Altercare Cambridge Inc.

In the surveyor’s words

From the most serious findings on record at Altercare Cambridge Inc., in the surveyor’s own words.

• Actual harm, isolatedF684Jan 7, 2026

  Based on closed medical record review, hospital record review, Self-Reported Incident (SRI) review, facility policy review, and interviews, the facility failed to timely identify and address a resident's change in condition following a mechanical lift transfer. This affected one resident (#55) of three residents reviewed for hospitalizations. The facility census was 47. Actual harm occurred on 11/16/25 when Resident #55, who was severely cognitively impaired and required staff assistance for activities of daily living, slammed her body down into a sit-to-stand (mechanical lift) device on her right side and back due to an episode of increased weakness. […]

• Actual harm, isolatedF686Jan 7, 2026

  Based on observation, medical record review, hospital record review, policy review and interview, the facility failed to implement a comprehensive and individualized pressure ulcer program to timely identify, treat and/or prevent a decline of pressure ulcers. This affected two residents (Resident #42 and #07) of three residents reviewed for pressure ulcers. Actual Harm occurred on 12/06/25 when Resident #42, who had been identified at risk for pressure ulcer development and required maximum staff assistance for bed mobility, returned from the hospital with a red and blanchable area to his (unidentified) buttock without evidence of a comprehensive skin assessment or implementation of pressure relieving interventions or wound treatment to prevent decline in the pressure ulcer. […]

• No harm, potential for more than minimal, widespreadF880Jan 7, 2026

  Based on observation, review of the facility policy, and interview with the staff, the facility failed to ensure the facility was cleaning the floors in the residents' rooms and hallways with a disinfectant. This had the potential to affect all 47 residents in the facility. The facility census was 47.Findings include:Observation of the gallon container of orange neutral cleaner on 12/23/25 at 9:30 A.M. with Environmental Service Coordinator #313 revealed there was no documentation on the bottle indicating it was a disinfectant. On 12/23/25 at 9:33 A.M. an interview with Environmental Service Coordinator #313 confirmed the facility used bleach wipes for the hard surfaces in the room and an orange neutral cleaner on the floors in the resident rooms. […]

• No harm, potential for more than minimal, widespreadF835Aug 26, 2025

  Based on review of the job descriptions, review of the employee handbook, review of a self-reported incident investigation, review of timed stamped and dated photographs, review of Centers for Disease Control (CDC) and the National Institute for Occupational Safety and Health (NIOSH) report, review of the facility assessment, review of time sheets, interviews, and policy review the facility failed to have systems in place to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to prevent staff sleeping while on duty and monitor to ensure licensed staff do not pre-pour medications for residents prior to administration. This had the potential to affect all 48 residents residing in the facility. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF812Aug 11, 2022

  Based on observation and interview, the facility failed to maintain the kitchen in a sanitary condition. This had the potential to affect all the residents in the facility except Residents #29 and #93 who did not receive nutrition from the kitchen. The facility census was 43. Findings include: Initial tour of the kitchen 08/01/22 at 8:45 A.M. revealed the following; 1. The ice machine had brown slimy film on the lip of the shoot. The slimy film wiped off with a paper towel. There was dried white debris around the door seal and lid. 2. In the dry storage, breadcrumbs were opened and not dated. 3. The vents above the range top and grill were dusty. There were grease traps on each side of the vents. The trap on the left had blowing dust stringing out an inch long. 4. […]