Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cambridge Care Center during CMS and state inspections, most recent first.
Multiple residents were subjected to physical abuse by another resident with cognitive impairment and poor impulse control, who pushed, hit, or kicked others when agitated or crowded, particularly around common areas like the coffee station and smoking area. Despite staff awareness of the resident's unpredictable behaviors and known triggers, incidents of physical aggression occurred repeatedly, and the facility did not consistently recognize these as abuse due to lack of injury or fear in the victims.
A facility failed to provide consistent dialysis care for a resident, not following physician orders, ensuring timely appointments, or completing communication forms. The resident, with multiple health issues, experienced delays due to late transportation, and staff interviews revealed a lack of responsibility for post-dialysis documentation.
A facility failed to effectively plan and implement a discharge for a resident with severe cognitive impairment, leading to potential delays. The resident's representative experienced inconsistent communication and follow-up from facility staff, despite providing lists of potential transfer facilities. Changes in personnel and inadequate documentation contributed to the deficiency.
The facility did not ensure proper discharge procedures for a resident with multiple medical conditions, including UTI, atrial fibrillation, diabetes, history of falls, depression, and anxiety. The resident was discharged without a 30-day notice, ombudsman notification, or necessary home health services for wound care, despite physician orders. The resident was found on the floor of his motel room three days post-discharge, indicating insufficient discharge planning. Staff interviews revealed gaps in coordination and documentation by the social services director, business office manager, DON, and LPN, highlighting financial considerations and assumptions about home health services.
The facility failed to provide a resident with an appropriate written notice of discharge, including reasons for the move, appeal rights, and ombudsman notification. The resident, an 80-year-old with multiple diagnoses, was discharged to a motel without home health services and was later hospitalized. Staff interviews confirmed the lack of proper discharge notice and ombudsman notification.
The facility failed to maintain accurate medical records for a resident, resulting in a discrepancy between the resident's MOST form indicating a wish to receive CPR and the physician's DNR order. Staff interviews revealed lapses in responsibility and auditing processes, contributing to the deficiency.
The facility failed to assist a resident in making appointments and arranging transportation for vision services. Despite the resident's complaints of worsening vision and the need for updated glasses, no follow-up was conducted by the staff to arrange an optometry appointment. Interviews with staff revealed a lack of communication and follow-through regarding the resident's vision needs.
The facility failed to ensure a resident received routine dental care, including obtaining dentures and addressing mild teeth pain. Despite the resident's complaints and requests since admission, there was no evidence that dental services were offered or provided. Staff interviews revealed a lack of awareness and communication regarding the resident's dental needs.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by another resident, resulting in several incidents where residents were pushed, hit, or kicked. In one incident, a resident with severe cognitive impairment and poor impulse control pushed another resident in the dining room, causing her to fall to the ground. The victim was startled and confused but did not sustain visible injuries. The assailant had a documented history of similar behaviors, including a prior physical occurrence, but did not have a behavior care plan at the time of the incident. Staff interviews and record reviews confirmed that the resident's behaviors were known to be unpredictable and triggered by crowded areas, particularly around the coffee station and during smoking breaks. Another incident involved the same resident pushing and hitting a different resident who was blocking his way to the smoking area. Multiple staff and resident interviews confirmed that the assailant became quickly agitated and used physical contact to move others out of his way. Despite these repeated behaviors, the facility's investigations often concluded that the incidents were unsubstantiated as abuse due to the absence of injury, pain, or fear in the victims. However, documentation and witness statements indicated that physical aggression did occur, and the assailant's behaviors were recognized by staff as a recurring issue. A third incident involved the same resident kicking another resident in the leg to get him out of the way at the coffee station. Staff and resident interviews, as well as progress notes, confirmed the physical contact, but again, the facility did not substantiate the incident as abuse due to lack of injury or fear. The assailant's care plan included interventions such as offering coffee, anticipating needs, and keeping other residents clear of him, but not all staff were aware of his triggers. The repeated failure to prevent these incidents and to recognize them as abuse led to the deficiency cited in the report.
