Inspection Reports for Cambridge Post Acute Care Center
2020 MCGEE ROAD, SNELLVILLE, GA, 30078
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 27, 2025, found that all previously cited Life Safety Code deficiencies had been corrected. Earlier inspections, including a February 10, 2025 survey, cited multiple deficiencies related to medication management, care planning, employee reference checks, labeling of resident care items, and unsafe hot water temperatures. Prior complaint investigations were mostly unsubstantiated, though some substantiated complaints led to citations for infection control and medication errors without enforcement actions or fines listed in the available reports. The facility also had past Life Safety Code issues involving fire alarm and smoke barrier door maintenance, which were addressed by the latest revisit. The trend shows improvement with recent revisits confirming correction of prior deficiencies.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
7.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
136 residents
Based on a March 2025 inspection.
Census over time
Inspection Report
Life Safety
Deficiencies: 0
Date: Mar 27, 2025
Visit Reason
A Life Safety Code Revisit was conducted to verify correction of previously cited Life Safety Code deficiencies.
Findings
All previously cited Life Safety Code deficiencies had been corrected.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 26, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Cambridge Post Acute Care Center following a regulatory inspection.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Follow-Up
Census: 136
Deficiencies: 0
Date: Mar 26, 2025
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the Recertification Survey on February 10, 2025.
Findings
All deficiencies cited during the February 10, 2025 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Annual Inspection
Census: 141
Deficiencies: 6
Date: Feb 10, 2025
Visit Reason
The inspection was conducted as a State Licensure survey from February 8 through February 10, 2025, to determine compliance with the State Long Term Care Requirements.
Findings
The facility was cited for multiple deficiencies including failure to obtain reference checks for new employees, unlabeled and uncovered resident basins, urinals, and bedpans in shared rooms, medication errors exceeding the acceptable rate, unsecured medications at residents' bedsides, lack of comprehensive person-centered care plans for certain residents, and unsafe hot water temperatures in resident rooms.
Deficiencies (6)
Failed to obtain reference checks for five of seven employees hired in the past four months.
Residents' basins, urinals, and bedpans were not labeled and covered in 11 of 69 shared rooms, risking cross-contamination.
Medication error rate was 7.69% for one resident, exceeding the facility's policy threshold of less than 5%.
Three residents had unauthorized and unsecured medications at the bedside, creating potential for medication errors and unauthorized access.
Failed to develop comprehensive person-centered care plans for two residents related to MRSA infection and oxygen therapy.
Hot water temperatures in four residents' rooms exceeded safe levels, reaching up to 119.4 degrees Fahrenheit.
Report Facts
Facility census: 141
Medication error rate: 7.69
Number of shared rooms with unlabeled items: 11
Number of residents with unsecured medications: 3
Number of residents without comprehensive care plans: 2
Hot water temperature range: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Named in medication error finding related to incorrect medication dosage and insulin pen administration |
| Human Resources Director | Confirmed failure to complete reference checks for new hires | |
| Administrator | Stated expectation for Department Managers to conduct reference checks | |
| Director of Nursing | Director of Nursing (DON) | Provided expectations on medication administration and care planning |
| LPN HH | Licensed Practical Nurse | Confirmed resident was not assessed for self-administration of medications |
| LPN DD | Licensed Practical Nurse | Confirmed presence of unauthorized eye drop medication at resident bedside |
| LPN/MDS Coordinator BB | Licensed Practical Nurse / MDS Coordinator | Acknowledged oversight in care planning for infection and oxygen therapy |
| Maintenance Director | Conducted hot water temperature measurements |
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 5
Date: Feb 10, 2025
Visit Reason
A standard survey was conducted from February 8 through February 10, 2025, including investigation of multiple complaint intake numbers related to the facility's compliance with Medicare/Medicaid regulations.
Complaint Details
The survey included investigation of Complaint Intake Numbers GA00253693, GA00253061, GA00251722, GA00250117.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to secure medications at bedside for three residents, lack of comprehensive care plans for two residents, improper oxygen therapy administration and maintenance for four residents, medication administration errors for one resident, and failure to label and cover basins, urinals, and bedpans in shared rooms.
Deficiencies (5)
Failure to ensure three residents did not have unauthorized and unsecured medications at bedside, risking medication errors and unauthorized access.
Failure to develop comprehensive person-centered care plans for two residents related to MRSA and oxygen therapy.
