Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
Surveyors found that staff did not consistently date and label food and supplemental drinks stored in two unit kitchenettes, with several undated or improperly labeled items observed, including opened containers of food and nutritional supplements. Interviews with the FSD and a nurse revealed confusion and inconsistency in following the facility's food storage policy, resulting in perishable items remaining past the required discard timeframe.
A resident with diabetes and severe cognitive impairment did not have insulin lispro administration accurately documented, despite physician orders requiring its use based on blood sugar readings. Multiple blood sugar checks indicated the need for insulin, but the MAR lacked documentation of administration or refusal. Nursing staff later stated the insulin was given but not recorded, and the DON confirmed a transcription error contributed to the documentation failure.
A resident with right-sided hemiplegia, cognitively intact and dependent on staff for bathing, was not provided showers as requested since admission. Despite repeated requests from the resident and family, and documentation indicating the need for staff assistance and a mechanical lift, the facility failed to provide a suitable shower chair in a timely manner. Staff and leadership interviews confirmed awareness of the issue and acknowledged significant delays in obtaining and modifying the necessary equipment, resulting in the resident only receiving bed baths.
A resident with a history of stroke, traumatic brain injury, and dementia developed worsening upper extremity contractures. Despite a nurse practitioner's recommendation for an occupational therapy (OT) referral, no order was placed and the OT was not notified, resulting in a 49-day delay before the resident was evaluated. Facility staff interviews and record review confirmed that the required referral process was not followed, and no documentation of a referral or contraindications was found.
Surveyors found that staff did not date opened medications with shortened expiry periods, including inhalers and an insulin pen, as required by facility policy. The DON and a unit manager confirmed these medications should have been dated when opened, but were not.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended on multiple occasions. Nurses admitted to leaving carts unlocked, and management confirmed that carts should be locked when not in use.
A resident with dementia and psychosis was found with a bruise of unknown origin, which was not immediately reported to the DON or Administrator as required by the facility's policy. The incident was reported to the state agency 30 hours after staff first became aware of it, indicating a failure to follow the abuse prohibition policy.
A facility failed to update a resident's care plan to reflect their independence in oral hygiene, toileting hygiene, and toilet transfer, as indicated by a comprehensive assessment. Despite being assessed as independent, the care plan continued to list the resident as requiring assistance. The DON confirmed that the interdisciplinary team did not update the care plan as required.
A resident with severe cognitive impairment and at risk for pressure ulcers was observed multiple times without offloading booties on their heels, contrary to physician's orders. Staff interviews confirmed the resident did not refuse the booties, and documentation inaccurately indicated compliance with the order.
A facility failed to ensure the correct size suprapubic catheter was used for a resident, as ordered by the physician. The resident, with conditions including Parkinson's and urine retention, was observed with a catheter that did not match the physician's specifications. Staff interviews revealed a previous catheter change due to leakage, but the correct size was not used, and the resident confirmed the catheter was not changed as ordered.
A resident with a G-tube did not receive the prescribed amount of Jevity 1.5 calorie due to a defect in the feeding machine and lack of routine checks by the nurse. The resident's feeding was supposed to be administered at 60 mL per hour, but observations showed no infusion throughout the day. The DON was aware of the physician's concerns about the feeding being stopped.
A resident with COPD and moderate cognitive impairment was observed receiving oxygen at three liters per minute, contrary to the physician's order of two liters per minute. The facility's policy requires adherence to physician orders for oxygen therapy, but staff failed to implement the correct flow rate, as confirmed by the DON.
A nurse failed to follow enhanced barrier precautions by not wearing a precaution gown while caring for a resident with a pressure ulcer wound. The facility's policy requires gowns and gloves for high-contact activities, but the nurse only wore gloves. Interviews with staff confirmed the need for a gown, highlighting a lapse in infection control practices.
A resident with COPD, stroke, dysphagia, and malnutrition experienced significant weight loss and a decline in mobility, but the facility failed to complete a Significant Change of Status MDS within the required timeframe. The resident's weight dropped from 129 to 109 pounds, and their transfer ability declined from requiring supervision to total dependence. The DON acknowledged the oversight, and the MDS Nurse was unavailable for comment.