Deficiency in Dialysis Care Coordination
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards of practice for a resident requiring such services. Specifically, the facility did not follow the physician's dialysis orders for the resident, failed to ensure the resident consistently attended dialysis appointments on time, and did not thoroughly complete dialysis communication forms between the facility and the dialysis center. These deficiencies were identified for one of the three residents reviewed for dialysis services. The resident in question, who was under 65 years old, had multiple diagnoses including end-stage renal disease, hepatitis C, venous hypertension, congestive heart failure, anemia in chronic kidney disease, and hypertension. The resident expressed a preference for early morning dialysis appointments but reported that transportation arranged by the facility was often late, causing delays in attending scheduled dialysis sessions. The facility's records showed multiple instances where the dialysis communication forms were incomplete, and the resident's late arrivals were noted by the dialysis center. Interviews with facility staff and the dialysis center social worker revealed a lack of communication and responsibility regarding the completion of post-dialysis documentation. The facility's nursing staff did not consistently fill out the necessary sections of the dialysis communication forms, and there was confusion about who was responsible for this task. The facility's nursing home administrator was unaware of the resident's late arrivals and the incomplete documentation until the survey, indicating a breakdown in oversight and communication within the facility.
Inadequate Discharge Planning and Communication
Penalty
Summary
The facility failed to develop and implement an effective discharge plan for a resident, resulting in a potential delay in the resident's discharge to another facility. The facility did not ensure consistent efforts in the discharge planning process, which included a lack of consistent communication with the resident's representative and inadequate documentation of the discharge planning process in the resident's electronic medical record (EMR). The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was admitted with the goal of being discharged to a facility closer to the resident's representative. The resident's representative expressed concerns about the lack of follow-through and inconsistent staff involvement in the discharge process. Despite the representative's efforts to work with various facility staff, including a corporate health plan liaison and an admissions coordinator, there was a lack of communication and updates regarding the status of referrals to other facilities. The representative provided lists of potential facilities for transfer, but there were delays and insufficient follow-up on these referrals, leading to frustration and a prolonged discharge process. Interviews with facility staff revealed that the referral process was not consistently managed, with changes in personnel contributing to the lack of continuity. The facility's social service director and nursing home administrator acknowledged the deficiencies in the discharge planning process, including inadequate documentation and communication with the resident's representative. The facility's corporate consultant also noted that the facility should have documented the discharge efforts more effectively.
Inadequate Discharge Planning and Execution for Resident with Multiple Medical Conditions
Penalty
Summary
The facility failed to ensure a facility-initiated discharge procedure for Resident #140, who had multiple medical conditions including urinary tract infection, atrial fibrillation, diabetes mellitus, history of falling, depression, and anxiety disorder. Despite the resident's refusal to transition to long term care insurance, the facility did not provide adequate preparations for a safe discharge. Resident #140 was found down on the floor of his motel room three days after discharge, indicating a lack of proper discharge planning and execution. Furthermore, the facility did not provide the resident with a 30-day discharge notice and failed to notify the ombudsman of the discharge, as required by regulations. The resident was discharged without necessary home health services for wound care, despite having physician orders for wound care treatment to his feet and toes. The facility also failed to provide and document resident education for wound care or issue wound care supplies at discharge, leading to potential harm to the resident's health and well-being. The staff interviews revealed discrepancies in the actions taken by the social services director, business office manager, director of nursing, and licensed practical nurse involved in the discharge process. The social services director did not contact/refer to home health services, assuming they did not go to motels, and failed to ensure the resident had necessary support systems in place post-discharge. The business office manager mentioned the discharge date was determined by the resident's managed care insurance company, highlighting financial considerations impacting the discharge process. The director of nursing acknowledged gaps in documentation and education provided to the resident, indicating a lack of comprehensive care planning and coordination in the facility's discharge procedures.