Failure to administer oxygen therapy according to physician orders and maintain clean oxygen concentrator filters for four residents.
Medication error rate exceeded five percent for one resident, including incorrect dosage of Linzess and failure to prime insulin pen needle before administration.
Failure to ensure residents' basins, urinals, and bedpans were labeled and covered in 11 of 69 shared rooms, risking cross-contamination.
Report Facts
Residents present: 141
Medication error rate: 7.69
Medication errors: 2
Medication opportunities: 26
Oxygen liters per minute: 2
Oxygen liters per minute observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Administered incorrect medication dosage and failed to prime insulin pen needle |
| LPN HH | Licensed Practical Nurse | Confirmed resident R113 was not assessed for self-administration of medications and observed medication on bedside |
| LPN DD | Licensed Practical Nurse | Confirmed presence of eye drop medication on bedside and responsibility for oxygen equipment cleaning |
| DON | Director of Nursing | Provided statements on medication administration expectations and oxygen therapy policies |
| ADON | Assistant Director of Nursing | Confirmed medication removal from bedside and facility policies on self-administration |
| LPN/MDS Coordinator BB | Licensed Practical Nurse / MDS Coordinator | Acknowledged oversight in care planning for infection and oxygen therapy |
| LPN CC | Licensed Practical Nurse | Confirmed oxygen concentrator filter conditions and oxygen flow discrepancies |
| ICP | Infection Control Preventionist | Observed unlabeled and uncovered basins, urinals, and bedpans in shared bathrooms |
| CNA GG | Certified Nursing Assistant | Unaware of resident's self-medication status |
Inspection Report
Life Safety
Census: 143
Capacity: 144
Deficiencies: 2
Date: Feb 9, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and related NFPA standards at Cambridge Post Acute Care Center.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failures in fire alarm system maintenance and smoke barrier door functionality, which could place residents at risk during fire or smoke events.
Deficiencies (2)
Fire alarm system was not maintained in reliable working order; multiple smoke detectors were not reporting to the Fire Alarm Control Panel and a ground fault was detected on Circuit E 26.
Smoke barrier doors on C Hall did not close completely upon activation.
Report Facts
Residents at risk due to fire alarm deficiencies: 60
Residents at risk due to smoke door deficiencies: 30
Census: 143
Total licensed beds: 144
Number of smoke detectors not reporting: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire alarm system and smoke door deficiencies during facility tour and record review. |
Inspection Report
Follow-Up
Census: 132
Deficiencies: 0
Date: Sep 12, 2024
Visit Reason
A revisit survey was conducted on 9/12/2024 in conjunction with a complaint investigation related to Complaint GA00248758.
Complaint Details
Complaint GA00248758 was investigated and found to be unsubstantiated.
Findings
The complaint investigation was found to be unsubstantiated, and all deficiencies cited during the 7/9/2024 complaint survey were corrected.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 12, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for the Cambridge Post Acute Care Center following a regulatory inspection.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.
Inspection Report
Re-Inspection
Census: 132
Deficiencies: 0
Date: Sep 12, 2024
Visit Reason
A revisit survey was conducted on 9/12/2024 to investigate Complaint Intake Number GA00248758 in conjunction with this revisit survey.
Complaint Details
Complaint Intake Number GA00248758 was investigated and found unsubstantiated.
Findings
All deficiencies cited as a result of the 7/9/2024 Complaint Survey were found to be corrected. The complaint investigation was found to be unsubstantiated.
Inspection Report
Annual Inspection
Census: 136
Deficiencies: 5
Date: Jul 9, 2024
Visit Reason
The inspection was conducted as a Licensure Survey from July 1, 2024 through July 9, 2024 to assess compliance with state regulations for the healthcare facility.
Findings
The facility was found deficient in multiple areas including failure to provide written bed-hold policy information to residents transferred to hospitals, lack of competency documentation for Certified Medication Technicians administering insulin, presence of expired insulin vials on medication carts, failure to implement enhanced barrier and transmission-based precautions for infection control, and failure to provide or document pneumonia vaccination for a resident.
Deficiencies (5)
Failed to provide written information about the facility's bed-hold policy to residents or their representatives upon hospital transfer.
Failed to provide evidence that three of five Certified Medication Technicians were competent to administer insulin before allowing them to do so.
Expired insulin vials were found on two medication carts, risking administration of ineffective medication.
Failed to ensure enhanced barrier precautions and transmission-based precautions were implemented, including lack of PPE availability and signage for residents requiring such precautions.
