveillance line listing reports. The facility's policy on antibiotic stewardship, revised in December 2016, requires the collection and documentation of antibiotic usage and outcome data using a surveillance tracking form. This data is intended to guide decisions for improving antibiotic prescribing practices. However, a review of the facility's surveillance line listings from June 2024 to August 2024 revealed a lack of documentation regarding signs and symptoms of infection for all residents listed, as well as the date of onset. This omission made it impossible to verify whether the minimum criteria for initiating antibiotics were met. Additionally, the line listings did not include the dates when pathogens were identified. During an interview, the Infection Preventionist (IP) acknowledged the absence of symptom documentation on the facility's monthly tracking tools, which is necessary to determine if residents met the clinical criteria for antibiotic initiation. The IP explained that the facility uses the Loeb evidence-based surveillance criteria to define infections, including the type of bacteria, treatment, duration, and whether the infection is facility-acquired. However, she admitted that there was no additional documentation to demonstrate that residents met the criteria for antibiotic stewardship. The IP emphasized that the purpose of the antibiotic stewardship program is to ensure appropriate antibiotic prescribing, limit antibiotic use, and prevent multidrug-resistant organisms (MDROs), indicating that the providers had more work to do in this area.
Failure to Maintain Comfortable Room Temperatures for Residents
Penalty
Summary
The facility failed to maintain comfortable room temperatures for two residents, leading to a deficiency in providing a safe and comfortable environment. Resident #18, who was cognitively intact and had multiple diagnoses including COVID-19, experienced a very warm and humid room due to a malfunctioning air conditioning unit and a window that would not close properly. Despite the resident's complaints and the room's uncomfortable conditions, maintenance staff were not informed of the issue until the surveyor's intervention. The maintenance staff later discovered that the air conditioning unit's temperature valve was stuck, which was subsequently fixed. Resident #19, who had severe cognitive impairment and was also diagnosed with COVID-19, was found in a hot and humid room with the thermostat set at 90 degrees Fahrenheit. The resident expressed discomfort and thirst due to the heat, and despite previous complaints, the issue was not addressed until the surveyor's visit. Maintenance staff later adjusted the thermostat, which resolved the temperature issue. The lack of communication and failure to enter maintenance requests into the TELS system contributed to the delay in addressing the residents' discomfort. Interviews with staff revealed that there was a breakdown in communication regarding the hot room temperatures. Nurse #6 and the Unit Manager were not aware of the issues until informed by the surveyor, and the Maintenance Director confirmed that no work orders were entered into the TELS system for the hot room temperatures. The Director of Nursing acknowledged that the process for entering work requests was not followed, leading to the deficiency in maintaining a comfortable environment for the residents.
Failure to Resolve Grievance of Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure a resolution for a grievance involving an allegation of physical abuse by a Certified Nursing Assistant (CNA) towards a resident. The grievance was filed by a resident who reported that the CNA pushed them roughly while assisting with a bedpan. The facility's grievance policy requires that such allegations be investigated and documented, including steps taken, findings, and any corrective actions. However, the grievance form was incomplete, lacking documentation of whether the grievance was confirmed, the recommended corrective action, and whether the resident was notified of the outcome. The resident involved was admitted to the facility with a diagnosis of left hip hemiarthroplasty and was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS). Despite reporting the incident to a nurse and the Social Worker, the resident was not updated on the outcome of their complaint. The Director of Social Services, responsible for overseeing the grievance process, acknowledged that the investigation was incomplete and not properly followed through.
Failure to Investigate and Report Allegation of Abuse
Penalty
Summary
The facility failed to implement its policies and procedures regarding the investigation and reporting of an allegation of physical abuse involving a resident. The resident, who was cognitively intact, reported that a CNA had roughly handled them while assisting with a bedpan, causing pain. The resident informed both a nurse and the Social Worker about the incident, but no follow-up or resolution was communicated to the resident. The facility's grievance form was incomplete, lacking confirmation of the grievance, recommended corrective actions, and signatures. The Director of Social Services acknowledged that the investigation was not completed as required, and the Director of Nursing confirmed that the investigation was incomplete and not conducted according to the facility's abuse policy. Additionally, the allegation was not reported to the state agency as mandated by state and federal regulations. This oversight indicates a failure to adhere to the facility's established protocols for handling abuse allegations.
