Inspection Report Summary
The most recent inspection on February 5, 2025, was a complaint investigation in which no deficiencies were identified. Earlier inspections showed a pattern of deficiencies primarily related to medication administration, oxygen therapy, care planning, and documentation, with some issues involving incontinent care and infection control noted in prior years. Complaint investigations included substantiated findings of inadequate resident care and documentation, while more recent complaints were unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history indicates some improvement, with the latest inspection showing no deficiencies after previous reports cited multiple issues.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
5.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
89% occupied
Based on a February 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 142
Capacity: 160
Deficiencies: 0
Date: Feb 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to complaint numbers #42646 and #42887.
Complaint Details
Complaint investigation for complaints #42646 and #42887; no violations were substantiated.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Report Facts
Licensed Bed Capacity: 160
Census: 142
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Asija | DNS | Personnel contacted during inspection |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jan 14, 2025
Visit Reason
Unannounced visits were made to Cambridge Health And Rehabilitation Center on January 14, 2025, by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations.
Complaint Details
Complaints #42378, #42530, #42574, #42615 were investigated as part of the visit.
Findings
The report identifies violations of Connecticut State regulations related to failure to timely notify physicians/designees about missed antipsychotic medication doses and failure to ensure oxygen was administered and assessed timely for residents with changes in condition. Specific deficiencies involved Resident #4 and Resident #2 regarding medication administration and oxygen therapy.
Deficiencies (3)
Failure to ensure timely notification to physician/designee when antipsychotic medication was not available for administration as ordered for Resident #4.
Failure to ensure antipsychotic medication was administered in accordance with physician orders for Resident #4.
Failure to ensure oxygen was administered in accordance with physician orders and failure to ensure timely assessment for Resident #2 with identified change in condition.
Report Facts
Medication dose: 400
Oxygen liters: 10
Dates: Nov 1, 2024
Dates: Dec 30, 2024
Dates: Dec 31, 2024
Audit frequency: 5
Audit frequency: 4
Inspection Report
Renewal
Census: 145
Capacity: 160
Deficiencies: 0
Date: Jul 30, 2024
Visit Reason
The inspection was conducted as a licensing inspection for renewal purposes and included a complaint investigation (Complaint Investigation # CT 30759).
Complaint Details
Complaint Investigation # CT 30759 was included in the inspection; no substantiation status is explicitly stated.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were identified, with attached violation letters and a narrative report referenced. Certification files were reviewed as part of the inspection.
Report Facts
Licensed Bed Capacity: 160
Census: 145
Inspection Report
Renewal
Deficiencies: 12
Date: Jul 30, 2024
Visit Reason
Unannounced visits were made to Cambridge Health And Rehabilitation Center concluding on July 30, 2024, for multiple investigations, a licensure renewal, and certification inspection.
Findings
The facility was found deficient in multiple areas including failure to obtain residents' code status on admission, failure to notify resident representatives of medication changes, inconsistent revision of care plans after falls, medication administration errors, failure to monitor vital signs and neurological checks, inconsistent administration of specialty medications, inadequate pressure ulcer assessments, delayed feeding assistance, improper oxygen administration, incomplete narcotic drug counts, unnecessary medication use, delayed resolution for lost dentures, and inaccurate fall risk documentation.
Deficiencies (12)
Failure to obtain residents' code status on admission for 2 of 5 residents.
Failure to notify resident representative of medication changes for 1 resident.
Failure to revise resident's care plan to reduce fall risk after multiple falls for 1 resident.
Medication left at bedside for 1 resident, risking accidental hazards.
Failure to monitor vital signs and neurological checks as required for multiple residents; failure to administer specialty medication timely for 1 resident.
Failure to ensure RN completed pressure ulcer assessments and air mattress set per manufacturer recommendations for 1 resident.
Failure to provide timely feeding assistance to a dependent resident with history of weight loss.
Failure to ensure oxygen was administered as ordered for 2 residents; tubing disconnected and taped.
Failure to consistently complete shift to shift narcotic/controlled drug counts on multiple units.
Failure to discontinue unnecessary nicotine patch medication for 1 resident.