Failed to provide education, offer, or provide pneumonia vaccination for one resident, with no documentation of vaccination or refusal.
Report Facts
Census: 136
Certified Medication Technicians: 5
CMTs lacking insulin competency documentation: 3
Bed hold days for Medicaid residents: 7
Bed hold days for therapeutic leave: 8
Date of inspection completion: Jul 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Minimum Data Set (MDS) Coordinator | Interviewed regarding bed-hold policy communication |
| MM | Certified Medication Technician | Interviewed about insulin administration competency; lacked completed checklist |
| LL | Certified Medication Technician | Interviewed about insulin administration competency; unaware of need for nurse verification |
| FF | Certified Medication Technician | Interviewed about insulin administration competency; checklist not signed |
| SDC | Staff Development Coordinator | Unable to provide competency documentation for CMT insulin administration |
| JJ | Licensed Practical Nurse | Observed medication cart with expired insulin vial |
| II | Licensed Practical Nurse | Observed medication cart with insulin vial lacking open/use date |
| Pharmacist | Reported ongoing problem with expired insulin on medication carts | |
| CC | Licensed Practical Nurse | Observed providing wound care without gown; unaware of enhanced barrier precautions |
| FF | Certified Nurse Aide | Placed PPE and signage for transmission-based precautions late after resident admission |
| UM | Unit Manager | Unaware of resident MRSA status and delayed implementation of precautions |
| ICP | Infection Control Preventionist | Responsible for signage placement; was absent during some observations |
| HH | Licensed Practical Nurse Unit Manager | Unaware of pneumonia vaccination status for resident R18 |
| Administrator | Acknowledged issues found during inspection | |
| DON | Director of Nursing | Confirmed residents and families were not advised of bed-hold policy; stated expired meds should be removed immediately |
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 12
Date: Jul 9, 2024
Visit Reason
A Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended survey investigating multiple complaint numbers initiated on 7/1/2024 and concluded on 7/9/2024.
Complaint Details
The survey was initiated to investigate multiple complaint numbers related to infection control and other concerns. Deficiencies were cited related to complaints GA00246398, GA00231635, GA00243015, GA00237349, GA00232155, GA00244971, GA00244898, and GA00231567. No deficiencies were cited related to other complaint numbers listed.
Findings
The facility was found not in compliance with infection control regulations and had multiple deficiencies including failure to provide bed hold policy information, incomplete care plans for communication needs, failure to revise care plans for pressure ulcers, incompetent medication aides administering insulin, missed medication doses, insulin administration errors, expired medications on carts, inadequate infection control precautions, deficient antibiotic stewardship, incomplete immunization documentation, and unsafe environmental conditions.
Deficiencies (12)
Failed to provide written information about the facility's bed-hold policy to residents or representatives upon hospital transfer.
Failed to develop comprehensive care plans addressing communication needs for residents with hearing loss and language barriers.
Failed to revise care plan related to sacral pressure ulcer interventions.
Failed to ensure Certified Medication Technicians were competent to administer insulin before allowing them to do so.
Failed to ensure medications were administered as ordered, including missed doses of inhalers, atorvastatin, and pregabalin.
Failed to ensure insulin was administered as ordered with multiple documentation discrepancies and missed doses.
Failed to remove expired insulin vials from medication carts.
Failed to ensure enhanced barrier precautions and transmission-based precautions were implemented with PPE readily available for residents requiring them.
Failed to assess clinical indications for antibiotic use and implement antibiotic stewardship protocols for residents on antibiotics.
Failed to ensure pneumonia vaccination was offered, provided, or refused with documentation for a sampled resident.
Failed to provide education, offer, or document Covid-19 vaccination or refusal for a sampled resident.
Failed to maintain a safe, functional, sanitary, and comfortable environment including bulking wallpaper, water-stained ceiling tiles, cat hair and urine odor on porch, and trash on exterior grounds.