Failure to Timely Report Alleged Abuse by CNA
Penalty
Summary
The facility failed to report an allegation of physical abuse by a Certified Nursing Assistant (CNA) to the state agency in a timely manner, as required by their policy. The incident involved a resident who was cognitively intact and had been admitted with a diagnosis of left hip hemiarthroplasty. The resident reported that a CNA had pushed them roughly while assisting with a bedpan, causing pain. The resident informed a nurse the night of the incident and the Social Worker the following day, but no updates were provided to the resident regarding the outcome of their complaint. The facility's policy mandates that allegations of abuse be reported to the state agency within two hours if they involve serious bodily injury. However, a review of the Health Care Facility Reporting System (HCFRS) showed no record of the incident being reported. The Director of Nursing acknowledged that the grievance was an allegation of abuse and that the investigation was incomplete. The grievance form lacked documentation of confirmation, recommended corrective actions, resolution, and administrator review, indicating a failure in the facility's reporting and documentation process.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident who reported being roughly handled by a CNA while being assisted onto a bedpan. The resident, who was cognitively intact, reported the incident to a nurse and the Social Worker, but did not receive any updates on the outcome of the complaint. The facility's policy requires a comprehensive investigation of all abuse allegations, including interviews with relevant individuals and a review of the resident's medical record, but these steps were not fully completed. The investigation documentation was incomplete, lacking interviews with all relevant parties and a resolution to the grievance. Key sections of the Grievance/Concern form, such as confirmation of the grievance, recommended corrective action, and notification to the resident, were left blank. Interviews with the Director of Social Services and the DON confirmed that the investigation was not conducted thoroughly, as required by the facility's abuse policy.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for a resident, which is a requirement according to their policy. The resident, admitted in July 2024, had multiple diagnoses including heart failure, urinary retention, anxiety, glaucoma, and difficulty walking. The comprehensive Minimum Data Set (MDS) assessment identified several care areas that needed attention, such as cognitive loss/dementia, visual function, communication, ADL functioning/rehabilitation potential, urinary incontinence, behavioral symptoms, falls, nutritional status, and pressure ulcers. Despite these identified needs, the facility did not have any comprehensive care plans documented in the resident's medical records, both paper and electronic. During an interview, the MDS Nurse confirmed the absence of these care plans, acknowledging that they should have been developed following the completion of the comprehensive MDS and the triggering of care areas. This oversight indicates a failure to adhere to the facility's policy, which mandates the creation of a comprehensive care plan within 21 days of admission.
Failure to Follow Physician Orders and Timely Diagnostic Testing
Penalty
Summary
The facility failed to follow physician's orders and ensure timely completion of diagnostic tests for two residents, leading to deficiencies in care. Resident #20, who had diagnoses including hypertension, chronic obstructive pulmonary disease, and anemia, was prescribed a complete metabolic panel (CMP), complete blood count (CBC), and thyroid stimulating hormone (TSH) tests on May 20, 2024. Despite the physician's order and the nurse's notation, these tests were not completed until July 3, 2024, six weeks after the initial order. The Unit Manager confirmed the absence of lab results for May and acknowledged the error, while the physician expressed that the delay was unacceptable and did not meet the standard of practice. Resident #13, diagnosed with dementia, hypertension, and a urinary tract infection (UTI), was ordered a urinalysis (U/A) culture and sensitivity (C&S) test on August 2, 2024, following a fall from bed. The order included the option to use a straight catheter if necessary. However, by August 7, 2024, the urine sample had not been collected, and there was no documentation of any attempts or issues in obtaining the sample. The physician expected the sample to be collected by the next day, and the family member expressed dissatisfaction with the delay, considering it excessive given the resident's history of frequent UTIs. The Director of Nurses acknowledged the delays in both cases, stating that the expected timeframe for obtaining lab results and urine samples was not met. The facility's policies and the Massachusetts Board of Registration in Nursing Advisory Ruling emphasize the responsibility of licensed nurses to ensure timely implementation of physician orders, which was not adhered to in these instances.
