Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Regalcare At Harwich during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and documented full-code status was found unresponsive by CNAs, who reported the change to a nurse. The nurse confirmed the resident was unresponsive, not breathing, pulseless, cold, and stiff, verified full-code status, and began CPR but did not call a Code Blue, did not activate 911, and did not direct staff to do so, contrary to facility policy. CPR was interrupted when the nurse stopped to redirect another resident who entered the room. The nurse sent a text message to the physician, DON, and unit manager and asked another nurse to complete an RN pronouncement, but there was no documentation of direct physician notification or an order for the pronouncement before CPR was discontinued.
A resident with multiple chronic conditions and documented full-code status was found unresponsive, not breathing, pulseless, and cold and stiff to the touch. An RN verified the full-code status, requested the crash cart, and began CPR but did not call a Code Blue, did not call 911, and did not direct staff to do so. The RN stopped CPR when another resident entered and became aggressive and did not resume resuscitation, then requested another RN to perform a pronouncement without disclosing that CPR had been started and stopped. The second RN, having heard no Code Blue, assumed the resident was DNR and pronounced death, resulting in a failure to provide required basic life support consistent with the resident’s advance directives, physician orders, facility policy, and state nursing guidance.
A resident with severe cognitive impairment and dependent on staff for self-care was not treated with dignity when a CNA repeatedly pretended to sit on the resident's lap, despite the resident's verbal protests. The incident was witnessed by another CNA and a family member, resulting in the resident becoming visibly upset.
The facility failed to maintain a clean and homelike environment on the Bayview and Cranview units, with issues such as unpainted areas, broken fixtures, and dirty conditions. Observations revealed chipped flooring, exposed wires, and damaged furniture. Residents' representatives expressed dissatisfaction with the facility's condition. A gap in maintenance coverage contributed to the neglect of these issues.
The facility failed to maintain sanitary conditions and proper temperature monitoring in two kitchenettes. In the Bayview kitchenette, the freezer temperature was not logged, and unsanitary conditions were observed, including sticky drawers and improperly stored food items. In the Cranview Unit, the freezer had significant frost buildup, and ice cream was found soft, with no thermometer or temperature log present. The Food Service Director acknowledged the issues, noting the impact on food quality and safety.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to PPE protocols for residents on droplet and contact precautions. A nurse entered a COVID-19 positive resident's room without full PPE, and an activity assistant entered another COVID-19 positive room without any PPE. Additionally, a housekeeper failed to follow contact precautions for residents with ESBL and C-diff, not wearing a gown or changing gloves between rooms.
A facility failed to obtain a court-approved treatment plan for administering antipsychotic medication to a resident with a legal guardian. Despite being notified of the guardianship, the facility administered Risperidone without the necessary documentation for over 40 days. Staff interviews revealed a lack of understanding of the consent process when a guardian is involved.
A resident with a history of falls and a right femur fracture had a care plan intervention to place a padded floor mat on the left side of the bed. However, observations revealed the mat was consistently found against the wall, not in use as intended. Staff interviews confirmed the mat was not placed on the floor, indicating non-compliance with the care plan.
A resident with Type 2 diabetes and chronic heart failure continued to receive an incorrect potassium chloride dosage due to the facility's failure to act on a consultant pharmacist's recommendation. The pharmacist advised reducing the dosage from 40 meq to 20 meq per day, but this was not communicated effectively to the attending physician and DON, resulting in the resident receiving the higher dosage until the error was discovered over a month later.
A facility failed to maintain accurate medical records, resulting in a discrepancy in the discharge destination for a resident with multiple health conditions. The resident was supposed to be transferred to a local SNF closer to family, as requested by the healthcare proxy, but the physician's order incorrectly listed a different SNF. The Unit Manager admitted the error was due to a transcription mistake.
The facility failed to accurately complete MDS assessments for two residents. One resident's admission date and contracture status were incorrectly documented, while another resident's discharge location was inaccurately coded. MDS nurses acknowledged the errors in the assessments.
