Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified that the facility failed to follow its own food storage and employee sanitary practices policies, potentially affecting all residents receiving meals. In dry storage and the walk-in freezer, multiple food items, including large containers of mayonnaise and relish, au gratin potatoes, cereal, coffee creamers, frozen peas, and biscuits, were found opened or removed from original packaging without required received or opened dates. A dietary aide was observed preparing food while wearing a bonnet that did not fully restrain her hair, leaving bangs and side hair exposed. The dietary manager, dietary staff, department head, and administrator all acknowledged in interviews that policy requires all food to be dated when received and when opened, and that anyone entering the kitchen must wear hair restraints that fully contain all hair to prevent contamination.
Infection control practices were not followed across the facility. Staff were observed failing to perform hand hygiene before and after resident contact, between room entries, and after handling trays or resident items. A resident with ESBL history was not consistently placed on EBP, with no door signage and staff entering for direct care without gowns; one aide wore gloves but not a gown and did not clean hands when leaving. Surveyors also found dirty utility and shower room sanitation problems, no non-permeable gowns in the laundry area, and a nurse returned a glucometer to storage without cleaning or disinfecting it after a fingerstick.
Surveyors identified that multiple resident rooms and both working shower rooms were not maintained in a safe, clean, and homelike condition, with findings including fecal staining and deposits, mold, visibly soiled shower equipment, dirty floors and baseboards, damaged and exposed drywall, cracked and holed flooring, water-stained and deteriorated ceilings, and corroded PTAC grilles with black grime. A resident reported anxiety and concern for safety due to water damage, floor damage, and rotted baseboards, and another resident and family stated that promised room and bathroom repairs had not occurred after more than a year. Staff interviews showed that while an LPN and a unit manager were aware of the process to enter maintenance requests, they had not recently or consistently done so, and the DON lacked access to track outstanding work orders. The Corporate Director of Plant Operations described use of a maintenance management system and separate task tracking that was not produced to surveyors, and the Administrator acknowledged that repairs were delayed because the facility prioritized maintaining full census rather than creating temporary vacancies to complete needed room repairs.
Medication Storage and Labeling Failures: Multiple medication carts and a medication refrigerator contained loose pills, opened medications without dates, and an expired product. An LPN, KMAs, the UM, the SDC, the DON, and the Administrator all described expectations for dating opened items, discarding loose pills, and keeping carts clean, but surveyors still found undated budesonide, Tubersol, Spiriva, and ProHeal, along with loose tablets and expired Glutose gel.
A resident on Hospice with CKD and HF did not have the CCP updated to include Hospice-oriented goals or interventions for comfort-focused care. The MDS Coordinator stated Hospice status should be reflected in the care plan, and the DON, Administrator, and Medical Director all stated care plans were expected to guide staff in meeting resident needs.
A long-term care facility failed to maintain effective infection control, as evidenced by staff not adhering to PPE protocols, improper handling of isolation linens, and inadequate enforcement of COVID-19 isolation measures. Observations included a resident receiving a nebulizer treatment with the door open, staff not wearing gloves while handling garbage, and residents not wearing masks as required.
A resident with dementia and a history of falls, assessed as a high elopement risk, exited the facility unsupervised after the discontinuation of 15-minute checks without the APRN's knowledge. Despite having a Wander Guard bracelet, the resident managed to leave the facility, and staff failed to respond promptly to the alarm. Interviews revealed that alarms were often ignored, and there was a lack of consistent monitoring of the resident's exit-seeking behavior.
