Inspection Reports for
Cambridge Care Center

The complaint investigation was triggered by reports of physical abuse incidents involving Resident #2 pushing and kicking other residents. The facility investigations concluded the abuse allegations were unsubstantiated due to lack of injury or fear, but physical abuse incidents were confirmed.

The facility failed to protect three residents (#8, #6, and #1) from physical abuse by Resident #2. Multiple incidents of pushing and kicking were documented, though no injuries or fear were substantiated. Resident #2 had a history of agitation and poor impulse control, with behavioral interventions in place.

The facility failed to follow physician dialysis orders, consistently get Resident #4 to dialysis appointments on time, and properly complete dialysis communication forms. The nursing staff did not fill in post-dialysis sections of communication forms, and the facility was late in addressing these issues until the survey date.

The complaint investigation focused on Resident #4's dialysis care. The dialysis center reported multiple late arrivals and missed make-up appointments. The facility's nursing staff failed to complete post-dialysis communication forms consistently. The Director of Nursing and corporate nurse acknowledged these issues and implemented corrective actions during the survey.

The facility failed to follow physician dialysis orders, consistently get the resident to dialysis appointments on time, and properly complete dialysis communication forms. The dialysis communication logs showed multiple missed or late appointments and incomplete documentation by nursing staff.

The complaint investigation focused on Resident #1's discharge planning. The resident's representative reported delays and lack of communication regarding transfer requests. The facility had inconsistent staff handling referrals, poor follow-up with potential admitting facilities, and inadequate communication with the resident's representative. Several facilities denied admission due to the resident's high care needs or payor status. Documentation of referral efforts and communication was insufficient.

The facility failed to ensure consistent efforts in the discharge planning process, resulting in potential delays in Resident #1's discharge to another facility. Communication with the resident's representative was inconsistent, and documentation of the discharge planning process in the electronic medical record was inadequate.

Complaint investigation focused on discharge procedures for Resident #140, substantiated by findings of actual harm due to improper discharge process and lack of support services.

The facility failed to provide a safe and orderly discharge for Resident #140, who was discharged to a motel without proper notice, ombudsman notification, wound care education, or home health services. The resident was later found down in the motel and admitted to the hospital with actual harm. Additional deficiencies included failure to provide timely discharge notices and failure to maintain accurate medical orders for resuscitation for another resident (#11). The facility also failed to assist Resident #14 with ancillary services including vision and dental care.

The facility was found deficient in multiple areas including ineffective discharge planning for Resident #76, inadequate supervision and safety measures for Resident #10, failure to provide appropriate mental health services to several residents, serving food at improper temperatures, unsanitary handling of drinks in the dining room, improper reheating of food in a resident's room, and lapses in infection control practices including hand hygiene and laundry handling.

The facility was found deficient in multiple areas including ineffective discharge planning for a resident, inadequate supervision to prevent accidents, failure to provide appropriate mental health services to several residents, serving food at improper temperatures, unsanitary food and drink handling practices, and lapses in infection prevention and control practices.

The complaint investigation was triggered by resident reports of cold showers. Resident council members and individual residents (#47, #40, and #45) reported ongoing issues with cold water temperatures in shower rooms. The complaint was substantiated by observations and interviews.

The facility failed to ensure warm water was available in three of four shower rooms, impacting three residents who reported cold showers over several months. Observations, interviews, and record reviews confirmed ongoing issues with shower water temperatures being too low for comfortable showering.

The investigation was triggered by resident complaints about cold showers reported in resident council meetings and directly by residents #47, #40, and #45. The complaints were substantiated by observations, interviews, and record reviews confirming cold water temperatures in shower rooms.

The facility failed to ensure warm water was available in three of four shower rooms, causing discomfort to residents. The plant maintenance director lacked a formal policy for checking water temperatures, and water temperatures were consistently below comfortable levels despite an action plan.