Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

CAPE COD POST ACUTE CARE

BREWSTER, MA · 135 certified beds · Last Life Safety survey May 8, 2025

CMS Certification Number 225667 · first certified February 1995

Ownership

Operated by MARQUIS HEALTH SERVICES · For profit - Limited Liability company

New ownershipOwnership changed October 31, 2024 (change of ownership)from PLEASANT BAY OF BREWSTER REHAB CENTER LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within MA

39 citations — more than 99% of the 341 certified nursing homes in MA. Compared within MA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 5 citations; the earlier surveys in the window averaged 17. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (May 2026 to July 2026), and past the point by which nine in ten MA facilities have been surveyed. This facility’s last Life Safety survey was May 2025. Facilities in MA are typically surveyed 12–15 months after the last one (median 13), measured over 556 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

9 of the 39 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 39 Life Safety citations above. The Physical Environment Index

F-0880 Provide and implement an infection prevention and control program.
F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in MA, and nationally. Surveyors differ markedly between states, so the MA figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	39
Median facility in MA	11
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
August 24, 2022	17
March 19, 2024	17
May 8, 2025	5

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	3	2025-05-08
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	2	2024-03-19
K-0711	Provide a written emergency evacuation plan.	2	2025-05-08
K-0351	Install an approved automatic sprinkler system.	2	2024-03-19
K-0712	Have simulated fire drills held at unexpected times.	2	2024-03-19
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2024-03-19
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	2	2025-05-08
K-0541	Install properly constructed and protected linen or trash chutes.	2	2025-05-08

What the citations cover

Citations by CMS category

Smoke Deficiencies 13
Emergency Preparedness Deficiencies 9
Miscellaneous Deficiencies 6
Gas, Vacuum, and Electrical Systems Deficiencies 5
Other 6

Citations by CMS category
Category	Citations
Smoke Deficiencies	13
Emergency Preparedness Deficiencies	9
Miscellaneous Deficiencies	6
Gas, Vacuum, and Electrical Systems Deficiencies	5
Egress Deficiencies	4
Services Deficiencies	2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

May 8, 2025 — 5 citations

Citations issued on May 8, 2025
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (June 3, 2025)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (June 3, 2025)
K-0541	Install properly constructed and protected linen or trash chutes.	Deficient, Provider has date of correction (June 3, 2025)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (June 3, 2025)
K-0911	Meet requirements for the installation and maintenance of electrical systems.	Deficient, Provider has date of correction (June 3, 2025)

March 19, 2024 — 17 citations

Citations issued on March 19, 2024
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (April 25, 2024)
E-0013	Develop Emergency Preparedness policies and procedures.	Deficient, Provider has date of correction (April 25, 2024)
E-0022	Establish policies and procedures for sheltering.	Deficient, Provider has date of correction (April 25, 2024)
E-0029	Develop a communication plan.	Deficient, Provider has date of correction (April 25, 2024)
E-0030	List the names and contact information of those in the facility.	Deficient, Provider has date of correction (April 25, 2024)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (April 25, 2024)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (April 25, 2024)
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (April 25, 2024)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (April 25, 2024)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (April 25, 2024)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (April 25, 2024)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (April 25, 2024)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (May 3, 2024)
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	Deficient, Provider has date of correction (April 25, 2024)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (April 25, 2024)
K-0911	Meet requirements for the installation and maintenance of electrical systems.	Deficient, Provider has date of correction (April 25, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (April 25, 2024)

August 24, 2022 — 17 citations

Citations issued on August 24, 2022
Tag	What the surveyor checks	Status
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (October 13, 2022)
K-0225	Have stairways and smokeproof enclosures used as exits that meet safety requirements.	Deficient, Provider has date of correction (October 13, 2022)
K-0311	Have an enclosure around a vertical opening shaft.	Deficient, Provider has date of correction (October 13, 2022)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (October 13, 2022)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (October 13, 2022)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (October 13, 2022)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (October 13, 2022)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (October 13, 2022)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (October 13, 2022)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (October 13, 2022)
K-0541	Install properly constructed and protected linen or trash chutes.	Deficient, Provider has date of correction (October 13, 2022)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (October 13, 2022)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (October 13, 2022)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (October 13, 2022)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (October 13, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (October 13, 2022)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (October 13, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.