Deficiency in Foley Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for the care of an indwelling catheter for a resident, leading to a deficiency in catheter care. The facility's policy required catheter care to be performed at least twice daily, with specific procedures to minimize the risk of catheter-associated urinary tract infections. However, the medical records for the resident did not indicate consistent documentation of Foley catheter care, and there was no order for such care in place. Observations by the surveyor revealed that the resident's catheter was draining urine with sediment, and the resident reported frequent urinary tract infections. Interviews with staff, including a nurse and the unit manager, confirmed that Foley catheter care was not being consistently documented or performed according to the facility's policy. The nurse acknowledged that the resident had frequent urinary tract infections and periods of inflammation at the catheter insertion site. The unit manager admitted uncertainty about the required care for Foley catheters and where it should be documented, further indicating a lack of adherence to the facility's policy. The Director of Nursing confirmed that the resident was at higher risk for complications due to the condition of the catheter site and the resident's legal blindness. Despite the facility's policy and the resident's care plan, catheter care interventions were not consistently implemented. The lack of a documented order set for Foley catheter care and the absence of consistent documentation and monitoring contributed to the deficiency identified by the surveyor.
Deficiencies in Hospice Service Coordination and Documentation
Penalty
Summary
The facility failed to coordinate hospice services effectively for three residents, leading to deficiencies in maintaining complete medical records and ensuring continuity of care. For one resident, the facility did not provide ongoing documentation or maintain a complete medical record of hospice services, which hindered effective communication for continuity of care. The hospice binder lacked a current hospice certification and plan of care, as well as documentation of visits by nursing, home health aides, or social services. The unit manager was unable to locate the hospice schedule, and a nurse was unaware of the required information for the hospice binder. Another resident's hospice binder was missing a current recertification statement and a schedule of hospice services, which are necessary for maintaining continuity of care. The unit manager acknowledged that the hospice record was incomplete and that the hospice schedule was not posted as it should be. The social worker, responsible for checking the binders weekly, confirmed that the recertification period was not current, indicating a lapse in updating the necessary documentation. For the third resident, the facility did not provide an official schedule of hospice services, and the nurse was unaware of the timing of these services. The Director of Nursing expected the most recent hospice certification and all related documentation to be included in the resident's record, along with a physician's order for hospice admission. However, these expectations were not met, as the hospice provider schedule was not posted on the unit or in the resident's record.
Inaccurate MDS Assessment for Hospice Services
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the status of a resident. The resident was admitted in January 2023 with diagnoses including major depressive disorder and chronic congestive heart failure. MDS assessments dated March 13, 2024, and June 12, 2024, incorrectly indicated that the resident received Hospice services. However, a review of both paper and electronic medical records showed no physician's order, documentation, or care plans to support that the resident received Hospice services. During an interview, MDS Nurse #2 confirmed that the resident did not receive Hospice services during those assessment dates and acknowledged that the MDS entries were made in error.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to consistently implement and follow safety interventions for a resident assessed as high risk for falls. The resident, who had multiple diagnoses including dementia with anxiety and psychotic disorder with delusions, was admitted in January 2024. The comprehensive care plan for this resident included the use of a floor mat next to the bed as a safety measure. However, the care plan did not specify the exact placement of the mat, leading to confusion among staff. On May 14, 2024, the resident fell out of bed and sustained a skin tear to the left side of the head because the floor mat was not in place. Interviews with staff revealed that on the day of the incident, the resident was agitated and restless. Despite the care plan's instructions, the floor mat was not placed on the floor next to the bed, as confirmed by both the nurse and CNA involved in the resident's care. The Director of Nurses acknowledged that the floor mat was part of the resident's care plan and should have been in place as a fall safety intervention. The failure to ensure the mat was consistently used as per the care plan led to the resident's fall and subsequent injury.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Yarmouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pavilion , The | 3.3 mi | — | 0 | 0 |
| Windsor Nursing & Retirement Home | 4.1 mi | — | 6 | 0 |
| Cape Regency Rehabilitation & Health Care Center | 4.4 mi | — | 0 | 0 |
| Regalcare At Harwich | 9.3 mi | — | 6 | 0 |
| Royal Of Cotuit | 11.1 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.