Report Facts
Resident census: 136
Missed inhaler doses: 20
Missed atorvastatin doses: 13
Missed pregabalin doses: 7
Insulin missed administrations: 16
Insulin missed administrations: 4
Insulin missed administrations: 2
Insulin missed administrations: 5
Insulin missed administrations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Minimum Data Set Coordinator | Stated no written or verbal bed hold information given to residents/families |
| NN | Certified Nurse Aide | Confirmed resident R18 did not speak English and staff used hand gestures |
| AA | Activity Assistant | Staff interpreter for resident R26, unaware of communication boards |
| MM | Certified Medication Technician | No competency checklist for insulin administration |
| LL | Certified Medication Technician | Unaware insulin dosage must be verified by licensed nurse |
| FF | Certified Medication Technician | Uncertain about yearly insulin competencies |
| SDC | Staff Development Coordinator | No competency documentation for CMT insulin administration |
| DON | Director of Nursing | Confirmed no bed hold info given, surprised by insulin administration issues |
| NP | Nurse Practitioner | Acknowledged medications not administered on time |
| ICP | Infection Control Preventionist | No infection surveillance or antibiotic stewardship training, unaware of McGreer criteria |
| UM | Unit Manager | Unaware resident R20 required enhanced barrier precautions on admission |
| JJ | Licensed Practical Nurse | Confirmed expired insulin vial used on medication cart |
| II | Licensed Practical Nurse | Confirmed insulin vial without open date used on medication cart |
| ED | Environmental Director | Confirmed trash and cat hair issues on facility exterior |
| HH | Licensed Practical Nurse Unit Manager | Unaware of resident R18 pneumonia vaccination status |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 6, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00232941.
Complaint Details
Complaint #GA00232941 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 1, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for the Cambridge Post Acute Care Center following a regulatory inspection.
Findings
The report contains a summary statement of deficiencies identified during the inspection; however, no specific deficiencies or severity levels are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 122
Deficiencies: 0
Date: Feb 1, 2023
Visit Reason
A revisit was conducted to verify correction of deficiencies cited in the prior survey that concluded on December 8, 2022.
Findings
All deficiencies cited in the previous survey were found to be corrected during the revisit.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 8, 2022
Visit Reason
A State Licensure Survey was conducted from December 6, 2022 through December 8, 2022 to determine compliance with State Long Term Care Requirements.
Findings
There were no deficiencies cited during the survey.
Inspection Report
Routine
Census: 116
Deficiencies: 3
Date: Dec 8, 2022
Visit Reason
A standard survey was conducted at Cambridge Post-Acute Care Center from December 6 through December 8, 2022, including investigation of multiple complaint intake numbers, all of which were unsubstantiated.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey; all complaints were unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including inaccurate Minimum Data Set (MDS) assessments for weight loss, failure to complete level two PASRR assessments for a resident with serious mental illness, and failure to accurately document medication administration records for intravenous fluids.
Deficiencies (3)
Failed to ensure MDS assessments were accurate for weight loss for one resident (R#54), including a coding error indicating the resident was on a prescribed weight loss program when they were not.
Failed to ensure one resident (R#30) was assessed for level two Preadmission Screening/Resident Review (PASRR), potentially affecting appropriate care.
Failed to ensure licensed nursing staff accurately documented medication administration record for one resident (R#25) receiving intravenous fluids as per physician's order.
Report Facts
Resident census: 116
Residents reviewed for MDS accuracy: 39
Residents reviewed for IV fluids/medications: 3
IV fluids order: 2
IV fluids rate: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | MDS Coordinator | Confirmed coding error for Section K of MDS for resident R#54 |
| Director of Nursing | Stated expectations for accurate MDS coding and nursing documentation; counseled nurse for failure to document IV fluids | |
| Social Services Director | Reported not responsible for PASRR applications and reviewed PASRR submission records | |
| Admission Director | Reported hospital completes PASRR Level 1 applications and she uploads them | |
| Nurse Practitioner | Wrote physician order for IV fluids for resident R#25 |
Inspection Report
Life Safety
Census: 121
Capacity: 144
Deficiencies: 0
Date: Dec 7, 2022
Visit Reason
The visit was conducted to perform a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found to be in compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in compliance with 42 CFR &483.73.
Inspection Report
Abbreviated Survey
Census: 116
Deficiencies: 0
Date: Nov 18, 2021
Visit Reason
A Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00216812, #GA00216579, and #GA00215721.
Complaint Details
Complaint #GA00216812 and #GA00216579 were unsubstantiated with no deficiencies cited. Complaint #GA00215721 was substantiated with no deficiencies cited.
Findings
Complaints #GA00216812 and #GA00216579 were unsubstantiated with no deficiencies cited. Complaint #GA00215721 was substantiated with no deficiencies cited. The facility was found to be in compliance with infection control regulations and COVID-19 preparedness requirements.