Failure to Initiate Code Blue and Notify Physician for Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of practice for a resident whose advance directives and physician’s orders identified the resident as a full code. The resident had multiple diagnoses including dementia, Alzheimer’s disease, adult failure to thrive, osteomyelitis of the right ankle and foot, hyperlipidemia, anxiety, severe protein-calorie malnutrition, and pressure ulcers. The facility’s Code Blue policy required staff who find a resident unresponsive to call a Code Blue overhead twice, including unit and room number, and specified that the first responding nurse would determine code status, lead the code, and remain with the patient throughout the event. On the night of the incident, a CNA performing rounds around 4:45 A.M. observed that the resident was lying in bed on his/her back, with eyes half open, not looking well, and not responding to verbal stimuli. The CNA asked a second CNA to assess the resident; the second CNA also felt the resident did not look well and reported to the nurse that the resident looked like he/she was dead. The second CNA stated that the nurse then asked her to bring the crash cart to the resident’s room. The first CNA reported that the nurse did not instruct her to call a Code Blue or 911. According to the nurse’s progress note and interview, around 5:00 A.M. he was notified that the resident was unresponsive. On entering the room, he found the resident unresponsive to verbal and tactile stimuli, with no response to sternal rub, not breathing, without a pulse, cold to the touch, and stiff. He verified that the resident was a full code and began CPR, and asked for the crash cart, but he did not call a Code Blue, did not activate 911, and did not direct CNAs to do so. While performing CPR, he stopped to redirect another resident who entered the room. He acknowledged that he knew the facility’s policies for Code Blue and CPR, and that once CPR is started it should not be stopped until EMS or other staff arrive. He sent a text message to the physician, DON, and unit manager and contacted another nurse to complete an RN pronouncement, but there was no documentation that he spoke with the physician to obtain an order for the pronouncement, and the physician was not notified of the change in condition prior to discontinuation of CPR.
Failure to Provide Continuous CPR and Activate Code Blue for Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide basic life support, including continuous CPR, in accordance with a resident’s full code status, physician orders, facility policy, and state nursing guidance. The resident had diagnoses including dementia, Alzheimer’s disease, adult failure to thrive, osteomyelitis of the right ankle and foot, hyperlipidemia, anxiety, severe protein-calorie malnutrition, and multiple pressure ulcers. The resident’s MOLST form and physician orders documented that the resident was a full code, directing staff to attempt resuscitation with CPR in the event of cardiac or respiratory arrest. On the night of the incident, during early morning rounds, a CNA observed that the resident did not look well and had eyes half open, and another CNA reported to the nurse that the resident looked like he or she was dead. The nurse (Nurse #1) responded and found the resident in bed, unresponsive to verbal and tactile stimuli, with no response to sternal rub, not breathing, without a pulse, and cold and stiff to the touch. Nurse #1 verified that the resident was a full code and requested that a CNA bring the crash cart to the room. Nurse #1 then began CPR on the resident but did so alone, without having called a Code Blue, without calling 911, and without directing any staff member to do so. While Nurse #1 was performing CPR, another resident entered the room and became aggressive. Nurse #1 stopped CPR on the full-code resident in order to redirect the other resident out of the room and did not resume CPR afterward. Nurse #1 then went to another unit and asked another nurse (Nurse #2) to perform an RN pronouncement, without informing Nurse #2 that CPR had been started and then stopped. Nurse #2, who had not heard any Code Blue called, assumed the resident was DNR and pronounced the resident deceased. The DON later confirmed through interview that Nurse #1 had not called a Code Blue, had not called 911, had started CPR and then stopped, and had not followed the facility’s Code Blue and CPR policies, which require activation of a Code Blue, assessment, and initiation and continuation of CPR for full-code residents found unresponsive and without signs of circulation. The Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice and CPR, as cited in the report, requires nurses to initiate CPR when a patient is found unresponsive and has not been declared dead by an authorized provider, except when there is a valid DNR order. The facility’s Code Blue policy similarly requires that for a full-code resident found unresponsive, staff must call a Code Blue overhead, identify the unit and room, and initiate CPR if there is no pulse or respiration, with the first responding nurse leading the code and remaining with the patient. In this case, despite confirming the resident’s full-code status and finding no pulse or respirations, Nurse #1 did not activate a Code Blue, did not ensure 911 was called, performed CPR alone, and then discontinued CPR prior to EMS arrival or physician notification, resulting in a failure to provide appropriate and necessary basic life-saving measures consistent with the resident’s advance directives and physician orders.