Failure to Properly Date and Label Food Items in Unit Kitchenettes
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as evidenced by multiple undated and improperly labeled food items found in two unit kitchenettes. During observations, surveyors identified several food containers and bags in the refrigerators that were either undated or not labeled with the required information, including resident names and dates. Items such as a green bag of food, a plastic container, a container of thickened water, and two 32-ounce containers of nutritionally fortified supplemental drinks were found opened but undated. Additionally, some items were found past the facility's stated discard timeframe, such as a bag dated 6/11/25 that had not been removed. Interviews with the Food Service Director (FSD) and a nurse revealed inconsistencies in the understanding and implementation of the facility's food storage policy. The FSD stated that nurses are responsible for labeling and dating food brought in by families before placing it in the kitchenette refrigerator, and that leftover food should be discarded after three days. However, a nurse indicated that all resident food items and leftovers should be dated and discarded after two days. Both agreed that open supplemental drinks should be dated. The facility's policy requires all perishable foods to be labeled with the resident's name and date and to be discarded after 48 hours, but these procedures were not consistently followed, leading to the deficiency.
Failure to Document Insulin Administration per Physician Order
Penalty
Summary
The facility failed to accurately document the administration of insulin lispro for one resident with diabetes and severe cognitive impairment. According to physician orders, the resident was to receive insulin lispro based on a sliding scale whenever blood sugar readings exceeded 200, with blood sugars checked three times daily. Review of the Medication Administration Record (MAR) for the specified period showed multiple instances where the resident's blood sugar was above 200, but there was no documentation that insulin lispro was administered as required. There was also no documentation of refusal or any rationale for not administering the insulin. Interviews with nursing staff and facility management confirmed that insulin administration should be documented at the time of administration, and that the resident did not refuse insulin. The DON acknowledged that the MAR was inaccurate and that the physician's order had been transcribed incorrectly as a PRN order, which failed to alert nurses to administer the insulin as scheduled. Subsequent statements from nursing staff indicated that insulin had been administered on the required occasions, but documentation was omitted.
Failure to Honor Resident's Shower Preference Due to Delayed Equipment Procurement
Penalty
Summary
The facility failed to honor a resident's personal care preferences by not providing showers as requested, instead only offering bed baths since the resident's admission. The resident, who was cognitively intact and dependent on staff for bathing due to right-sided hemiplegia following a stroke, repeatedly expressed a preference for showers, stating that bed baths were degrading and did not adequately clean their long hair. Family members also voiced concerns to staff and the resident's physician about the lack of showers and the use of dry shampoo, which left the resident's hair greasy and covered in residue. Despite the resident's care plan and care card indicating a need for staff assistance and a mechanical lift for shower transfers, documentation failed to show that any showers were provided. Staff interviews revealed that although safe shower chairs were available for residents with similar needs, the primary CNA and facility administration believed there was no appropriate shower chair for this resident. Occupational therapy records indicated that showering was a goal, but the resident was dependent and unsafe for showers without specialized equipment. The occupational therapist reported notifying her supervisor months prior about the need for a suitable chair, and a new chair was only recently obtained but not yet evaluated for use. Further interviews with facility leadership confirmed awareness of the resident's unmet preference and acknowledged significant delays in ordering and modifying the necessary shower chair. The Regional Director of Rehab admitted that the process to research, order, and modify the chair took several months longer than acceptable, resulting in the resident being denied showers for an extended period. The DON stated that all residents should be able to choose between a bath or shower and that equipment should be obtained in a timely manner, but was unaware of the timeline for this request.
Failure to Initiate Timely Occupational Therapy Referral for Contracture Management
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and care in accordance with professional standards for a resident with upper extremity contractures. The resident, who had a history of stroke, traumatic brain injury, and dementia, was observed to have significant contractures in both upper extremities. The resident was unable to communicate effectively and was noted to have impaired range of motion, with both hands closed and arms held closely to the chest. The care plan and multiple assessments documented the presence of contractures and the need for monitoring changes in functional abilities. On a specific date, the nurse practitioner (NP) documented a recommendation for an occupational therapy (OT) referral to address the resident's worsening contractures. However, there was no evidence that an order for OT services was placed in the medical record following this recommendation. Interviews with facility staff, including the Director of Rehab (DOR), OT, and DON, revealed that the referral process was not followed, and the OT was not made aware of the NP's recommendation until the issue was brought up by a surveyor. The facility's policy required that therapy referrals be evaluated within 48 hours, but the resident was not evaluated by OT until 49 days after the NP's recommendation. Documentation failed to show that a paper referral form was completed or that any contraindications for therapy were documented. Staff interviews indicated a lack of clarity and communication regarding the referral process, with the NP assuming therapy had begun and the DOR and OT unaware of the referral. As a result, the resident did not receive timely OT evaluation and intervention for contracture management as recommended by the NP and required by facility policy.