Report Facts
Resident Census: 116
Inspection Report
Deficiencies: 0
Date: Aug 3, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection conducted at Cambridge Post Acute Care Center.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 112
Deficiencies: 0
Date: Aug 3, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the July 1, 2021 Standard Survey.
Findings
All deficiencies cited in the previous July 1, 2021 Standard Survey were found to be corrected during this revisit survey.
Inspection Report
Renewal
Deficiencies: 1
Date: Jul 1, 2021
Visit Reason
A licensure survey was conducted from 6/29/2021 through 7/1/2021 to assess compliance with facility regulations and identify any deficiencies.
Findings
The facility failed to obtain a Physician's Order for the use of bed rails for one of three sampled residents (Resident #52), which is required by the facility's Bed Rail Safety Policy. Observations and interviews confirmed the bed rails were in use without a physician's order.
Deficiencies (1)
Failure to obtain a Physician's Order for the use of bed rails for Resident #52.
Report Facts
Deficiency sample size: 3
Dates of survey: 6/29/2021 through 7/1/2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Occupational Therapy Assistant | COTA | Interviewed regarding bed rail assessment for Resident #52 |
| Administrator | Interviewed jointly with Director of Nursing about missing Physician Order | |
| Director of Nursing | DON | Interviewed jointly with Administrator about missing Physician Order |
Inspection Report
Annual Inspection
Census: 116
Deficiencies: 1
Date: Jul 1, 2021
Visit Reason
A recertification survey was conducted at Cambridge Post-Acute Care Center from June 28, 2021 through July 1, 2021 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to obtain a Physician's Order for the use of bed rails for one sampled resident (Resident #52), despite policy requirements and assessments indicating the need for bed rails.
Deficiencies (1)
Failure to obtain a Physician's Order for the use of bed rails for Resident #52.
Report Facts
Resident census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Occupational Therapy Assistant (COTA) | Interviewed regarding bed rail assessment for Resident #52 | |
| Administrator | Joint interview regarding missing Physician Order for bed rails | |
| Director of Nursing (DON) | Joint interview regarding missing Physician Order for bed rails |
Inspection Report
Life Safety
Census: 111
Capacity: 144
Deficiencies: 0
Date: Jun 30, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and related NFPA 101 Life Safety Code standards.
Findings
The facility was found to be in compliance with the Emergency Preparedness Program requirements and Life Safety Code standards as of the survey date.
Report Facts
Certified beds: 144
Census: 111
Inspection Report
Abbreviated Survey
Census: 107
Deficiencies: 0
Date: May 27, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00213818 and #GA00212400.
Complaint Details
Complaint #GA00213818 was unsubstantiated. Complaint #GA00212400 was substantiated with no regulatory violations cited.
Findings
Complaint #GA00213818 was unsubstantiated with no regulatory violations cited. Complaint #GA00212400 was substantiated but with no regulatory violations cited.
Inspection Report
Abbreviated Survey
Census: 106
Deficiencies: 0
Date: Feb 5, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00210094, #GA00209001, and #GA00204905.
Complaint Details
Complaints #GA00210094, #GA00209001, and #GA00204905 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Routine
Census: 119
Deficiencies: 0
Date: Jan 5, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and 42 CFR 483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 13, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00208039 and GA00208129.
Complaint Details
Complaints #GA00208039 and GA00208129 were investigated and found to be unsubstantiated.
Findings
The complaints #GA00208039 and GA00208129 were found to be unsubstantiated following the investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 31, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00202540.
Complaint Details
Complaint #GA00202540 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 117
Deficiencies: 0
Date: Jul 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and CDC recommended practices related to COVID-19.
Complaint Details
Complaint #204905 was submitted anonymously with allegations reviewed during the survey; no deficiencies were found related to this complaint.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices. No deficiencies were cited related to the complaint investigated.
Inspection Report
Routine
Census: 117
Deficiencies: 0
Date: Jul 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations for COVID-19.
Report Facts
Total census: 117
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 27, 2019
Visit Reason
A complaint survey was conducted on 8/27/2019 to investigate a complaint by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint was unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Re-Inspection
Census: 130
Deficiencies: 0
Date: Mar 18, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the Abbreviated Survey of 1/25/19.
Findings
All deficiencies cited in the prior abbreviated survey were found to be corrected during this revisit survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 20, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint numbers GA00194765 and GA00194592.
Complaint Details
Complaint numbers GA00194765 and GA00194592 were investigated and found to be unsubstantiated.