Failure to provide timely resolution for lost dentures for 1 resident due to payment issues.
Failure to ensure clinical record reflected clear and accurate documentation related to fall risk evaluation assessments for 1 resident.
Report Facts
Missing narcotic count signatures: 167
Days delayed for code status order: 61
Number of falls: 9
Missed specialty medication doses: 3
Late specialty medication doses: 4
Weight setting on air mattress: 325
Weight setting on air mattress after correction: 200
Time feeding tray left unattended: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed the initial notice letter for the inspection. |
| LPN #8 | Signed advance directive form alone, which was deemed invalid. | |
| LPN #4 | Interviewed regarding code status consent process and medication administration. | |
| ADNS | Assistant Director of Nursing Services | Provided multiple interviews regarding code status, medication notifications, and oxygen therapy. |
| DNS | Director of Nursing Services | Provided multiple interviews regarding code status, medication notifications, care plan revisions, neurological checks, oxygen therapy, narcotic counts, and denture replacement. |
| RN #1 | Interviewed regarding advance directives and medication administration. | |
| APRN #1 | Advanced Practice Registered Nurse | Interviewed regarding nicotine patch medication and pharmacy recommendations. |
| APRN #6 | Advanced Practice Registered Nurse | Interviewed regarding diabetes care and specialty medication management. |
| RN #7 | Corporate Clinical Director | Interviewed regarding diabetes lab monitoring. |
| RN #5 | MDS Coordinator | Documented denture loss and care plan changes. |
| LPN #1 | Interviewed regarding medication administration and narcotic counts. | |
| LPN #2 | Interviewed regarding oxygen tubing and narcotic counts. | |
| LPN #3 | Discharge Planner | Interviewed regarding narcotic counts. |
| LPN #7 | Interviewed regarding narcotic counts. | |
| Pharmacist #1 | Interviewed regarding Humira medication supply and delivery. | |
| RDH #1 | Dental Hygienist | Interviewed regarding lost dentures and dental services. |
| SW #2 | Social Worker | Interviewed regarding denture replacement and grievance process. |
| Administrator | Interviewed regarding grievance process and narcotic count expectations. |
Inspection Report
Renewal
Census: 142
Capacity: 160
Deficiencies: 0
Date: Jun 25, 2024
Visit Reason
A desk audit was completed on 6/25/24 to review the implementation of the Plan of Correction for the Violation letter dated 4/30/24.
Findings
Violations #1 and #2 were identified as corrected as of 6/11/24. The Administrator was notified via telephone on 6/25/24 that all violations were corrected.
Report Facts
Licensed Bed Capacity: 160
Census: 142
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Catarina Zhao | Administrator | Personnel contacted during inspection |
| Anna Durkovic | Administrator | Notified via telephone that all violations were corrected |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 160
Deficiencies: 3
Date: Apr 30, 2024
Visit Reason
Unannounced visits were made on April 26, 29, and 30, 2024, to conduct multiple investigations related to complaints #38412, #38534, and #34231.
Complaint Details
The investigation was triggered by complaints #38412, #38534, and #34231. The violations were substantiated as the facility failed to provide required care and documentation for residents as per state regulations.
Findings
Violations of Connecticut State regulations were identified involving failure to provide incontinent care, inadequate monitoring of intake and output during intravenous therapy, and medication reconciliation errors. The facility was found deficient in ensuring proper care and documentation for residents.
Deficiencies (3)
Failure to ensure Resident #2 was provided incontinent care from 12:30 AM to 5:30 AM, resulting in neglect.
Failure to monitor intake and output for Resident #3 receiving intravenous fluids and lack of facility policy for such monitoring.
Failure to ensure medication reconciliation for Resident #1 upon readmission, resulting in omitted doses of Digoxin and Diltiazem.
Report Facts
Census: 130
Total Capacity: 160
Hours without incontinent care: 5
Missed doses: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anna Durkovic | Administrator | Personnel contacted during inspection |
| Linda Burney | DNS | Personnel contacted during inspection |
| Karen Gworek | Supervising Nurse Consultant | Author of notice letter regarding violations and plan of correction |
| Connie Vumback | RN NC | Signature on licensing inspection report |
| Vicky Golab | RN NC | Signature on licensing inspection report |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 160
Deficiencies: 0
Date: Oct 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation to determine compliance with 42 CFR Part 483 requirements for long term care facilities, triggered by complaint investigation numbers CT35922, CT35997, and CT36102.
