Cambridge Care Center

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Egress Deficiencies

Install proper backup exit lighting.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Quality of Life and Care Deficiencies

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Miscellaneous Deficiencies

Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Based on observations, record review and interviews, the facility failed to ensure three (#8, #6 and #1) of six residents reviewed for abuse out of 12 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #9 from physical abuse by Resident #2; -Protect Resident #6 from physical abuse by Resident #2; and, -Protect Resident #1 from physical abuse by Resident #2. Findings include:.. *** CITATION TEXT NOT FOUND *** A complaint survey, prompted by #CO39907, #CO39909 and Incident #39937 was conducted on 6/16/25 to 6/17/25. One deficiency was cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A complaint survey, prompted by #CO38997, #CO39002, #CO39099, #CO39162 and Incident #39235 was conducted on 2/11/25 to 2/12/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for one (#4) of three residents reviewed for dialysis out of 13 sample residents. Specifically, the facility failed to:-Follow the physician' s dialysis orders for Resident #4;-Consistently get Resident #4 to his dialysis appointments at his scheduled time; and,-Consistently and thoroughly complete dialysis communication forms between the facility and the dialysis center for Resident #4.Findings include:I. Facility policy and procedureThe Hemodialysis Residents Policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 2/11/25 at 12:18 p.m. via email. It revealed in pertinent part,"The facility provides residents with safe, accurate, and appropriate care, assessments and interventions to improve resident outcomes in coordination/collaboration with (the) dialysis center."Review and ensure orders upon admission are received for follow-up dialysis center appointments, shunt care, no BP (blood pressure) in arm that has shunt, diet and fluid restriction (physician discretionary)."A dialysis communication record is initiated and sent to the dialysis center each appointment; ensure it is received upon return."Post Hemodialysis/ongoing care:"Check vital signs post dialysis or per physician' s order. Do not take blood pressure on the arm with dialysis shunt. Monitor for signs of postural hypotension. Instruct the resident to change positions slowly for a short time to avoid dizziness and possible falls."Monitor resident for signs and symptoms of toxic or adverse medication reactions."Documentation:"Dialysis communication record"Key medical record documentation elements: vital signs, pertinent comments related to resident status and weight."II. Resident #4A. Resident statusResident #4, age less than 65, was admitted on 12/23/24. According to the February 2025 computerized physician orders (CPO), diagnoses included end stage renal disease, hepatitis C, venous hypertens..

A complaint survey, prompted by #CO37066, #CO37107 and #CO37240 was conducted on 8/20/24 to 8/21/24. One deficiency was cited. Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#1) of three residents reviewed for discharge planning out of 12 sample residents. Specifically, the facility failed to: -Ensure consistent efforts in the discharge planning process were made, which resulted in the potential delay in Resident #1' s discharge to another facility;-Ensure Resident #1' s representative received consistent communication regarding Resident #1' s discharge planning process; and,-Ensure the discharge planning process was documented in Resident #1' s electronic medical record (EMR).Findings include:I. Facility policy and procedureThe Social Service policy and procedure, dated 8/31/22, was provided by the corporate consultant (CC) on 7/21/24 at 7:30 p.m. via email. The policy read in pertinent part, "Social services members are responsible for planning, organizing, and directing all administrative and operational activities of the social services department in accordance with current federal, state, and local standards, guidelines and regulations, and the facility' s established policies and procedures."Assisting residents in planning for discharge by coordinating service delivery with the nursing staff and by assessing availability and facilitating use of financial and social support services in the community."Coordinating transfers (other than medical transfers) within and out of the facility and assist residents in adjusting to intra-facility transfers."II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on 6/24/21 and readmitted on 7/17/24. According to the August 2024 computerized physician orders (CPO), diagnoses included anoxic brain damage, acute respiratory failure with hypoxia, aphasia, unspecified intracranial injury without loss of consciousness and the need for assistance with personal care.The 7/19/24 minimum data set (MDS) assessment identified the resident had severe cognitive impairment. The staff assessment for mental status revealed the resident had short and long term memory problems...