Cambridge Health and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF600May 20, 2026

  Based on observation, interviews, review of the clinical record, facility documentation, and facility policy, for 2 of 3 residents (Resident #93 and Resident #90) reviewed for abuse, the facility failed to protect residents' rights to be free from abuse and neglect. Specifically, for Resident #93, the facility failed to protect the resident from neglect when multiple nursing staff - including the supervising RN, the charge nurse, and multiple nurse aides - failed to provide or ensure timely toileting assistance despite the resident's repeated call light activations over a period of more than 2 hours, resulting in the resident experiencing a urinary and fecal incontinence accident, and causing the resident to experience significant emotional distress, including uncontrollable crying,… […]

• Actual harm, isolatedF689Nov 1, 2022

  Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) reviewed for an for injury of unknown origin, (Resident #1), the facility failed to ensure Resident #1 was transferred in accordance with Resident #1's plan of care resulting in an injury. The findings include: Resident #1 was admitted to the facility with diagnoses that included anxiety, Alzheimer's disease, psychotic disorder with delusions, dementia, and cerebrovascular disease. The quarterly MDS dated [DATE] identified Resident #1 had severely impaired cognition, was an extensive assist that required two staff for transfers and was not steady, only to able to stabilize with staff, when moved from a seated to a standing position. […]

• No harm, potential for more than minimal, patternF880May 20, 2026

  Based on observations, interviews, review of the clinical record and policy review for 1 of 4 sampled residents (Resident #44) reviewed for respiratory care, the facility failed to follow infection control precautions for a resident with an unidentified respiratory illness and for 1 of 3 sampled residents, (Resident #138) reviewed for pressure ulcers, the facility failed to don (put on) Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Precautions while providing incontinent care and for for 1 of 5 sampled residents (Resident #140) observed during medication administration, the facility failed to complete hand hygiene and wear gloves during eye drop administration. The findings include: 1. […]

• No harm, potential for more than minimal, patternF755Jul 30, 2024

  Based on observation, review of facility documentation, facility policy, and interviews for 6 of 6 medication carts, the facility failed to consistently complete shift to shift narcotic/controlled drug counts. The findings include: Observation on 7/28/24 between 7:25 AM - 8:05 AM of the medication carts with LPN #3 (Discharge Planner) identified the July 2024 narcotic drug change of shift audit sheet (the narcotic count that the on-coming and off-going nurses complete to ensure the narcotic medications are counted) were missing signatures on multiple dates on the 7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift on the following units: The Passport A unit was missing 38 signatures. The Passport B unit was missing 44 signatures. […]

• No harm, potential for more than minimal, patternF812Feb 16, 2022

  Based on observation, review of facility documentation, facility policy, and interviews the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure food items were dated according to policy. The findings included: An observation on 2/7/22 at 10:05 AM identified the following: 1.Unlabeled juice (nectar oranges), 10 bowels of dried cereal, 6 bowels of hot cereal without a date on the cover or tray they were placed. 2.Large amount of thick dried solid brown matter with flecks of varied colored crusted matter observed on the floor under and behind the oven/stove region and under food preparation counter. A scooping utensil was also noted underneath the counter. 3. […]