Findings
The complaints investigated during the survey were found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Census: 130
Deficiencies: 2
Date: Jan 25, 2019
Visit Reason
An abbreviated survey was conducted from January 7, 2019 through January 25, 2019 to investigate complaints GA00193238 and GA00193024 and to assess compliance with Medicare/Medicaid regulations.
Complaint Details
The survey was conducted in response to complaints alleging possible physical abuse and inadequate care. The allegation of abuse was investigated and found unsubstantiated but was not reported to the State Agency as required.
Findings
The facility was found not in substantial compliance with federal regulations, including failure to report an allegation of physical abuse to the State Agency and failure to provide timely activities of daily living (ADL) care to five residents, resulting in unmet toileting and hydration needs.
Deficiencies (2)
Failure to report an allegation of physical abuse to the State Agency for one resident.
Failure to provide timely ADL care to five residents, including assistance with toileting and hydration.
Report Facts
Resident census: 130
Residents affected: 5
Sample size: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Conducted investigation of abuse allegation and confirmed failure to report to State Agency. |
| Administrator | Administrator and Abuse Coordinator | Received abuse allegation and confirmed it was not reported to State Agency. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 25, 2019
Visit Reason
The inspection was conducted following complaints regarding inadequate nursing care, specifically delays in staff responding to call lights and assistance with toileting for residents.
Complaint Details
The visit was complaint-related based on multiple resident and family member reports of delayed toileting assistance, inadequate hydration, and poor hygiene care. Complaints were also made to the Ombudsman and resident council meetings. No formal grievances were filed by residents.
Findings
The investigation found multiple residents experiencing delays of 30 minutes to over an hour in receiving toileting assistance, inadequate hydration, and insufficient staffing levels. Several residents and family members reported frequent incontinence and lack of timely help, contributing to urinary tract infections and poor hygiene.
Deficiencies (3)
Failure to provide timely assistance to residents for toileting needs, resulting in prolonged waiting times and incontinence.
Inadequate staffing levels impacting the ability to meet residents' toileting and hydration needs.
Lack of proper documentation and reassessment regarding discontinuation and restarting of toileting programs.
Report Facts
Call light response time: 40
Call light waiting time: 60
BIMS score: 9
BIMS score: 11
BIMS score: 15
BIMS score: 8
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Mentioned in relation to complaints about toileting and hygiene by resident #4's daughter. |
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 0
Date: Nov 20, 2018
Visit Reason
A revisit survey was conducted in conjunction with an abbreviated survey to investigate complaints GA00192652 and GA00192053.
Complaint Details
Investigation of complaints GA00192652 and GA00192053 found the facility in substantial compliance with regulations.
Findings
All deficiencies from the prior annual survey were corrected. The complaint investigation found the facility to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B.
Report Facts
Resident census: 131
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 0
Date: Nov 20, 2018
Visit Reason
A revisit survey was conducted in conjunction with an abbreviated survey to investigate complaints GA00192652 and GA00192053.
Complaint Details
Investigation of complaints GA00192652 and GA00192053 found the facility in substantial compliance with regulations.
Findings
All deficiencies from the prior annual survey were corrected, and the complaint investigation found the facility to be in substantial compliance with Medicare/Medicaid regulations.
Report Facts
Resident Census: 131
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 15, 2018
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
The follow-up survey noted that all previously cited tags have been corrected.
Inspection Report
Routine
Census: 132
Deficiencies: 8
Date: Sep 27, 2018
Visit Reason
A standard survey was conducted at Cambridge Post Acute Care from September 24, 2018 to September 27, 2018, including investigation of Complaint Intake Number GA00190805.
Complaint Details
Complaint Intake Number GA00190805 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide bed hold policy upon hospital transfer, failure to implement comprehensive care plans for residents, failure to meet professional standards in medication administration, failure to provide assistance with activities of daily living, failure to provide ordered pressure ulcer care, failure to maintain accident prevention interventions, failure to provide nutritional interventions as planned, and failure to maintain communication with dialysis center for coordination of care.
Deficiencies (8)
Failed to provide 'Bed Hold Policy' to six residents transferred to hospital.
Failed to implement comprehensive care plans for three residents, including failure to assist with showers and pressure ulcer care.
Failed to ensure professional standards in medication administration for resident prepared for surgery.
Failed to provide assistance with activities of daily living, including showers, for one resident.
Failed to provide physician ordered care and services for pressure ulcers for two residents.