Improper Food Storage and Inadequate Hair Restraints in Dietary Services
Penalty
Summary
The deficiency involves the facility’s failure to store and prepare food in accordance with its own policies and professional standards for food safety, potentially affecting 106 residents who received food from the kitchen. Surveyors reviewed the facility’s “Food Storage” policy, which required all foods to be covered, dated, and labeled, including dating items removed from shipping containers, and the “Employee Sanitary Practices” policy, which required hair restraints for all food and nutrition services employees. Despite these policies, observations in dry storage and the walk-in freezer revealed multiple food items that were opened or removed from original packaging without any received or opened dates. During an observation of dry storage, surveyors found two unopened 128-ounce jars of mayonnaise and one unopened 128-ounce jar of sweet pickle relish that were out of their original box packaging and undated, a 36-ounce box of au gratin potatoes with no opened date, an opened bag of cereal that was rolled up, unsealed, and undated, and an opened box of 1000 coffee creamers with no received date. In the walk-in freezer, they observed an opened 30-pound bag of frozen sweet peas inside an opened box with no opened date, and an opened case of 210 frozen biscuits with no opened date. The Head of the department acknowledged that received dates were important to calculate use-by dates and confirmed that all items should have been dated. The deficiency also included failures in employee sanitary practices related to hair restraints. Surveyors observed a dietary aide at a food preparation table wearing a hair bonnet that only partially restrained her hair, with bangs and hair on both sides of her face loose. The Dietary Manager stated that the aide should have worn a hairnet under the bonnet to fully restrain her hair and that hairnets were required for anyone entering the kitchen. Multiple dietary staff, including dietary aides and the Head of the department, confirmed in interviews that staff were expected to date delivered and opened food items and that everyone entering the kitchen must wear hair restraints that fully contain all hair, including beards, to prevent contamination. The Administrator also stated his expectation that kitchen staff follow policy for dating stored and opened food items and wear hair restraints with all hair covered.
Infection Control Failures With Hand Hygiene, EBP, Glucometer Disinfection, and Environmental Sanitation
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not following hand hygiene, enhanced barrier precaution, and glucometer disinfection practices, and by allowing contaminated and soiled areas to remain improperly maintained. Surveyors observed multiple staff members entering and exiting resident rooms, providing care, handling trays, and touching resident items without performing hand hygiene before or after contact. The [NAME] Unit Manager failed to perform hand hygiene before entering or after exiting a resident’s room, failed to clean hands after touching a resident’s hearing assistive device, and failed to use hand sanitizer while moving between resident rooms and handling trays. A State Registered Nurse Aide also failed to perform hand hygiene while collecting meal trays from two residents’ rooms. The facility also failed to implement enhanced barrier precautions for a resident with a history of ESBL in urine. The resident had been admitted with stage 5 chronic kidney disease, debility, and ESBL in urine, and the quarterly MDS showed a BIMS score of 15. Although the resident’s care plan had been revised, it did not include EBP goals or interventions related to ESBL. Surveyors observed no isolation signage on the resident’s door, and staff entered the room to provide direct care without wearing gowns. One aide provided care such as repositioning, linen adjustment, and changing an underpad without a gown, and another aide entered the room, donned gloves but not a gown, and exited without performing hand hygiene. Staff interviewed about the resident stated they believed EBP was no longer needed after the urinary catheter was removed, while the Infection Preventionist stated the resident had been colonized with an MDRO and should have remained on EBP. Surveyors also observed environmental and equipment-related infection control failures. In the East Wing dirty utility room, medical supplies including IV poles, oxygen concentrators, suction machines, and a bedside commode were stored with dirty linen and trash. The East Wing shower room contained multiple areas of fecal staining and formed fecal deposits on the floor. In the laundry room, no non-permeable gowns were available for handling contaminated laundry, and debris, dust, lint, trash, and other items were present on the floor near the sink and behind the washing machines. In addition, a nurse tested a resident’s blood glucose and returned the glucometer to the bedside drawer without cleaning or disinfecting it, despite the manufacturer’s instructions requiring disinfection after each use and the facility’s expectation that bleach wipes be used.
