Cape Cod Post Acute Care
383 South Orleans Road, Brewster, MA 02631 · Barnstable County · 135 certified beds · avg 125 residents/day · certified since Feb 16, 1995
Part of chain: MARQUIS HEALTH SERVICES (87 facilities, chain avg rating 3.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, repeated · Mar 19, 2024 · F-0580
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Apr 26, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Mar 19, 2024 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Apr 26, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Mar 19, 2024 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Apr 26, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 19, 2024 · F-0656
The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 26, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 19, 2024 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 26, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Aug 24, 2022 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Sep 30, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Aug 24, 2022 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Oct 7, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 24, 2022 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 30, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (69)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 8, 2025 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| May 8, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 8, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 8, 2025 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| May 8, 2025 | E · Potential for harm, repeated | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| May 8, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 8, 2025 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| May 8, 2025 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 29, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jul 24, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jul 24, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| May 21, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Mar 19, 2024 | ▲ H · Actual harm, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Mar 19, 2024 | ▲ H · Actual harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 19, 2024 | ▲ H · Actual harm, repeated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Mar 19, 2024 | ▲ G · Actual harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 19, 2024 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Mar 19, 2024 | F · Potential for harm, facility-wide | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Mar 19, 2024 | F · Potential for harm, facility-wide | The facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials. |
| Mar 19, 2024 | F · Potential for harm, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. |
| Mar 19, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Mar 19, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Mar 19, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Mar 19, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 19, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Mar 19, 2024 | B · Minimal risk, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Mar 19, 2024 | B · Minimal risk, repeated | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. |
| Sep 20, 2023 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Aug 24, 2022 | ▲ H · Actual harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 24, 2022 | ▲ H · Actual harm, repeated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Aug 24, 2022 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Aug 24, 2022 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Aug 24, 2022 | F · Potential for harm, facility-wide | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Aug 24, 2022 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 24, 2022 | F · Potential for harm, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. |
| Aug 24, 2022 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Aug 24, 2022 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 24, 2022 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Aug 24, 2022 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Aug 24, 2022 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Aug 24, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 24, 2022 | E · Potential for harm, repeated | The facility did not perform required COVID-19 testing on residents and staff. |
| Aug 24, 2022 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Aug 24, 2022 | D · Potential for harm, one-off | The facility did not allow a resident's chosen representative — often a family member or someone with power of attorney — to exercise the resident's rights on their behalf. When a resident can't speak for themselves, their representative steps into that role. |
| Aug 24, 2022 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Aug 24, 2022 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 24, 2022 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Aug 24, 2022 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Aug 24, 2022 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 24, 2022 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| Aug 24, 2022 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Aug 24, 2022 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (29 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 24 | 3 | H ▲ |
| 2023 | 4 | 0 | E |
| 2024 | 32 | 5 | H ▲ |
| 2025 | 9 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $298,483, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Mar 19, 2024 | Fine | $298,483 |
| Mar 19, 2024 | Payment Denial | 38 days from May 2, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Massachusetts avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.06 | 3.89 | 3.95 | bottom 9% in Massachusetts; bottom 16% in the U.S. |
| Registered Nurse hours | 0.72 | 0.65 | 0.69 | top 28% in Massachusetts; top 34% in the U.S. |
| Weekend total nurse staffing | 2.75 | 3.51 | 3.50 | bottom 9% in Massachusetts; bottom 18% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.61 | 0.46 | 0.48 | top 18% in Massachusetts; top 22% in the U.S. |
| Total nursing staff turnover (%) | 50.0 | 38.2 | 45.8 | bottom 18% in Massachusetts; bottom 38% in the U.S. |
| RN turnover (%) | 53.1 | 42.6 | 42.9 | bottom 28% in Massachusetts; bottom 31% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.35, RN 0.79, weekend 3.01. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Kahanow, Aviva | Individual | Indirect Ownership Interest | NOT APPLICABLE | 10/31/2024 |
| Rokeach, Fraide | Individual | Indirect Ownership Interest | NOT APPLICABLE | 10/31/2024 |
| Skilled Venture LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 09/12/2024 |
| Cape Cod Property LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/31/2024 |
| Flagler, Osher | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 02/26/2025 |
| Forbright Bank | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 10/31/2024 |
| Harman, Dina | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/31/2024 |
| Harman, Dina | Individual | ADP of the SNF | NOT APPLICABLE | 01/13/2025 |
| Levovitz, Tzvi | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 02/26/2025 |
| Lordan, Nancy | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/17/2025 |
| Lordan, Nancy | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/17/2025 |
| Lordan, Nancy | Individual | ADP of the SNF | NOT APPLICABLE | 02/17/2025 |
| Marquis Limited LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 10/31/2024 |
| Marquis Limited LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/11/2025 |
| NFR 2020 Irrv Tr | Organization | ADP of the SNF | NOT APPLICABLE | 01/11/2025 |
| Posen, Mindee | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/31/2024 |
| Posen, Mindee | Individual | ADP of the SNF | NOT APPLICABLE | 10/31/2024 |
| Quinto Nexgen LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/11/2025 |
| Reliant Pro Rehab LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/11/2025 |
| Reliant Pro Rehab LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/11/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Liberty Commons | 3.1 mi | North Chatham, MA | ★★★☆☆ | 2/5 | |
| Regalcare at Harwich | 4.9 mi | Harwich, MA | ★★★☆☆ | 3/5 | |
| Windsor Nursing & Retirement Home | 10.1 mi | South Yarmouth, MA | ★★☆☆☆ | 3/5 | |
| Mayflower Place Nursing & Rehabilitation Center | 14.2 mi | West Yarmouth, MA | ★★★☆☆ | 3/5 | |
| Pavilion , the | 17.3 mi | Hyannis, MA | ★★★★★ | 5/5 | |
| Cape Regency Rehabilitation & Health Care Center | 18.5 mi | Centerville, MA | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 225667.