Cambridge Care Center

In the surveyor’s words

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

• Actual harm, isolatedF622Apr 2, 2024

  Based on record review and interviews, the facility failed to ensure a facility-initiated discharge procedure for non-payment was followed for one (#140) of three residents reviewed for discharge out of 34 sample residents. Resident #140, who had a diagnosis of urinary tract infection, atrial fibrillation (abnormal heart rhythm), type II diabetes mellitus, history of falling, depression and anxiety disorder, was admitted to the facility on [DATE] and discharged on [DATE]. The facility failed to provide preparations for a safe and orderly facility-initiated discharge for non payment. The resident chose not to transition to long term care (LTC) insurance. […]

• No harm, potential for more than minimal, patternF880Jun 11, 2026

  Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of four units.Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate infection control procedures when cleaning and disinfecting residents' rooms and high-frequency touched areas (call lights, door handles, light switches and bed controls); and,-Ensure housekeeping staff followed disinfectant dwell times (the amount of time required to ensure germs are eliminated) when cleaning residents' rooms.Findings include:I. […]

• No harm, potential for more than minimal, patternF600Jun 17, 2025

  Based on observations, record review and interviews, the facility failed to ensure three (#8, #6 and #1) of six residents reviewed for abuse out of 12 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #9 from physical abuse by Resident #2; -Protect Resident #6 from physical abuse by Resident #2; and, -Protect Resident #1 from physical abuse by Resident #2. Findings include: I. Incident of physical abuse by Resident #2 towards Resident #8 on 1/30/25 A. Facility investigation The facility investigation, dated 1/30/25, was provided by the nursing home administrator (NHA) on 6/17/25 at 11:45 a.m. The investigation revealed the following: On 1/30/25 Resident #2 pushed Resident #8 in the coffee area of the dining room. […]

• No harm, potential for more than minimal, patternF742Dec 15, 2022

  Based on record review and interviews, the facility failed to ensure four (#2, #9, #65 and #76) of seven out of 22 sample residents who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, the facility failed to provide mental health services for Residents #2, #9, #65 and #76. Findings include: I. Facility policy and procedure The Behavioral Health Services policy and procedure, revised February 2019, was provided by the nursing home administrator (NHA) on 12/15/22 at 12:13 p.m. […]

• No harm, potential for more than minimal, patternF804Dec 15, 2022

  Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures for all residents. Specifically, the facility failed to ensure resident food was palatable in temperature. Findings include: I. Resident interviews Resident #29 was interviewed on 12/12/22 at 1:36 p.m. He said the temperature of his meals were always cold. He said sometimes staff would reheat his food, but not always. Resident #39 ws interviewed on 12/12/22 at 2:05 p.m. She stated the temperature of the food was never good. She said hot foods were cold and cold foods were hot. Resident #76 was interviewed on 12/12/22 at 2:40 p.m. He said the food was often terrible. He said the food was frequently served cold. […]