Complaint Details
Complaint Investigation Survey, ACTS Reference Numbers CT #35922 was conducted to determine compliance with 42 CFR Part 483 requirements. Violations were cited as a result of this survey.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of the inspection. The facility was cited for violations as a result of this complaint investigation survey.
Report Facts
Licensed Bed Capacity: 160
Census: 139
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anna Durkovic | Administrator | Personnel contacted during inspection |
| Kara Taylor | Director of Nursing | Personnel contacted during inspection |
| Danuta Bruzas | RN | Report submitted by |
| Aneta Predka | Signature of FLIS Staff | |
| Connie Greene | Supervisor | Supervisor of inspection |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 160
Deficiencies: 0
Date: Nov 1, 2022
Visit Reason
The inspection was conducted as a complaint investigation referenced by Complaint Investigation #33184 to determine compliance with regulatory requirements.
Complaint Details
Complaint Investigation Survey, ACTS Reference Numbers CT# 33184, was conducted to determine compliance with 42 CFR Part 483 requirements for long term care facilities. Deficiencies were cited as a result of this survey.
Findings
Deficiencies were cited as a result of the complaint investigation survey conducted at the facility on 11/1/22.
Report Facts
Licensed Bed Capacity: 160
Census: 141
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anna Durkovic | Administrator | Personnel contacted during inspection |
| Jacquelyn Harris | Survey Team Leader | Conducted and signed the inspection report |
| Meg McKinney | Supervisor | Supervisor of the survey team |
Inspection Report
Renewal
Census: 139
Capacity: 160
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
The inspection was conducted as a licensing inspection for renewal purposes at Cambridge Health & Rehab.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anna Durkovic | Administrator | Personnel contacted during the inspection |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Jan 28, 2021
Visit Reason
An unannounced visit was made to Cambridge Health And Rehabilitation Center on January 28, 2021, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a Covid-19 focused infection control survey.
Findings
The inspection identified violations related to food storage and sanitation practices in the kitchen, including unlabeled and undated food items in the refrigerator, improper sanitizing procedures, and failure to discard expired foods. The Administrator and dietary staff acknowledged these issues and facility policies were reviewed to ensure proper food safety and sanitizing protocols.
Deficiencies (3)
Food items in the refrigerator were not labeled or dated, including applesauce bowls, bowls with pureed peaches, cottage cheese, salad mix, and Parmesan cheese with expired or missing dates.
Sanitizing procedures were inadequate; test strips for sanitizer were not used correctly, resulting in sanitizer concentration below required levels.
Dietary staff lacked a schedule to discard expired, unlabeled, or undated food items and failed to test sanitizer water before use.
Report Facts
Date of inspection: Jan 28, 2021
Plan of correction submission deadline: Mar 11, 2021
Sanitizer concentration: 200
Sanitizer concentration tested: 100
Expiration date of cottage cheese: Jan 23, 2021
Expiration date of Parmesan cheese: Jan 19, 2021
Plan of correction compliance date: Feb 22, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed the notice letter regarding the inspection |
| Anna Durkovic | Administrator | Named as facility administrator and referenced in findings |
| Cook #1 | Interviewed and observed during inspection regarding food handling and sanitizing | |
| RN #1 | Observed and interviewed during inspection regarding sanitizing procedures |
Inspection Report
Routine
Census: 132
Capacity: 160
Deficiencies: 1
Date: Jan 28, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to determine compliance with infection control regulations for Long Term Care Facilities, including proper infection prevention and control practices to prevent COVID-19 transmission.
Findings
The facility failed to discard expired food items, failed to label and date food items properly, and did not maintain proper sanitizer levels in the kitchen's 3-bay sink. Deficiencies were observed in food storage, labeling, and sanitizing practices.
Deficiencies (1)
Failed to discard expired food items and date items in containers ready for serving; items without date and/or label were not discarded.