Failure to Maintain Clean, Safe, and Homelike Resident Rooms and Shower Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in multiple resident rooms and shower areas. Surveyors observed that 11 of 25 sampled rooms had significant maintenance and cleanliness issues, including damaged drywall and baseboards, cracked and dented flooring, unpainted drywall patches, wall stains, dirty floors and baseboards, and a PTAC unit with a heavily rusted, corroded grille containing black grime and debris on and within the vent slats. In one room, there was a large dried food stain on the wall, dried food on the bed rail and floor, and dirt and dried material consistent with food residue beneath a fall mat. Another room had extensive brown water staining and deterioration on the ceiling, black discoloration on a bathroom baseboard, a newly replaced raw wood baseboard, and holes and unsecured edges in the linoleum flooring, including by the commode and near a bed. Surveyors also found that both working shower rooms had significant cleanliness problems. The East Unit shower room had multiple areas of fecal staining and several formed fecal deposits on the floor, red mold in the shower area, and a visibly soiled shower chair. The other shower room had mold around the base, faucet, and grab bars, and a dirty floor with dark-stained grout lines. These conditions were observed despite a facility policy titled “Homelike Environment” that required provision of a safe, clean, comfortable, and homelike environment and minimization of institutional characteristics. Maintenance documentation showed periodic entries for cleaning air filters and inspecting condenser coils on PTAC systems, but did not identify which specific units were serviced. Interviews revealed that staff were aware of needed repairs but did not consistently initiate or track maintenance requests. One LPN stated she would enter maintenance requests into the computer portal but had not done so recently. The East Unit manager acknowledged knowing that several rooms needed repairs but had not personally submitted work orders for the damaged rooms on her unit. A resident in a room with water-stained ceilings, cracked areas, a large gash in the bathroom floor, and rotted wood on a baseboard reported having voiced concerns to staff and the Administrator and stated these conditions made her feel anxious and concerned for her safety, including fear of potential mold exposure and that the bathroom floor was a safety hazard. Another resident and family reported they had been told the room floor and bathroom would be refinished and remodeled, but after 14 months had not seen any repairs. The Corporate Director of Plant Operations stated that repairs to walls, ceilings, floors, and baseboards were done when rooms were vacant and that some tasks were tracked outside the electronic system, but the requested separate log of tasks was not provided to surveyors. The DON stated she expected staff to enter repair requests but did not have access to track them and did not believe the disrepair prevented a homelike environment, while the Administrator acknowledged that repairs had not been completed because the facility maintained full census instead of creating vacancies to complete room repairs.
Medication Storage and Labeling Failures
Penalty
Summary
The facility failed to ensure that resident medications and biologicals were stored and labeled according to policy and accepted professional principles. Review of the facility policy showed that medications dispensed by the pharmacy were to remain in labeled containers, multi-dose packaging was to have beyond-use dating per pharmacy protocol, and opened manufacturer containers or vials were to be marked with the date opened. Observation of the East 1 medication cart found R90's budesonide inhalation suspension opened with no opened date, three loose vials in the pouch, and R90's Glutose 15 oral glucose gel with an expired date. The same cart also contained 14 loose pills in the drawers. Observation of the [NAME] 1 medication cart found 17 loose pills. Observation of the East Wing medication refrigerator found an opened vial of Tubersol with no opened date on the bottle or box. Observation of the [NAME] 3 medication cart found seven loose pills, including vitamin D, nifedipine, famotidine, Buspar, sertraline, and sacubitril-valsartan. R58's Spiriva inhaler was opened with no opened date recorded, and a house stock bottle of ProHeal was opened but undated. Staff interviews stated loose pills should be discarded and reported, opened medications should be dated, and medication carts should be kept free of loose pills, but the observations showed these practices were not consistently followed.
