Inspection Reports for
Cambridge Care Center

The complaint involved allegations of physical abuse by Resident #2 towards Residents #8, #6, and #1. The facility investigations found incidents of pushing and kicking but concluded the allegations were unsubstantiated due to no injuries, no intent to harm, and no fear by the victims.

The facility failed to protect three residents from physical abuse by Resident #2. Multiple incidents of pushing and kicking were documented, but the facility concluded the abuse allegations were unsubstantiated due to lack of injury, intent to harm, or fear by victims. Interventions included behavior care plans, frequent checks, education, and plans to move Resident #2 to a different unit.

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 #1's discharge planning process. The resident's representative reported delays and lack of communication regarding transfer requests to other facilities. The facility's social service department had minimal involvement, and referrals were inconsistently handled. Several facilities denied admission due to the resident's high care needs or payor status. The resident's representative expressed frustration with the lack of follow-up and communication.

The facility failed to ensure consistent discharge planning efforts, timely communication with Resident #1's representative, and proper documentation of the discharge process in the electronic medical record. Multiple referrals to other facilities were delayed or not followed up, and the resident's representative reported poor communication and lack of assistance from facility staff.

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 complaint investigation focused on Resident #140's discharge process. The resident was discharged due to non-payment without proper notice or support, was found down in a motel room three days later, and admitted to the hospital with actual harm. The facility failed to notify the ombudsman or provide a discharge notice with appeal rights.

The facility failed to provide a 30-day discharge notice, failed to notify the ombudsman, did not arrange home health services or provide wound care supplies and education, and discharged the resident to a motel without adequate support. The resident was later found down in the motel and admitted to the hospital with actual harm due to lack of capacity to make medical or discharge decisions.

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 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.