Report Facts
Capacity: 160
Census: 132
Sanitizer PPM: 100
Sanitizer PPM: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook #1 | Cook | Responsible for food labeling, discarding expired food, and sanitizing pots and pans; involved in observations and interviews regarding deficiencies. |
| RN #1 | Infection Control Nurse | Participated in kitchen tour and observations during infection control visit. |
| Administrator | Administrator | Interviewed regarding education plans for dietary staff and facility policies. |
Inspection Report
Routine
Deficiencies: 2
Date: May 15, 2020
Visit Reason
An unannounced visit was conducted on May 15, 2020, at Cambridge Health And Rehabilitation Center by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a COVID-19 focused infection control survey.
Findings
The facility failed to ensure infection control standards were followed during visitor entry and screening practices and failed to ensure the proper use of PPE according to facility policy. Specific observations included improper cleaning and disinfection of a tympanic thermometer and staff not wearing face shields or adequate eye protection as required.
Deficiencies (2)
Failure to ensure infection control standards during visitor entry and screening, including improper cleaning and disinfection of a tympanic thermometer.
Staff observed not wearing face shields or adequate eye protection while in the building as required by facility policy and interim COVID-19 guidance.
Report Facts
Staff observed without face shield: 4
Temperature check observation time: 720
Temperature check observation time: 805
Plan of correction submission deadline: Jun 5, 2020
Compliance monitoring end date: Jun 15, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alice M. Martinez | Supervising Nurse Consultant | Signed the notice letter from the Facility Licensing and Investigations Section. |
| Anna Durkovic | Administrator | Addressee of the notice letter. |
| Director of Maintenance | Observed improperly disinfecting tympanic thermometer and unaware of disinfection requirements. | |
| Director of Nursing Services | Interviewed regarding staff PPE use and infection control practices. |
Inspection Report
Renewal
Census: 133
Capacity: 160
Deficiencies: 1
Date: Feb 3, 2020
Visit Reason
The inspection was conducted as a renewal licensing inspection with multiple onsite inspection dates in early February 2020.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection, as noted in an attached violation letter. The report also references a focused infection control inspection later in the year with no violations found.
Deficiencies (1)
Failure to ensure infection control standards were followed during visitor entry and screening practices, including improper use of PPE and inadequate cleaning of medical devices such as tympanic thermometers.
Report Facts
Licensed Bed Capacity: 160
Census: 133
Inspection Dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anna Durkovic | Administrator | Personnel contacted during inspection |
| Donna Dwyer | Interim DNS | Personnel contacted during inspection |
| Scott Kegley | DNS | Personnel contacted during focused infection control inspection |
| Alice M. Martinez | Supervising Nurse Consultant | Author of the notice of noncompliance letter |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Aug 30, 2019
Visit Reason
This document is a plan of correction submitted by Cambridge Health & Rehabilitation Center in response to alleged violations cited during a regulatory inspection.
Findings
The plan addresses multiple alleged deficient practices including timely provision of ice cream, notification of family members regarding psychotropic medication changes, completion of significant change MDS, quarterly assessments, accurate gender status coding, and food service safety. The facility outlines education, auditing, and monitoring plans to achieve compliance by 9/3/19.
Deficiencies (7)
Facility provided ice cream in timely manner
Notification of family members when psychotropic medication is changed and/or initiated
Completion of significant change MDS within 14 days of initiation of hospice services
Completion of quarterly assessments as required
Accurate coding of gender status in assessments
Education on PASRR process and auditing of residents with new psychotic diagnosis
Education and auditing of food service safety including storage, preparation, and serving
Report Facts
Compliance deadline: Sep 3, 2019
Audit frequency: 3
Audit duration: 4
Audit duration: 3
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anna Durkovic | LNHA | Submitted the plan of correction |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 160
Deficiencies: 9
Date: Jul 22, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to multiple complaints (CT #25016, CT #24775, CT #25725) and included a renewal licensing inspection and desk audit.
Complaint Details
Complaint investigation was conducted for complaints CT #25016, CT #24775, and CT #25725. The investigation found multiple deficiencies related to medication notification, abuse and neglect policies, and resident care. The allegations were substantiated with corrective actions required.