Failed to provide interventions for fall prevention including proper use of bed and chair alarms for one resident.
Failed to provide nutritional interventions as planned, including fortified foods and feeding assistance for one resident with weight loss.
Failed to maintain communication with dialysis center to coordinate care for one resident receiving dialysis.
Report Facts
Resident census: 132
Sample size: 31
Weight loss: 33
Weight loss percentage: 21
Pressure ulcer size: 7.5
Pressure ulcer size: 5.5
Pressure ulcer size: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Assistant Director of Nursing | Interviewed regarding bed hold policy and shower assistance |
| DD | Licensed Practical Nurse | Worked extra hours on weekend for wound treatments but did not complete all treatments |
| EE | Licensed Practical Nurse / Staffing Coordinator | Reported on weekend nursing coverage and treatment completion |
| JJ | Certified Nursing Assistant | Interviewed regarding resident shower assistance and fall prevention alarms |
| AA | Assistant Director of Nursing | Interviewed regarding wound care and dialysis communication |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including shower assistance, wound care, fall prevention, nutrition, and dialysis communication |
| WCN | Wound Care Nurse | Interviewed and observed wound care procedures |
| WCMD | Wound Care Medical Doctor | Interviewed regarding wound care orders and treatment |
| DM | Dietary Manager | Interviewed regarding nutrition interventions and fortified foods |
| Dietician | Registered Dietitian | Interviewed regarding nutrition monitoring and recommendations |
| LPN HH | Licensed Practical Nurse | Interviewed regarding dialysis communication procedures |
Inspection Report
Routine
Deficiencies: 5
Date: Sep 27, 2018
Visit Reason
Routine inspection of Cambridge Post Acute Care Center to assess compliance with healthcare facility regulations including dietary service, nursing care, wound care, and dialysis care.
Findings
The facility failed to provide adequate nutritional interventions including fortified foods and assistance with meals for a resident with significant weight loss. There were deficiencies in nursing care related to bathing assistance and shower provision. Wound care treatments were not consistently provided as ordered, including missed dressing changes over a weekend. Communication with dialysis centers was inadequate, with missing returned dialysis information forms.
Deficiencies (5)
Failure to provide nutritional interventions as ordered, including fortified foods and assistance with meals for resident with weight loss.
Failure to provide scheduled showers and bathing assistance to resident requiring extensive assistance.
Failure to ensure heel protectors were applied as ordered to prevent pressure ulcers.
Failure to provide wound care treatments and dressing changes as ordered, including missed treatments over a weekend.
Failure to ensure effective communication and documentation between facility and dialysis center regarding resident care.
Report Facts
Weight loss: 33
Weight measurements: 156.6
Weight measurements: 121.3
Wound size: 7.9
Wound size: 4.4
Wound size: 2.5
Wound size: 7.5
Wound size: 5.5
Wound size: 3.5
Dialysis chair time: 9.15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JJ | Certified Nurse Aide | Named in observation and interview regarding feeding assistance for resident #98. |
| BB | Assistant Director of Nursing | Interviewed regarding shower schedule and bathing assistance for resident #10. |
| OO | Certified Nursing Assistant | Interviewed regarding care and shower assistance for resident #10. |
| RR | Certified Nursing Assistant | Observed feeding resident #58 and noted absence of heel protectors. |
| LL | Certified Nursing Assistant | Observed feeding resident #58 and unaware of heel protector use. |
| DD | Licensed Practical Nurse | Worked extra weekend hours and reported incomplete wound treatments for resident #330. |
| EE | Licensed Practical Nurse | Staffing Coordinator who coordinated weekend wound treatment coverage. |
| FF | Registered Nurse | Informed about incomplete wound treatments for resident #330. |
| AA | Assistant Director of Nursing | Interviewed regarding wound care and treatment nurse responsibilities. |
| CC | Licensed Practical Nurse | Assisted with wound care and dressing change for resident #330. |
| HH | Licensed Practical Nurse | Interviewed regarding dialysis communication and transfer form procedures. |
Inspection Report
Life Safety
Census: 131
Capacity: 192
Deficiencies: 5
Date: Sep 25, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with several Life Safety Code requirements, including non-functioning exterior emergency lighting, missing fire alarm strobes in staff/patient restrooms and kitchen, lack of battery-powered emergency lights in mechanical rooms, combustible decorations in patient areas, and inadequate signage for oxygen tank storage.
