Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Gracepointe Crossing Gables during CMS and state inspections, most recent first.
Staff served fruit salad, a cold menu item, to memory care residents at a temperature of 62°F after it was left unrefrigerated on the counter for an extended period. The dietary aide and culinary staff confirmed the food was not kept at the required temperature, and facility policy indicated cold foods should be stored at or below 41°F. Seventeen residents were potentially affected by this failure to maintain safe food temperatures.
Staff failed to properly disinfect a shared glucometer between uses, using alcohol pads instead of the required bleach-based disinfectant, and inconsistently followed PPE protocols when assisting a resident on contact precautions for shingles. Observations and interviews revealed that staff used soiled gowns and sometimes entered the room without any PPE or hand hygiene, contrary to facility policy and infection control standards.
A resident with type 2 diabetes and other comorbidities was prescribed Trulicity, a GLP-1 medication, but two consecutive MDS assessments incorrectly coded this medication as insulin. The error was identified through document review and staff interviews, which revealed that MDS assessments were completed offsite and that there may be a lack of staff training regarding GLP-1 medications. Facility policy requires accurate documentation from multiple sources, but this was not followed, leading to the deficiency.
A deficiency was cited when a facility area was found to contain accident hazards and lacked sufficient supervision to prevent accidents. Surveyors observed that the environment was not adequately maintained to ensure resident safety, and necessary oversight was not provided.
A resident with multiple health conditions and a history of falls was being assisted to the bathroom with a walker by a nurse aide, but a gait belt was not used as required by facility policy. During the transfer, the resident fell and sustained a nondisplaced shoulder fracture. Staff interviews and documentation indicated inconsistent use of gait belts and a lack of explicit care plan instructions for their use.
A facility failed to assess a resident for self-administration of medications, despite the resident having a severe allergy requiring an EpiPen. The EpiPen was found in the resident's room without proper labeling or inclusion in the care plan. Staff interviews revealed that the required assessment and safety measures were not conducted, and the EpiPen was expired. The resident confirmed staff awareness of the EpiPen, yet no action was taken to secure it.
Cold Food Served Above Safe Temperature
Penalty
Summary
The facility failed to provide a palatable diet by serving cold food, specifically fruit salad, at a temperature significantly above the recommended safe range. On the day of observation, the fruit salad was prepared and plated at 11:45 a.m., with the facility's temperature log showing it was 38 degrees Fahrenheit at 11:50 a.m. However, the individual bowls of fruit salad were left on the counter and not refrigerated. When lunch was served to residents in the memory care unit, the fruit salad had reached a temperature of 62 degrees Fahrenheit. Staff interviews confirmed that the fruit salad was intended to be served cold and should have been kept at or below 41 degrees Fahrenheit, as per facility policy and food safety guidelines. Seventeen residents in the memory care unit were potentially affected by this practice. Staff, including the dietary aide and culinary director, acknowledged that the fruit salad was not refrigerated after plating and that serving it at 60 degrees was inappropriate for a cold item. The director of nursing also stated that cold food should not be left on the counter for extended periods, as it would warm up and could pose a risk. Facility documentation confirmed that cold foods should be maintained at 41 degrees or below, and the observed practice did not meet these standards.
Failure to Disinfect Glucometers and Ensure Proper PPE Use for Residents on Contact Precautions
Penalty
Summary
The facility failed to ensure proper disinfection of glucometers between uses for residents requiring blood sugar monitoring. Specifically, a licensed practical nurse (LPN) was observed using an Accu-Check glucometer on a resident with diabetes and then cleaning the device with alcohol pads instead of the manufacturer-recommended bleach-based disinfectant wipes. Interviews with multiple staff members revealed inconsistent practices and understanding regarding the correct disinfection procedure, with some staff stating that alcohol wipes were used, while others mentioned bleach wipes or claimed each resident had their own glucometer. The facility's policy and the manufacturer's instructions both require the use of bleach-based disinfectant wipes for proper disinfection between residents, which was not consistently followed. Additionally, the facility failed to ensure that personal protective equipment (PPE) was properly used by staff when assisting a resident on contact precautions due to a diagnosis of shingles. A nursing assistant (NA) was observed entering the resident's room and donning a gown taken from a soiled laundry basket, rather than using a clean gown from the designated bin outside the room. The NA also entered the room on another occasion to retrieve meal trays without wearing any PPE or performing hand hygiene before or after the task. Interviews with staff confirmed that gowns in the laundry basket were soiled and should not be reused, and that staff were expected to wear gowns and gloves for all interactions with residents on contact precautions, including when entering the room to pick up trays. The residents involved had significant medical histories, including diabetes, Alzheimer's disease, and shingles, and required assistance with activities of daily living. The observed failures in infection prevention and control practices, including improper disinfection of shared medical equipment and inconsistent use of PPE, were not in accordance with facility policy or manufacturer guidelines. These deficiencies were identified through direct observation, staff interviews, and review of facility policies and procedures.