Failure to Date Opened Medications with Shortened Expiry
Penalty
Summary
Surveyors observed that staff failed to store drugs and biologicals in accordance with State and Federal laws, specifically by not dating medications with shortened expiry dates once opened, as required by the facility's own policy. During an inspection of a medication cart, one fluticasone propionate and salmeterol inhaler, two incruse ellipta inhalers, and one lantus solostar insulin pen were found opened but undated. Interviews with the Unit Manager and the DON confirmed that these medications should have been dated upon opening due to their shortened expiry periods, but this was not done.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely in accordance with accepted professional standards of practice. During a medication storage observation on the first-floor unit, a nurse left the medication cart unlocked and unattended while walking to the other end of the hallway. The nurse acknowledged that the cart should not have been left unlocked. Similarly, on the second-floor unit, another nurse left her medication cart unlocked and unattended while administering medications to a resident. Both nurses admitted that the carts should have been locked when not in use. Additionally, an unlocked treatment cart was observed on the first-floor unit with no licensed nurse in view. The cart contained prescription creams and was accessible to anyone passing by. The unit manager and another nurse confirmed that the treatment cart should have been locked when unattended. The Corporate Director and the Director of Nursing reiterated that medication and treatment carts should be locked when not within the nurse's view.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse prohibition policy for a resident who was admitted with diagnoses including dementia and psychosis. The resident was found with a bruise of unknown origin on the left side of the face, which was not immediately reported to the Director of Nursing (DON) or the Administrator as required by the facility's policy. The policy mandates that any incident meeting the criteria of a reportable incident, such as alleged physical abuse, should be immediately reported to the DON and Administrator. However, the nursing staff did not notify the administration about the bruise, leading to a delay in reporting the incident to the state agency. The incident was first noted by a nurse on duty, who did not recall seeing the bruise and did not report it to the DON. Another nurse, who worked the following shift, also noticed the bruise but did not notify the administration. It was only after the DON read the nursing note that the administration became aware of the bruise, which was then reported to the state agency 30 hours after the staff first became aware of it. The Administrator confirmed that the direct care staff should have reported the injury of unknown origin to the administration, but this did not occur, resulting in a breach of the facility's abuse prohibition policy.
Failure to Update Care Plan for Resident's Independence
Penalty
Summary
The facility failed to ensure that care plans were reviewed and updated by the interdisciplinary team as required, specifically for one resident. This resident, admitted in November 2022 with a diagnosis of irritable bowel syndrome, was assessed as cognitively intact with a BIMS score of 15 out of 15. The Minimum Data Set (MDS) assessment dated February 7, 2024, indicated that the resident was independent in oral hygiene, toileting hygiene, and toilet transfer. However, the resident's care plan, last revised on various dates in 2023 and January 2024, did not reflect these independent capabilities and instead indicated the need for assistance in these areas. The care plan's failure to be updated was confirmed through a review of the resident's ADL flow sheets from February 2024, which consistently coded the resident as independent in oral hygiene, toileting hygiene, and toilet transfer. During an interview, the Director of Nursing acknowledged that the interdisciplinary team responsible for completing section GG under the MDS should have updated the care plan following the comprehensive assessment on February 7, 2024, but this was not done.
Failure to Apply Offloading Booties as Ordered
Penalty
Summary
The facility failed to meet professional standards of quality for one resident by not adhering to physician's orders regarding the application of offloading booties to the resident's heels while in bed. The resident, who was admitted with diagnoses including adult failure to thrive and repeated falls, was at risk for pressure ulcers as indicated in their Minimum Data Set (MDS) assessment. Despite the physician's order dated 5/31/24 to apply booties to the resident's bilateral heels while in bed, observations on multiple occasions revealed the resident lying in bed with their heels directly on the mattress, and the booties were found across the room. Interviews with facility staff, including a Certified Nurse Assistant (CNA) and a nurse, confirmed that the resident should have been wearing the offloading booties while in bed and that the resident did not refuse to wear them. The Treatment Administration Record (TAR) inaccurately documented that the booties were applied as ordered, and there was no record of the resident refusing the booties. The Director of Nursing (DON) also confirmed that the booties should have been worn according to the physician's order, and any refusal would have been documented in the TAR or a progress note.