Deficiencies (5)
Exterior emergency lighting was not working at the ambulance entrance and the entrance to A-Hall.
Fire alarm strobes were not installed in the staff/patient restrooms at the nurses station, therapy room, and main kitchen area.
Flammable fall decorations (scarecrows made of dried corn silk) were hanging on patient doors and within patient sleeping areas.
Battery powered emergency lights were not present in the two mechanical rooms housing generator transfer switches.
Inadequate signage for oxygen tank storage in the clean utility room.
Report Facts
Residents at risk due to non-working exterior emergency lighting: 30
Residents at risk due to missing fire alarm strobes: 10
Residents at risk due to combustible decorations: 131
Residents/staff at risk due to lack of emergency lighting in mechanical rooms: 20
Residents at risk due to inadequate oxygen storage signage: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 15, 2018
Visit Reason
A complaint survey was conducted from 2018-08-14 through 2018-08-16 to investigate complaints GA0018911 and GA00190437 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The complaint was substantiated with no deficiencies cited.
Findings
The complaint was substantiated but no deficiencies were cited during the investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 3, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint GA 00189498 at Cambridge Post Acute Care Center.
Complaint Details
Investigation of complaint GA 00189498; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 28, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00186450 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00186450 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 0
Date: Feb 5, 2018
Visit Reason
An unannounced Complaint Survey was conducted to investigate complaint # GA 00184810 at Cambridge Post Acute Care Center.
Complaint Details
Investigation of complaint # GA 00184810; facility found in substantial compliance.
Findings
The complaint survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 43 for Long Term Care Facilities.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 31, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00184101 at Cambridge Post Acute Care Center on January 30-31, 2018.
Complaint Details
Investigation of complaint GA00184101; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 5, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Annual Inspection
Census: 137
Deficiencies: 0
Date: Oct 19, 2017
Visit Reason
A standard survey was conducted at Cambridge Health and Rehabilitation from October 16, 2017 through October 19, 2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 135
Capacity: 144
Deficiencies: 10
Date: Oct 17, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements including failure to maintain self-closing doors, hazardous area enclosures, fire alarm system installation and maintenance, sprinkler system maintenance, corridor doors, rated walls and ceilings, electrical system maintenance, evacuation and relocation plan updates, and oxygen storage safety.
Deficiencies (10)
Doors with self-closing devices in exit passageways and smoke barriers failed to close upon fire alarm activation.
Facility failed to provide self-closers on all storage room doors.
Fire alarm system installation deficiencies including improperly mounted visual devices, pull stations, and missing smoke detectors.
Fire alarm system testing and maintenance deficiencies including untested devices and unrepaired smoke detectors.
Sprinkler system maintenance deficiencies including corroded and loaded sprinkler heads, wiring and trash on sprinkler pipes, and uncorrected quick opening device failure.
Corridor doors failed to maintain smoke resistant seals and had other maintenance issues.
Facility failed to properly maintain rated walls and ceilings with unprotected penetrations and mixed fire protection products.
Electrical system deficiencies including missing knockouts in junction boxes.
Evacuation and relocation plan was incomplete and not properly updated, missing key elements and copies for supervisory staff.
Oxygen storage area deficiencies including failure to identify full and empty cylinders and improper storage separation.
Report Facts
Residents at risk: 120
Residents at risk: 135
Residents at risk: 135
Residents at risk: 120
Residents at risk: 135
Residents at risk: 15
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 3, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate allegations identified as GA00175755.
Complaint Details
The allegations investigated during this abbreviated survey were unsubstantiated.
Findings
The allegations were unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 23, 2017
Visit Reason
A complaint investigation (GA00174102) was initiated on 4/23/17 and concluded on 4/24/17.
Complaint Details
Complaint investigation GA00174102 was initiated on 2017-04-23 and concluded on 2017-04-24. No deficiencies were cited.
Findings
The facility was in compliance with 42 CFR, Part 483, Subpart B for Long Term Care Requirements for Long Term Care Facilities. No deficiencies were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 25, 2017
Visit Reason
An Abbreviated Survey was conducted to investigate complaints GA00170675 and GA00170983 at Cambridge Post Acute Care Center.
Complaint Details
The complaints GA00170675 and GA00170983 were investigated and found to be not substantiated.
Findings
The complaints were not substantiated and the facility was found to be in compliance with Federal and State Long Term Care Requirements 42 CFR, Part 483, Subpart B.
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