Embassy of Cambridge

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 22, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, review of the facility incident log, review of a facility investigation, review of the facility elopement policy and interview, the facility failed to provide adequate supervision to Resident #58, who had a developmental disability, exhibited severe cognitive impairment (with a Brief Interview for Mental Status score of four), had exit seeking behaviors and required the use of a wander guard device (a special bracelet to alert staff when a resident exits the facility), to prevent the resident from exiting the facility without staff knowledge. […]

• Immediate jeopardy, isolatedF684Feb 16, 2023

  Based on medical record review, review of hospital records, review of the facility policy and procedures related to change of condition, diagnostic testing services, culture and sensitivity lab results, and physical assessment and interviews with staff and Resident #65's family, the facility failed to provide timely and adequate care and treatment for Resident #65 who exhibited acute changes in condition with resident/family requests for hospitalization . This resulted in Immediate Jeopardy with serious life-threatening harm beginning on 12/23/22 when Resident #65, who was symptomatic of a C-Diff infection was not tested for the infection as ordered by the physician, properly treated or transferred to the hospital until 01/02/23 where he was admitted for nine days for treatment of C-Diff,… […]

• Immediate jeopardy, isolatedF684Mar 29, 2021

  Based on closed record review, review of hospital records, review of the facility policy and procedures related to Notification, interviews with facility staff, Medical Director #81 and Certified Nurse Practitioner (NP) #80 the facility failed to seek proper, timely and adequate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to timely report the abnormal lab result to the physician, failed to hold the resident's routine dose of K+ and failed to immediately transfer the resident to the hospital for treatment following the identification of the abnormal laboratory result. This resulted in Immediate Jeopardy and serious life-threatening harm on [DATE] at 4:17 A.M. […]

• Actual harm, isolatedF697Nov 22, 2024

  Based on medical record review, interview, and policy review the facility failed to implement an effective pain management program, including the administration of scheduled and as needed opioid medication for Resident #7. Actual Harm occurred on 11/09/24, when Resident #7, who was identified with chronic pain and a new onset of acute pain related to a fall resulting in a fractured sternum, did not receive her scheduled or as needed Percocet (narcotic pain medication) as requested, resulting in uncontrolled pain that affected the resident's ability to participate in activities of daily living and required the administration of a one-time emergent dose of Percocet to re-gain control of the resident's pain. This affected one resident (#7) of five residents reviewed for pain. […]

• Actual harm, isolatedF689May 21, 2024

  Based on medical record review, review of hospital records, staff interview, and policy review, the facility failed to ensure fall interventions were implemented and residents were provided the appropriate level of assistance to prevent falls. This affected one (Resident #27) of six residents reviewed for accidents. The facility census was 68. Actual Harm occurred on 04/29/24 at approximately 4:30 A.M. when Resident #27, who was assessed to have severely impaired cognition, required physical assistance of one staff member for lower body dressing and was identified as a high fall risk, fell after having been instructed by staff (while in the shower room with the resident) to stand up and remove his pants, without staff assistance on a wet floor. […]