Cambridge Post Acute Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF625Jul 9, 2024

  Based on observation, record review, interviews, and review of the policy titled Bed Hold Policy, the facility failed to provide written information about the facility's bed-hold policy to the resident or resident representative when the facility transfers a resident to the hospital for three of three residents (R) (R3, R14, R17) reviewed for Bed Hold. This failure had the potential to contribute to possible denial of re-admission following hospitalization for residents discharged emergently to the hospital. Findings included: A review of the Bed-Hold Policy revised January 2011 revealed it is necessary for the facility to explain the policies concerning reserving beds for residents that must be in the hospital for an undetermined number of days. 1. […]

• No harm, potential for more than minimal, widespreadF881Jul 9, 2024

  Based on record review, interviews, and review of the policy titled Antibiotic Stewardship, the facility failed to assess and determine clinical indications for use of antibiotics utilizing the McGreer Criteria, failed to implement systematic protocols to monitor, decrease use, and measure effectiveness of antibiotics and create an action plan to lower the use of antibiotics for two of three sampled residents (R) (R16 and R17). Findings included. Review of the policy titled Antibiotic Stewardship, dated April 2022, revealed the policy is the center will develop an Antibiotic Stewardship program to monitor antibiotics and determine true infections as part of the Infection Prevention and Control Program. Procedure: Program Overview: Number 1. […]

• No harm, potential for more than minimal, widespreadF882Jul 9, 2024

  Based on record review, interviews, and review of the policy titled Infection Control -Infection Preventionist, the facility failed to ensure that the person in the role of the Infection Control Preventionist (ICP) adequately assessed, developed, implemented, monitored, and managed the Infection Control and Prevention (IPCP) program, to prevent and control the spread of infections. This failure created the potential for an ineffective infection control program that placed residents at risk for the potential transmission of infections and communicable diseases. […]

• No harm, potential for more than minimal, widespreadF921Jul 9, 2024

  Based on observations, interviews, and review of the policy titled Maintenance Service, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors. Specifically, the facility failed to address and remove bulking wallpaper and water-stained ceiling tiles from room C14. In addition, the facility failed to maintain the aesthetic appeal of the exterior of the facility and a clean and safe porch area at the entrance of the facility. The census was 136. Findings included: Review of the policy titled Maintenance Service dated April 2022 documented Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: Number 1. […]

• No harm, potential for more than minimal, patternF880Feb 10, 2025

  Based on observation, staff interview, and review of the facility's policy titled Giving a Bed bath, the facility failed to ensure residents' basins, urinals, and bedpans were labeled and covered for 11 of 69 shared rooms (D2, D5, D18, D16, C9, C15, B16, B5, A15, A5, and A11). These failures had the potential to expose patients to infections due to cross-contamination. Findings include: A review of the facility policy, Giving a Bed bath, dated April 2022 under the section titled Steps in the Procedure revealed, 23. […]