Inspection Reports for
Cambridge Health and Rehabilitation Center

The complaint investigation focused on allegations of abuse and neglect related to wound care for Resident #2. The complaint was substantiated as the facility failed to transcribe wound care orders correctly and failed to provide treatments as ordered, resulting in incomplete and inaccurate medical records and treatment administration.

The facility failed to ensure wound care orders were accurately transcribed and treatments were provided as ordered for Resident #2, who had a surgical amputation of the right index finger. Multiple errors in transcription and documentation led to missed or refused treatments, inaccurate signing of treatment records, and failure to follow updated hospital wound care orders.

Complaints #42378, #42530, #42574, #42615 were investigated as part of the visit.

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.

The facility failed to ensure timely notification to the physician/designee when an antipsychotic medication was not administered as ordered for Resident #4, and failed to administer oxygen according to physician orders and complete timely assessments for Resident #2 with a change in condition. Staff education and audits were initiated to address these issues.

The complaint involved an allegation that NA #2 poked Resident #4 in the leg and back on 9/30/24. The allegation was investigated and found not substantiated. The DNS confirmed NA #2 did not follow the care plan requiring two staff for care during the incident.

The investigation found that NA #2 did not follow the care plan intervention by assisting Resident #4 to the toilet without another staff member present. However, the allegation of staff to resident abuse was not substantiated. The facility failed to ensure two staff provided care as required by the care plan.

The facility was found deficient in multiple areas including failure to obtain valid advance directives on admission, failure to notify resident representatives of medication changes, medication left unattended at bedside, failure to monitor vital signs and neurological checks after falls, inconsistent administration of specialty medication, delayed feeding assistance, disconnected oxygen tubing, incomplete narcotic counts, failure to discontinue unnecessary medications, and failure to provide timely replacement of lost dentures.

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.

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.

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.

The complaint investigation involved allegations of neglect related to Resident #2 not receiving incontinent care for five hours, and significant medication errors involving Residents #1 and #3. The investigation found substantiated failures in care provision and medication reconciliation.

The facility failed to provide incontinent care to Resident #2 for five hours, failed to monitor intake and output for Resident #3 receiving IV fluids, and failed to reconcile medications for Resident #1 upon readmission, resulting in omitted doses of critical cardiac medications. Facility policies and staff interviews confirmed these deficiencies.

The facility was found deficient in protecting residents from abuse, timely reporting of abuse allegations, developing comprehensive care plans for residents with contractures, and completing annual performance evaluations for nurse aides. Deficiencies involved minimal harm or potential for actual harm affecting a few or some residents.

The facility was found deficient in ensuring diagnostic testing was completed per physician orders for a resident with diarrhea, accurate and consistent monitoring of resident weights, maintaining kitchen cleanliness and proper food labeling, and implementing timely contact precautions for infection control. Deficiencies were generally of minimal harm with some residents affected.

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.

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.

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.

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.

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.

The facility was found deficient in multiple areas including failure to honor resident food preferences, failure to notify responsible parties of medication changes, inadequate investigation and reporting of abuse allegations, failure to complete significant change MDS assessments, failure to refer residents for PASRR evaluations, failure to ensure adaptive equipment availability upon discharge, and food service safety violations including improper food storage temperatures and poor hygiene practices.

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.

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.

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.