Resident Not Treated with Dignity During Staff Interaction
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to treat a resident with dignity and respect. The incident involved a resident with severe cognitive impairment, dementia, and psychotic disorder with delusions, who was dependent on staff for self-care. The CNA engaged in teasing behavior by repeatedly pretending to sit on the resident's lap while the resident was seated on an unoccupied bed in another resident's room. Despite the resident's verbal protests, the CNA continued the behavior multiple times. This interaction was witnessed by another CNA, who confirmed that the resident yelled each time the CNA attempted to sit on their lap and that the behavior was repeated three times. A family member, upon hearing the resident yelling, entered the room and observed the CNA sitting on the resident's lap, which caused the resident to become upset and seek comfort from the family member. The family member described the CNA's behavior as bizarre and inappropriate. The facility's internal investigation corroborated that the CNA's actions were intended as a joke but were not appropriate, especially given the resident's cognitive status and distress during the incident.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents on the Bayview and Cranview units. Observations revealed numerous issues, including unpainted areas, chipped and discolored moldings, and missing or broken fixtures such as blinds, thermostats, and closet doors. The Bayview unit's breakfast dining room had significant damage, including chipped wood flooring and a scuffed wall. Several resident rooms had exposed wires, broken molding, and discolored ceiling tiles, indicating a lack of maintenance and repair. On the Cranview unit, similar deficiencies were noted, such as a large hole in the residents' shower room wall with exposed wood and crumbled plaster. One resident's room was found to be dirty, with broken furniture and a damaged blind. Additionally, a hallway window was cracked, and the screen was frayed with a hole, further contributing to the unkempt environment. These observations were corroborated by interviews with residents' representatives, who expressed dissatisfaction with the facility's condition, describing it as depressing and in disrepair. The facility experienced a gap in maintenance coverage due to the absence of a full-time Maintenance Director, during which emergent issues were prioritized over routine maintenance. The Regional Plant Manager acknowledged that the neglect of maintenance issues extended beyond the three-week gap. The facility's Administrator confirmed the hiring of a new maintenance director and acknowledged that preventative maintenance was not conducted during the lapse in coverage.
Sanitation and Temperature Monitoring Deficiencies in Kitchenettes
Penalty
Summary
The facility failed to maintain sanitary conditions in two out of three kitchenettes, as observed by the surveyor. In the Bayview kitchenette, the refrigerator temperature log lacked a section for freezer temperatures, and no temperatures were recorded for the freezer from the beginning of the month until the survey date. The freezer was found full of small individual ice creams, with the thermometer covered in ice particles, indicating improper storage. Additionally, the kitchenette's counter drawers were sticky, with one containing a brown sticky substance on condiment packets. A baseball-sized tin foil containing a hamburger was found in a cabinet, and an open, undated bottle of ranch dressing, which should have been refrigerated, was also discovered. The Unit Manager was unaware of who was responsible for cleaning the kitchenette and acknowledged that the hamburger and ranch dressing should not have been stored in the cabinets. In the Cranview Unit nourishment kitchen, the surveyor observed a significant frost buildup in the freezer, which contained individual portion-sized ice cream cups and a half-gallon container of ice cream, all of which were soft to the touch. There was no thermometer in the freezer, and no log for monitoring freezer temperatures was maintained. The Food Service Director confirmed that frozen items should not be soft and acknowledged the absence of a thermometer and temperature monitoring log, admitting that improper temperatures could affect food quality and safety.
Inadequate PPE Use and Infection Control in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple instances where staff did not adhere to required personal protective equipment (PPE) protocols. For Resident #24, who tested positive for COVID-19, Nurse #3 entered the room to administer medication without wearing the necessary PPE, including a gown, N-95 mask, and eye protection. Despite the presence of a red isolation sign indicating droplet precautions, Nurse #3 initially wore only a surgical mask and gloves, failing to ensure proper protection against potential transmission. Similarly, for Residents #19 and #82, who were also on droplet precautions due to COVID-19, Activity Assistant #2 entered their room without donning any PPE, despite the red isolation sign posted at the doorway. This oversight occurred while delivering coffee, a snack, and the Daily Chronicle, and the assistant did not perform hand hygiene between resident interactions. The assistant was unaware of the need for PPE, mistakenly believing the residents were no longer positive for COVID-19. Additionally, the facility failed to enforce contact precautions for Residents #16 and #57, who were on contact precautions for ESBL and C-diff, respectively. Housekeeper #2 entered both residents' rooms without wearing a gown and did not change gloves or perform hand hygiene between room entries. This breach of protocol was observed despite clear signage indicating the need for contact precautions, highlighting a lack of adherence to infection control measures by the housekeeping staff.
