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.

• Immediate jeopardy, patternF686Feb 1, 2024

  Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for 1 (CR #1) of 6 residents reviewed for pressure ulcers. -The facility failed to prevent the development of CR #1's Stage IV facility acquired sacrum pressure wound and left heel deep tissue injury resulting in debridement and hospitalization . […]

• Immediate jeopardy, patternF678Sep 29, 2023

  Based on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) for 1 (CR#1) of 12 residents reviewed for advanced directives. 1. The facility failed to immediately initiate CPR on [DATE] at about 7:20 AM when CR#1 was found unresponsive. 2. The facility failed to immediately contact EMS when CR#1 was found unresponsive between 7:00 AM and 7:20 AM. EMS was called at about 7:32 AM. (,d+[DATE]-minute delay). 3. The facility failed to ensure CPR was performed on a cardiac board once initiated by staff. A cardiac board is used in the administration of cardiopulmonary resuscitation (CPR) by creating a flat, rigid surface to use under the person in need of care. An Immediate Jeopardy (IJ) situation was identified on [DATE]. […]

• Immediate jeopardy, isolatedF726Sep 29, 2023

  Based on interviews and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 of 21 nurses (LVN A and LVN G) reviewed for competencies and skill sets for assessments. 1. The facility failed to ensure LVN A immediately and properly assessed CR#1 after the resident's change in condition was identified by CNA B as reported to be acting abnormally. 2. The facility failed to immediately and properly assess CR#1 after an additional change in condition was identified by CNA B as reported to appear pale and not look good. 3. […]

• Immediate jeopardy, isolatedF689Aug 30, 2023

  Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards and failed to provide adequate supervision to prevent accidents for 1 resident (Resident #1) of four residents reviewed for accidents and hazards. -The side rail on Resident #1's bed was not properly fastened to the bed frame, causing it to rotate and expose a metal rod. Resident #1 was transferred from the wheelchair to the bed, his lower right leg was punctured with the exposed metal rod, resulting in Resident #1 receiving 10 staples to his right leg. -Staff transferred Resident #1 from the wheelchair to the bed using one-person transfer. Resident #1 required two persons for transfers. An Immediate Jeopardy (IJ) was identified on 08/29/2023 at 02:54 p.m. […]

• Actual harm, isolatedF656Feb 26, 2026

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for one (Resident #1) of six residents reviewed for care plans.The facility failed to specify in the care plan whether Resident #1 would be a 1-person or 2-person assist for bed mobility. Resident #1 sustained a fall out of her bed on 1/6/26 when CNA A attempted to provide a 1-person assist during incontinent care. […]