Failure to Ensure Correct Catheter Size for Resident
Penalty
Summary
The facility failed to maintain professional standards in the management and care of urinary catheter devices for a resident. Specifically, the staff did not ensure the correct size suprapubic indwelling urinary catheter was in place as ordered by the physician. The resident, who was admitted with diagnoses including Parkinson's disease, urine retention, and legal blindness, was observed with a 16 French catheter with a 5 cc balloon, contrary to the physician's order for a 16 French 10 cc catheter. The facility's policy requires verification of the correct catheter size before insertion, but this was not adhered to. Interviews with staff revealed that the catheter was changed on a previous date due to leakage, but the correct size was not used. The resident confirmed that the catheter was not changed on the date specified in the physician's order and expressed a preference for changes every four to six weeks. The Director of Nursing acknowledged that the physician's order should have been implemented, indicating a lapse in following the prescribed medical orders for catheter care.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Gastrostomy tube (G-tube), as the amount of tube feeding infused did not match the physician's orders. The resident, who was admitted with diagnoses including stroke, dementia, dysphagia, and PTSD, had an active physician's order for Jevity 1.5 calorie to be administered via pump at 60 mL per hour, with specific instructions to hold and resume feeding at designated times. However, observations revealed that the tube feeding was not infusing as ordered, with the 1500 mL bottle of Jevity remaining unchanged throughout the day. The issue was compounded by a defect in the feeding machine, which was not identified until later in the day. Nurse #7, who was responsible for the resident's care, admitted to not routinely checking the enteral feeding during her shift and was unaware of any staff pausing or turning off the machine. The Director of Nursing expected the tube feeding to be assessed and monitored, and was aware of the physician's concerns about the feeding being stopped. Despite these expectations, the deficiency occurred, leading to the resident not receiving the prescribed amount of nutrition.
Failure to Implement Physician-Ordered Oxygen Flow Rate
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards of practice for a resident with chronic obstructive pulmonary disease (COPD), stroke, dysphagia, and malnutrition. The resident, who had moderate cognitive impairment, was observed receiving oxygen at a flow rate of three liters per minute, contrary to the physician's order of two liters per minute via nasal cannula continuously. This discrepancy was noted during multiple observations by the surveyor. The facility's policy on oxygen therapy requires a physician's order to initiate oxygen therapy, and the resident's care plan indicated that oxygen should be administered continuously as ordered. Despite this, the resident's oxygen was set incorrectly, and the Director of Nursing confirmed the error upon observation. Interviews with nursing staff revealed that the resident does not adjust the oxygen settings, indicating that the staff failed to implement the physician's order correctly.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that transmission-based precautions were followed to prevent the spread of infections. Specifically, a nurse did not appropriately don a precaution gown while caring for a resident on enhanced barrier precautions (EBP). The facility's policy on Enhanced Barrier Precautions for Multidrug-Resistant Organisms (MDROs) requires the use of gowns and gloves during high-contact resident care activities, such as wound care, for residents with open wounds requiring dressing changes. Despite this policy, Unit Manager #1 was observed not wearing a precaution gown while removing a dressing from a resident's right lateral foot, which had a pressure ulcer wound. The incident was confirmed through interviews with various staff members, including a Certified Nurse Assistant (CNA), the Corporate Director, and the Director of Nursing (DON). All acknowledged that a precaution gown should have been worn in addition to gloves when handling the resident's wound, as the resident was on EBP. The failure to adhere to the facility's infection control policy was evident when Unit Manager #1 only wore gloves and not a gown during the wound care procedure, despite the presence of signage indicating the need for both gloves and a gown.
Failure to Complete Significant Change of Status MDS
Penalty
Summary
The facility failed to adequately identify and assess a significant change in condition for a resident, leading to a deficiency. The resident, admitted in February 2019 with chronic obstructive pulmonary disease (COPD), stroke, dysphagia, and malnutrition, experienced significant weight loss and a decline in mobility. The resident's weight dropped from 129 pounds to 109 pounds, indicating a significant weight loss of over 12% in 30 days. Additionally, the resident's ability to transfer from bed to chair deteriorated from requiring supervision to being totally dependent on staff. Despite these changes, the facility did not complete a Significant Change of Status Minimum Data Set (MDS) assessment within the required 14-day period following the determination of the significant change. The Director of Nursing acknowledged that a Significant Change of Status MDS should have been completed. The MDS Nurse responsible for this task was unavailable for an interview as she no longer worked at the facility.
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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 Cambridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spaulding Nursing And Therapy Center - Brighton | 2 mi | ★★★★★ | 0 | 0 |
| Care One At Brookline | 2.2 mi | ★★★★★ | 7 | 0 |
| Watertown Rehabilitation And Nursing Center | 2.2 mi | ★★★★★ | 3 | 0 |
| Neville Center At Fresh Pond For Nursing & Rehab | 2.4 mi | ★★★★★ | 0 | 0 |
| Brighton Post Acute Care | 2.4 mi | ★★★★★ | 12 | 0 |
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