Care plan lacked Hospice interventions for a resident on Hospice
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 60 that included measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs. Review of the resident’s records showed an active order on 01/21/2026 for Hospice care with a life expectancy of less than six months related to chronic kidney disease and heart failure, but the comprehensive care plan revised on 01/27/2026 did not include Hospice-oriented goals or interventions to support end-of-life care. The resident was admitted to the facility on 08/07/2023 with diagnoses including stage 5 chronic kidney disease, debility, and atrial fibrillation, and the quarterly MDS dated 02/05/2026 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. During interview, the resident stated she had been in and out of Hospice services and had recently resumed Hospice care, but she had not noticed any additional attention or changes in care since resuming Hospice and could not recall when Hospice staff last visited. The MDS Coordinator stated that when a resident was placed on Hospice services, the care plan should be addressed to ensure comfort-focused interventions were implemented and that Hospice status should be communicated so staff could prioritize comfort; she acknowledged the issue and stated Hospice services should have been added to the care plan. The DON, Administrator, and Medical Director each stated that care plans were expected to direct staff in meeting resident needs and be followed as written.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations and interviews. One incident involved a State Registered Nurse Aide (SRNA) entering an Enhanced Barrier Precautions (EBP) room without donning the required personal protective equipment (PPE). The SRNA admitted to changing a resident's linens without wearing a gown and gloves, despite having received training on EBP protocols. The resident in question had a history of methicillin-resistant Staphylococcus aureus infection and was under EBP orders due to a wound, which had since resolved. Another deficiency was observed when a garbage bag full of dirty linens from a droplet precaution isolation room was left on the floor in the hallway. Staff interviews revealed that linens from isolation rooms should be bagged and taken directly to the dirty utility room, where they are placed in blue biohazard bags to prevent cross-contamination. The housekeeping supervisor confirmed that the protocol was not followed, which could lead to the spread of infection. Additional issues included residents with COVID-19 not adhering to isolation protocols. One resident was observed sitting in a doorway without a mask, while another was receiving a nebulizer treatment with the door and privacy curtain open, contrary to CDC guidelines. Staff interviews indicated a lack of enforcement of mask-wearing and room confinement for COVID-19 positive residents. Furthermore, a housekeeper was seen removing garbage bags without wearing gloves or practicing hand hygiene, and an SRNA improperly donned and doffed PPE, failing to cover their clothing fully and not performing hand hygiene after handling contaminated items.
Failure to Supervise High-Risk Resident Leads to Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for a resident who exhibited wandering behaviors and was assessed at risk for elopement. The resident, diagnosed with dementia and a history of falls, was ordered to be on 15-minute checks by an Advanced Practice Nurse Practitioner (APRN) due to high elopement risk. However, the order for these checks was discontinued without the APRN's knowledge, leading to the resident exiting the facility unsupervised and unescorted. The resident was found approximately 60 to 70 feet from the facility, near a two-lane road, after an alarm sounded but was not responded to in a timely manner by the staff. The facility's policy required an Elopement Risk Assessment to be completed on admission, quarterly, and whenever there was a significant change in the resident's status. The resident's assessments indicated a high risk for elopement, and interventions such as 15-minute checks and a Wander Guard bracelet were put in place. Despite these measures, the resident managed to leave the facility, highlighting a failure in the system to ensure the resident's safety. Interviews with staff revealed that alarms were frequently ignored, and there was a lack of immediate response to the alarm that signaled the resident's exit. Interviews with various staff members, including the Unit Manager, Housekeeper, Registered Nurse, and others, indicated a general awareness of the resident's wandering behavior and confusion. However, there was a lack of consistent monitoring and response to the resident's exit-seeking behavior. The Director of Nursing (DON) and the acting interim Administrator acknowledged the expectation for staff to respond immediately to alarms and provide supervision, but this was not effectively implemented, resulting in the resident's unsupervised exit from the facility.
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Illustrative
What surveyors actually found near you
We read the 61 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lexington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cardinal Hill Skilled Rehabilitation Unit | 0.5 mi | ★★★★★ | 8 | 0 |
| Homestead Post Acute | 0.9 mi | ★★★★★ | 0 | 0 |
| Pine Meadows Post Acute | 0.9 mi | ★★★★★ | 6 | 0 |
| Lexington Country Place | 1.6 mi | ★★★★★ | 0 | 0 |
| The Willows At Citation | 4.1 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.