Findings
The facility was found to have multiple deficiencies related to resident care, medication administration, abuse and neglect policies, and documentation. Several residents were reviewed for changes in condition, abuse, neglect, and discharge planning. The facility failed to notify responsible parties of medication changes, failed to follow abuse prohibition policies, and had issues with food service safety. Plans of correction were submitted addressing these deficiencies.
Deficiencies (9)
Failure to notify responsible party of change in medication for residents.
Failure to follow and implement abuse prohibition policy.
Failure to report an allegation of abuse/neglect to the state agency.
Failure to thoroughly investigate an allegation of abuse/neglect.
Failure to ensure resident had required adaptive equipment upon discharge.
Failure to submit resident MDS assessment data within required timeframes.
Failure to submit accurate assessment of resident's gender status.
Failure to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Facility provided ice cream in a timely manner.
Report Facts
Licensed Bed Capacity: 160
Census: 150
Complaint Numbers: 3
Inspection Dates: 2019-07-22 to 2019-07-25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Starzman | Director of Nursing Services (DNS) | Personnel contacted during inspection and named in medication notification findings. |
| Ann Durkovic | Administrator | Personnel contacted during inspection and named in plan of correction submissions. |
| Connie Greene | Supervising Nurse Consultant | Signed important notice and correspondence related to complaint investigation. |
| Karen Gworek | Supervising Nurse Consultant | Signed letter regarding plan of correction acceptance. |
Inspection Report
Renewal
Census: 152
Capacity: 160
Deficiencies: 0
Date: May 22, 2018
Visit Reason
The inspection was conducted as a licensing inspection with a renewal purpose.
Findings
The report indicates that violations were identified and an amended letter was issued on 2018-08-06. A desk audit was also conducted during the inspection.
Report Facts
Licensed Bed Capacity: 160
Census: 152
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anna Durkovic | Administrator | Personnel contacted during the inspection |
| Sheryl Bilyard | DNS | Personnel contacted during the inspection |
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Plan of Correction Cambridge state poc 7 30 24 without vl
Visit Reason
This document is a Plan of Correction submitted by Cambridge Health & Rehabilitation Center in response to alleged violations of Connecticut State Agencies regulations.
Findings
The plan addresses multiple alleged deficient practices involving residents and staff, including issues related to advance directives, medication administration, fall care plans, neurological checks, pressure ulcer assessments, feeding assistance, oxygen therapy, controlled substance handling, pharmacy medication review, dental services, and fall risk evaluations. Licensed nurses and staff were educated, and audits will be conducted to ensure compliance.
Deficiencies (12)
Alleged deficient practice related to advance directive forms and CPR.
Alleged deficient practice related to medication changes and notification.
Alleged deficient practice related to updating and auditing fall care plans.
Alleged deficient practice related to medication pass policy and audits.
Alleged deficient practice related to neurological checks, vital signs monitoring, and blood sugar/HgA1c monitoring.
Alleged deficient practice related to pressure ulcer assessments and air mattress settings.
Alleged deficient practice related to feeding assistance provided to dependent residents.
Alleged deficient practice related to oxygen therapy administration and tubing connection.
Alleged deficient practice related to controlled substance handling and drug count documentation.
Alleged deficient practice related to pharmacy medication review and nicotine cravings management.
Alleged deficient practice related to dental services and lost denture resolution.
Alleged deficient practice related to fall risk evaluation and assessment accuracy.
Report Facts
Audit frequency: 10
Audit frequency: 5
Audit frequency: 5
Audit frequency: 5
Audit frequency: 10
Audit frequency: 5
Audit frequency: 5
Audit frequency: 2
Audit frequency: 5
Audit frequency: 5
Audit frequency: 5
Audit frequency: 5
Audit frequency: 2
Audit frequency: 5
Audit frequency: 5
Audit frequency: 5
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Nov 24, 2025
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Jan 14, 2025
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Oct 9, 2024
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Jul 30, 2024
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Apr 30, 2024
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Oct 17, 2023
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Feb 16, 2022
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Jul 25, 2019
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