Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Housekeeping staff failed to follow infection control procedures while cleaning resident rooms and bathrooms. In two observed rooms, staff did not keep disinfectant wet for the required dwell time, used the toilet brush beyond the toilet bowl, and missed multiple high-touch surfaces such as call lights, door knobs, light switches, grab bars, and bed controls. Interviews confirmed staff knew the correct process, including the need for a three- to five-minute wet contact time and daily disinfection of high-touch areas.
Failure to protect a resident from resident-to-resident physical abuse occurred when one cognitively intact resident struck another resident in the face after being told not to enter the room. The injured resident had a swollen cheek, facial pain, and bruising under the eye, while the other resident had a documented history of wandering into peers’ rooms, seeking cigarettes, and taking items. The behavior care plan did not include interventions for that specific pattern of room entry and theft-related behavior, and the incident was not substantiated despite the physical injury.
A resident with CAD, CHF, DM, dementia, and schizophrenia was kept in bed instead of being supported in her preference to use a wheelchair. Surveyors found no wheelchair or walker available in her room, while the MDS showed she used a wheelchair for mobility and needed substantial to maximal ADL assistance. The care plan did not identify wheelchair use, PT was limited by agitation and refusal, and restorative nursing documented repeated refusals without documentation of why she was refusing.
A resident with COPD, schizoaffective disorder, TBI history, MDD, and anxiety reported a missing laptop charger, but the grievance was not documented in the grievance log or EMR and was not followed up on in a timely manner. Staff acknowledged that a grievance form was not completed, follow-up was not ensured, and the issue was not handled through the facility’s grievance process.
Failure to Replace Broken Hearing Aids: A resident with dementia and significant hearing loss reported broken hearing aids and months of difficulty hearing staff, family, and peers. The resident’s representative said OTC hearing aids had been purchased, but communication remained difficult. Records showed audiology confirmed moderate-to-severe bilateral SNHL and recommended new hearing aids, yet the EMR lacked documentation of replacement, and staff said a denied PETI had not been acted on or resubmitted. No alternative functional hearing device was documented while the resident waited.
A resident with COPD and oxygen dependence had a physician order for oxygen via nasal cannula at 2 LPM, but observations found the concentrator and portable tank set at 4 LPM on multiple occasions. The resident said staff controlled the flow rate, and CNA and LPN interviews confirmed they knew the order was for 2 LPM but did not verify the setting. The care plan listed 2 LPM, while vital signs records documented oxygen saturations without the oxygen flow rate.
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.
Infection Control Lapses During Room Cleaning
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment on two of four units. During observations in a double-occupancy room, housekeeping staff were seen cleaning resident bathrooms and room surfaces without following the disinfectant dwell time required by the product label. One housekeeper sprayed Clorox disinfectant on the toilet, sink, and other surfaces, then wiped areas before the required three- to five-minute wet contact time had elapsed. The same housekeeper also used the same wash towel on multiple surfaces and did not disinfect several high-touch areas in the room, including door knobs, light switches, grab bars, and bed controls. A second housekeeper was observed spraying the toilet and sink area, then allowing the disinfectant to dry before returning later to wipe the surfaces with a wet rag and water from the faucet. The disinfectant had dried up, leaving the sink surface dry with no visible disinfectant before cleaning resumed. This housekeeper also did not clean several high-frequency touched areas, including the grab bar, toilet door handle, and toilet call light. In both observations, the toilet brush was used beyond the toilet bowl, including on the toilet seat and surrounding areas, and the toilet was not cleaned in a top-to-bottom or clean-to-dirty sequence. Staff interviews confirmed the expected cleaning process and the importance of keeping disinfectant visibly wet for three to five minutes, using the toilet brush only in the toilet bowl, and cleaning high-touch surfaces daily. The housekeeping supervisor and infection preventionist both stated that residents' rooms were to be cleaned daily and that high-touch areas such as over-bed tables, call lights, bed controllers, door knobs, and light switches should be disinfected. The observations showed that these procedures were not followed during the room cleaning events.
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to keep one resident free from resident-to-resident physical abuse when Resident #58 struck Resident #39 in the face during an altercation in the hallway outside Resident #39’s room. Resident #39 was cognitively intact with a BIMS score of 15 out of 15 and had no behavioral symptoms or wandering behaviors documented. After the incident, Resident #39 had a swollen cheek, facial pain, and later reported bruising under the right eye. Resident #58 was also cognitively intact with a BIMS score of 14 or 15 and had diagnoses including schizophrenia, anxiety disorder, COPD, chronic bronchitis, peripheral arterial disease, and hyperlipidemia. His record showed a history of wandering into other residents’ rooms and using their bathrooms, and the investigation documented that he had a history of entering other residents’ rooms in search of cigarettes and taking personal items. His behavior care plan addressed wandering and redirection, but it did not include interventions specific to his documented history of entering other residents’ rooms to seek cigarettes or take items. The incident occurred when Resident #58 went to visit another resident’s roommate and approached Resident #39’s room. Resident #39 told him not to enter, grabbed his shirt, and Resident #58 hit him in the face. Staff witnessed the event, assessed both residents, and the facility documented the contact as inconclusive and unsubstantiated despite the physical injury to Resident #39. The facility’s behavioral documentation for Resident #58 was not updated to reflect the aggression-related interventions identified in the interdisciplinary note, and the investigation concluded without recognizing the incident as substantiated abuse.