Failure to Obtain Court-Approved Treatment Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain a court-approved [NAME] Treatment Plan for the administration of antipsychotic medication to Resident #24, who was admitted with diagnoses including traumatic brain injury and dementia with behavioral disturbances. Upon admission, the resident's medical record indicated a Health Care Proxy was in effect, but it was later discovered that the resident had a legal guardian with authority to approve antipsychotic treatment. Despite this, the facility administered Risperidone without the necessary [NAME] Treatment Plan, as the guardian was unaware of the resident's location and had limited documentation. The facility was notified of the guardianship in June 2024, but failed to obtain the required treatment plan for over 40 days. The surveyor requested the document on August 8, 2024, but the facility was unable to provide it. Interviews with staff revealed a lack of understanding of the process for obtaining consent when a guardian is involved. The Director of Nurses and the Administrator acknowledged the absence of the treatment plan and admitted that the request for authorization was only sent after the surveyor's inquiry.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a comprehensive and individualized care plan for a resident, who was at high risk for falls due to a history of falling and a fracture of the right femur. The care plan, initiated in March 2022, included an intervention to place a padded floor mat on the left side of the resident's bed to prevent falls. However, during multiple observations by the surveyor on consecutive days, the padded floor mat was found standing against the wall opposite the foot of the bed, rather than being placed on the floor as required by the care plan. Interviews with facility staff, including a nurse, a certified nursing assistant (CNA), and a unit manager, confirmed that the padded floor mat was not in use as per the care plan. The CNA admitted to not placing the mat on the floor after putting the resident to bed, and the unit manager acknowledged that the staff had not followed the resident's fall care plan. This oversight indicates a failure to adhere to the established care plan designed to meet the resident's needs and prevent falls.
Failure to Act on Pharmacist's Medication Review Recommendation
Penalty
Summary
The facility failed to ensure that the pharmacy's monthly medication regimen review for a resident was reported to the attending physician and director of nursing and acted upon in a timely manner. The resident, who was admitted with diagnoses including Type 2 diabetes mellitus and chronic systolic heart failure, had their medications reviewed by a consultant pharmacist. On June 2, 2024, the pharmacist recommended decreasing the resident's potassium chloride dosage from 40 milliequivalents (meq) per day to 20 meq per day. However, this recommendation was not communicated effectively to the necessary parties, and the resident continued to receive the higher dosage. The Director of Nurses acknowledged during an interview that the facility missed the pharmacist's recommendation. A subsequent report from the consultant pharmacist on July 4, 2024, reiterated the recommendation to decrease the potassium dosage, noting that the resident's potassium blood level was 4.6, which suggested a reduction to 20 meq daily. Despite this, the recommendation status from the physician was listed as no response, and the resident continued to receive the higher dosage until the omission was discovered and corrected on July 12, 2024.
Discrepancy in Discharge Destination for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, leading to a discrepancy in the physician's order for the destination of discharge. The resident, who had been admitted with diagnoses including hypertension, heart failure, chronic kidney disease, and dementia, was supposed to be discharged to a local skilled nursing facility (SNF) closer to family, as requested by the healthcare proxy. Documentation indicated that the resident was to be transferred to Local SNF A, and this was confirmed by the social worker. However, the physician's order inaccurately stated that the resident was to be discharged to Local SNF B. During an interview, the Unit Manager acknowledged the error, attributing it to a transcription mistake while managing multiple discharges that week.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents. For one resident, admitted in October 2018, the MDS assessments dated February, May, and August 2024 inaccurately reflected the admission date. Additionally, the resident developed a contracture, and the Occupational Therapy Discharge Summary indicated significant contractures in the resident's bilateral hands and wrists. However, the MDS assessments from May and August 2024 inaccurately reported no functional impairment in the resident's upper extremities. MDS Nurse #1 acknowledged the incorrect admission date, and MDS Nurse #2 admitted to not being aware of the contracture, leading to inaccurate MDS documentation. Another resident, admitted in July 2024 with multiple diagnoses, was discharged to a skilled nursing facility as per a physician's order and family request. However, the Discharge MDS assessment inaccurately indicated that the resident was discharged to an acute care hospital. MDS Nurse #2 confirmed the discharge status was incorrectly coded, which should have reflected the transfer to a skilled nursing facility.
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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.
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Nursing homes near Harwich
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cape Cod Post Acute Care | 4.9 mi | — | 0 | 0 |
| Windsor Nursing & Retirement Home | 5.2 mi | — | 6 | 0 |
| Liberty Commons | 6.3 mi | — | 0 | 0 |
| Mayflower Place Nursing & Rehabilitation Center | 9.3 mi | — | 8 | 0 |
| Pavilion , The | 12.5 mi | — | 0 | 0 |
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