Incorrect MDS Coding of GLP-1 Medication as Insulin
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessment for a resident with type 2 diabetes, morbid obesity, and a history of intestinal bypass. The resident was prescribed Trulicity, a GLP-1 receptor agonist, for diabetes management. However, in two consecutive comprehensive MDS assessments, the medication was incorrectly coded as insulin in Section N (Medications). Documentation and medication reference materials clearly indicate that Trulicity is not insulin, but rather a non-insulin injectable medication used to improve glycemic control in adults with type 2 diabetes. Interviews with the DON and a corporate RN revealed that MDS assessments were completed offsite, with input from unit managers and the onsite MDS coordinator responsible for scheduling and ensuring timely completion. The staff acknowledged a potential gap in training regarding GLP-1 medications. Facility policy requires accurate assessment and documentation from multiple sources, including clinical records, to support MDS coding, but this process was not followed in this instance, resulting in the incorrect coding of the resident's medication.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Failure to Use Gait Belt During Assisted Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident who required assistance with transfers and ambulation, including the use of a gait belt, was not provided with this safety device during a transfer. The resident had a history of heart failure, acute respiratory failure, muscle weakness, and previous falls, and her care plan indicated she needed partial to moderate assistance with transfers and ambulation, as well as the use of a walker. On the date of the incident, the resident was being assisted to the bathroom with her walker by a nursing assistant, but a gait belt was not used. During this transfer, the resident fell and subsequently experienced increased pain in her left arm and shoulder, which was later diagnosed as a nondisplaced fracture of the neck of the acromion. Interviews and document reviews revealed that while staff generally reported using gait belts for transfers and ambulation, the resident stated that a gait belt was not used at the time of her fall and that staff used the gait belt about 90% of the time. The nursing assistant involved in the incident confirmed that she had not used a gait belt during the transfer and had not been specifically instructed to do so for one-person assists, despite facility policy requiring gait belt use for all such transfers. The care plans did not explicitly direct the use of gait belts, relying instead on facility policy and standard practice.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess and determine the safety of a resident, R205, for self-administration of medications. Despite the resident's hospital discharge orders indicating a severe allergy to onions and the need for an EpiPen, the facility's order summary did not include an order for an EpiPen or epinephrine. The Nursing Minimum Data Set (MDS) for R205 indicated that the resident did not wish to self-administer medications. However, an EpiPen was observed on the resident's bedside table without a pharmacy label or patient identification, and it was not included in the resident's care plan. Interviews with staff revealed that the facility's policy required an assessment for self-administration of medications, which was not conducted for R205. The EpiPen found in the resident's room was expired and improperly labeled. Staff members acknowledged that they would report medications found in a resident's room to a nurse, but this protocol was not followed in R205's case. The Director of Nursing confirmed that an assessment should have been completed if the resident wanted to self-administer medications, and a lockbox should have been provided for safety. The resident stated that staff were aware of the EpiPen in his room, yet no action was taken to secure it or update the care plan accordingly.
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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) |
|---|---|---|---|---|
| Ecumen North Branch | 12.8 mi | ★★★★★ | 0 | 0 |
| The Estates At Rush City Llc | 15.5 mi | ★★★★★ | 7 | 0 |
| Elim Wellspring Health Care Center | 16.4 mi | ★★★★★ | 2 | 0 |
| Meadows On Fairview | 21.2 mi | ★★★★★ | 1 | 0 |
| St Clare Living Community Of Mora | 21.6 mi | ★★★★★ | 8 | 1 |
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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.