Resident’s Choice for Wheelchair Use Not Honored
Penalty
Summary
The facility failed to honor a resident’s right to self-determination and choice by not supporting her preference to get out of bed and sit in a wheelchair. The resident had diagnoses including CAD, CHF, diabetes mellitus, dementia, and schizophrenia, and the MDS showed moderate cognitive impairment with a BIMS score of 11 out of 15. The MDS also indicated she used a wheelchair for mobility and required substantial to maximal assistance with ADLs, while the assessment noted behaviors and refusals of care one to three times per day. The resident stated that she preferred to get out of bed and into a wheelchair, but had remained in bed all day and all night for several months because the facility could not provide a wheelchair that did not leave her feet dangling and cause severe pain. Survey observations on multiple days found her lying in bed with no walker or wheelchair present, stored, or accessible in her room or bathroom. CNA staff reported she had been confined to bed for a long time and that they had not seen a wheelchair or walker in her room for a long time. Record review showed the ADL and mobility care plans did not identify that the resident used a wheelchair, despite the MDS indicating she required one for mobility. The PT evaluation documented agitation and violence toward staff when mobilization was attempted and was limited to evaluation only, without exploring ways to adapt interventions to her needs and choices. The restorative nursing program documented zero days of participation with multiple refusals, and there was no documentation that staff attempted to identify the reason for those refusals. The DON stated the wheelchair and walker were removed from the resident’s room due to refusals, and the resident’s mobility devices were not available in her room.
Failure to Document and Promptly Resolve a Resident Grievance
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a resident grievance involving a missing personal item. Resident #80, who was cognitively intact with a BIMS score of 14 out of 15 and had diagnoses including COPD, obesity class 3, schizoaffective disorder, traumatic brain injury history, hypertensive heart disease, obstructive sleep apnea, major depressive disorder, and anxiety disorder, reported that his laptop charger was missing. He stated that he had told social services assistant #2 about the missing charger several weeks earlier and that no one had helped him locate it since then. Resident #80 reported that social services assistant #2 took a picture of the laptop charging port when he first raised the issue, but he received no feedback or updates afterward. He also stated that no formal grievance form was completed at the time of the initial report or during the following weeks. During the survey, review of the facility grievance log from the prior year showed no entry documenting the resident’s report of the missing computer charger. Staff interviews confirmed the grievance was not handled through the facility’s grievance process. Social services assistant #2 said she remembered the resident reporting the missing charger, informed the housekeeping manager to look for it, but did not follow up to ensure it was found. She also acknowledged that no grievance form was completed and that the report and her actions were not documented in the EMR. The social services director stated the grievance process required completion of a grievance form and prompt action, and the nursing home administrator said missing personal items should be addressed immediately, but at most within a few days.
Failure to Replace Broken Hearing Aids
Penalty
Summary
The facility failed to ensure that Resident #34 received proper treatment and assistive devices to maintain hearing abilities. Resident #34 had diagnoses including dementia, cardiomyopathy, and pleural effusion, and the MDS showed highly impaired hearing with a need for a hearing aid. The resident reported that his hearing aids were broken, that he had difficulty hearing and communicating with staff, family, and peers, and that he had been waiting for help obtaining a replacement for several months. During the interview, he repeatedly indicated that he could not hear what was being said. The resident’s representative stated that the resident’s hearing problems were ongoing and that the representative had purchased over-the-counter hearing aids for him. The representative also said phone conversations and even face-to-face conversations remained difficult because the hearing aids were not functioning, and the representative often had to come to the facility to speak with him. The resident’s care plan identified a communication problem related to hearing deficit and included use of alternative communication tools and assessment for adaptive devices as indicated. Record review showed an audiology visit documented moderate-to-severe sensorineural hearing loss in both ears and recommended repeat evaluation in one year or sooner if hearing changed. The EMR did not show further documentation about replacement of the hearing aids. Staff interviews indicated the resident’s PETI for hearing aids had been denied months earlier and was not acted upon by prior staff, and the facility could not explain why the request was not resubmitted after the issue was discovered. The facility also did not provide documentation that an alternative functional hearing device was offered while the resident waited for replacement hearing aids.
Oxygen Flow Rate Not Provided Per Order
Penalty
Summary
The facility failed to ensure respiratory care was provided in accordance with professional standards for one resident receiving oxygen therapy. The resident had diagnoses including COPD, schizoaffective disorder, hypertensive heart disease, personality disorder, generalized anxiety disorder, and dependence on supplemental oxygen. The resident’s MDS showed moderate cognitive impairment, shortness of breath with exertion and when lying flat, and use of oxygen therapy. The physician’s order in the June 2026 CPO directed oxygen via nasal cannula at 2 LPM, ordered 10/1/24. However, survey observations on 6/8/26, 6/9/26, 6/10/26, and 6/11/26 found the resident’s oxygen concentrator and portable oxygen canister set at 4 LPM. The resident stated his oxygen order was for 2 LPM and said staff regulated the flow rate, while staff interviews confirmed they were aware the order was for 2 LPM and that oxygen was a medication requiring a physician’s order. The resident’s oxygen therapy care plan identified oxygen settings via nasal cannula at 2 LPM, but the vital signs record from 6/2/26 through 6/10/26 documented oxygen saturations ranging from 96% to 98% without documenting the LPM oxygen flow rate. Staff interviews showed CNA #2 and LPN #5 did not verify the oxygen flow rate during their shifts, and the DON stated nursing staff were expected to monitor and document oxygen liter flow rates for all residents receiving oxygen therapy.
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 | ★★★★★ | 0 | 0 |
| Cedars Healthcare Center | 0.1 mi | ★★★★★ | 22 | 0 |
| Sierra Post Acute | 0.3 mi | ★★★★★ | 11 | 0 |
| Harmony Pointe Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Wheatridge Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
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