Failure to Provide Appropriate Discharge Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide Resident #140 with an appropriate written notice of discharge that included the reasons for the move, the effective date, the location to which the resident was transferred, a statement of the resident's appeal rights, and contact information for the Office of the State. Additionally, the facility did not notify the ombudsman of the discharge. This deficiency was identified through record review and staff interviews, which revealed that the facility did not issue a discharge notice to the resident or notify the ombudsman as required by policy and federal regulations. Resident #140, an 80-year-old with diagnoses including urinary tract infection, atrial fibrillation, type II diabetes mellitus, history of falling, depression, and anxiety disorder, was discharged to a motel without home health services. The resident was cognitively intact with a BIMS score of 15 out of 15 at admission and 14 out of 15 at discharge. The discharge was initiated due to the end of insurance coverage, and the facility paid for the resident's motel stay for three days. However, the resident was found down and admitted to the hospital shortly after being discharged, indicating a lack of proper discharge planning and support. Interviews with the social services director and the regional clinical resource confirmed that the facility did not issue a discharge notice to the resident or notify the ombudsman. The social services summary and nurse notes further corroborated the lack of appropriate discharge planning and notification. The facility's failure to adhere to its own policies and federal regulations resulted in the resident being discharged without adequate support and notification, leading to the resident's subsequent hospitalization.
Discrepancy in Resident's Resuscitation Orders
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the resident's medical orders for scope of treatment (MOST) form and the corresponding physician orders for resuscitation. The resident, who was under 65 years old and had diagnoses including respiratory failure, COPD, and schizoaffective disorder, had a MOST form indicating a wish to receive CPR. However, the electronic medical record had a physician order for do not resuscitate (DNR), creating a discrepancy between the resident's documented wishes and the physician's orders after the resident was readmitted to the facility. Interviews with staff revealed that the admitting nurse was responsible for obtaining signatures for the MOST form, and it was the responsibility of the registered nurse to ensure the forms were filled out completely and accurately. The nursing home administrator noted that the health information manager, a position currently vacant, was responsible for auditing the MOST forms. The director of nursing confirmed that the MOST form should be reviewed and updated if a resident's wishes changed after readmission. Despite monthly audits, the discrepancy between the MOST form and the physician order was not corrected, leading to the deficiency identified in the report.
Failure to Assist Resident with Vision Services
Penalty
Summary
The facility failed to assist a resident in making appointments and arranging transportation for vision services. Specifically, the facility did not offer or make an appointment for optometry services for a resident who had reported vision problems. The resident, who had diagnoses including bipolar disorder, schizoaffective disorder, type 2 diabetes, hypertension, and depression, had moderate cognitive impairment and was independent with eating and toileting. Despite the resident's complaints of worsening vision and the need for updated glasses, no follow-up was conducted by the staff to arrange an optometry appointment. Interviews with staff revealed a lack of communication and follow-through regarding the resident's vision needs. A CNA mentioned that she would inform the nurse if a resident complained about vision issues but admitted it was sometimes hard to remember. An LPN acknowledged the resident's need for glasses and stated she would notify the social services director (SSD) for optometry services. However, the SSD confirmed that there was no documentation indicating the resident or their representative had been offered optometry services since admission. The director of nursing (DON) also confirmed that nursing staff should notify the SSD to place the resident on the ancillary services list but acknowledged the need for staff education on this process.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to ensure that Resident #14 received routine dental care, including obtaining dentures and addressing mild teeth pain. The resident, who had moderate cognitive impairment and several medical conditions including bipolar disorder, schizoaffective disorder, type 2 diabetes, hypertension, and depression, reported having difficulty chewing food due to pain and missing teeth. Despite the resident's complaints and requests for dental care since admission, there was no evidence in the medical records that dental services were offered or provided. The resident's care plan did not include any provisions for dental care or oral hygiene until it was updated during the survey. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's dental needs. The CNA was unsure if the resident had missing teeth or wanted dentures, and the RN mistakenly believed the resident should be referred to the eye doctor instead of the dentist. The SSD admitted that there was no documentation indicating that dental services were offered to the resident since admission. The DON confirmed that nursing staff should notify the physician and SSD for dental concerns but acknowledged the need for staff education on ancillary services.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewater Health And Rehabilitation | 0 mi | ★★★★★ | 14 | 0 |
| Cedars Healthcare Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Sierra Post Acute | 0.3 mi | ★★★★★ | 10 | 0 |
| Harmony Pointe Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Wheatridge Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.