Above average — CMS composite of the measures below.
The next survey window likely opens 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 Altercare Cambridge Inc. during CMS and state inspections, most recent first.
PRN psychotropic meds were continued beyond the 14-day limit without documented rationale for two residents. One resident with multiple chronic conditions, including depression and ESRD, had lorazepam ordered PRN for anxiety, and another resident with CHF, COPD, CKD, and panic/anxiety disorder had lorazepam ordered PRN for terminal restlessness despite not being on hospice. The DON confirmed both orders lacked a stop date or rationale.
Incomplete abuse investigation after bruising allegation: A resident with severe cognitive impairment and extensive medical issues developed a right hip area and possible back bruising after staff attempted a sit-to-stand transfer. The facility unsubstantiated the abuse allegation, but the investigation lacked complete witness statements, omitted a statement from a staff member identified as present, and had no documentation of physical assessments for non-interviewable residents, despite policy requiring interviews and written statements from the resident, accused, and witnesses.
Surveyors found that the facility did not manage its operations to ensure effective and efficient use of resources, resulting in noncompliance with regulatory standards.
An LPN was observed pre-pouring meds instead of administering them at the time prepared, and she was also found asleep multiple times during an overnight shift. Staff and a resident reported the nurse grouped med passes together, slept on the couch while on duty, and delayed access to meds and other care needs. The DON confirmed the nurse had worked multiple long shifts and that staff had reported similar concerns before.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
A facility failed to maintain the dignity of a resident with an indwelling urinary catheter. The resident was observed in a public area with catheter tubing on the floor and an uncovered drainage bag containing urine. The ADON confirmed the observation, acknowledging the drainage bag should have been covered.
A resident with Alzheimer's and other conditions was found with long, jagged fingernails despite regular shower schedules. The resident expressed a desire for nail care, which was not initially provided, leading to a deficiency in maintaining activities of daily living. The facility lacked a specific nail care policy.
A resident, dependent on staff for self-care, was found with long, jagged nails and a brown substance underneath them, indicating a failure in providing necessary nail care. Despite the facility's policy on cleanliness during showers, there was no documented evidence of nail care being provided, and no specific nail care policy was available for review. The ADON confirmed the observation, highlighting a lapse in hygiene procedures.
A resident with a history of UTIs was observed with their indwelling urinary catheter tubing lying on the floor under their wheelchair, contrary to infection control practices. The ADON confirmed the improper placement, and the tubing was changed. The facility's infection control policy aimed to prevent healthcare-associated infections, but this incident revealed a lapse in adherence.
The facility failed to post accurate nurse staffing information as required by BIPA. Observations revealed that the BIPA Report indicated a census of 46 residents, while the actual census was 49. The Administrator acknowledged that the BIPA Report was outdated and did not reflect the current census, potentially affecting all 49 residents.
A facility failed to ensure the accuracy of a PASRR document for a resident, which did not reflect the use of anti-anxiety medication and a psychiatric hospitalization. The resident, with multiple diagnoses including Alzheimer's and major depressive disorder, was receiving Xanax as per physician orders, but the PASRR inaccurately indicated no such medication. Additionally, the document failed to note a prior psychiatric hospitalization. The Social Services Designee confirmed these inaccuracies.
A facility failed to change and document oxygen tubing weekly for a resident using supplemental oxygen. Observations showed undated tubing, and interviews with staff confirmed the tubing was not replaced as per policy. The resident, with chronic conditions, used oxygen daily, but there was no documentation of routine tubing changes in the medical record or MAR.
A facility failed to ensure consistent communication with a dialysis center for a resident with end-stage renal disease, resulting in missing dialysis visit notes for 13 out of 14 treatments. The resident's medical record also inaccurately reflected a fluid restriction order, with discrepancies between care plans and meal tickets. Staff interviews revealed a lack of awareness about the resident's fluid restriction, contributing to the deficiency in providing safe dialysis care.
A facility failed to follow appropriate transmission-based precautions for a resident with Clostridium difficile. An Activity Coordinator was observed sitting on the resident's bed with an improperly secured gown, allowing her pants to contact the bed linens, despite the resident being on contact precautions. The staff member acknowledged the oversight during an interview.
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical records. An unattended medication cart with the resident's information visible on the computer screen was observed, and a nurse confirmed leaving the information exposed while attending to the resident. The facility's HIPAA policy was not followed.
The facility failed to ensure medications were not left unattended on top of the medication cart and failed to ensure the medication cart was locked while unattended. This incident had the potential to affect three cognitively impaired and independently mobile residents. The nurse verified she had left the cart unlocked and the medication unattended because the resident wanted to take the medication after eating.
The facility failed to ensure staff performed proper hand hygiene during medication administration, affecting two residents. A Registered Nurse administered medication to one resident and then prepared and administered medication to another without washing her hands in between. This pattern continued with a third resident, although the nurse did wash her hands after the administration. The facility's policies required hand washing before handling medications and after resident contact.
PRN Psychotropic Medications Continued Without Required Rationale
Penalty
Summary
The facility failed to ensure as-needed psychotropic medications were not used beyond 14 days without a documented rationale. Resident #1 was admitted with multiple diagnoses including sepsis, pneumonia, dysphagia, end stage renal disease, chronic respiratory failure with hypoxia, congestive heart failure, hypertension, rheumatoid arthritis, macular degeneration, depression, chronic kidney disease, osteoarthritis, and atrial fibrillation. The resident’s quarterly MDS showed intact cognition, no behaviors, and no antipsychotic use, yet the December 2025 physician’s orders included lorazepam 0.5 mg twice daily as needed for anxiety with no rationale documented. A pharmacy note dated 12/10/25 stated the resident was receiving lorazepam as needed for longer than 14 days and requested documentation of the rationale and duration if the medication was to continue; the note was signed by the NP on 12/22/25. The DON confirmed the medication had been given longer than 14 days without a stop date or rationale. Resident #51 also had lorazepam ordered beyond the 14-day limit without a documented rationale. This resident was admitted with diagnoses including metabolic encephalopathy, streptococcal infection, dysphagia, cognitive communication deficit, CHF, UTI, COPD, atrial fibrillation, CKD, depression, panic disorder/anxiety disorder, and low back pain. The December 2025 physician’s orders included lorazepam 0.5 mg every four hours as needed for terminal restlessness, and the resident was not receiving hospice services. During interview on 12/22/25, the DON verified Resident #51 was on lorazepam for longer than 14 days without a stop date or rationale.
Incomplete Abuse Investigation After Bruising Allegation
Penalty
Summary
The facility failed to complete a thorough investigation after an allegation of physical abuse involving a resident who was severely cognitively impaired and required physical assistance with ADLs. Resident #55 had been admitted with diagnoses including infection following a surgical procedure, cellulitis, muscle weakness, dysphagia, cognitive communication deficit, repeated falls, fracture of the left femur, acute respiratory failure with hypoxia, anemia, and anxiety. The allegation began after the resident’s daughter reported bruising on the resident’s right hip and possibly small bruises on her back after the resident had been discharged to the hospital for a non-SRI related critical lab finding. Facility staff reported that over the weekend prior to the allegation, they attempted to use a sit-to-stand mechanical lift to transfer the resident, and the resident leaned to the right, had to be encouraged to keep her feet in place, and rubbed her right hip against the device while leaning into the back support brace. Staff later noticed a small reddened/pink area on the right hip during care, and the CNA notified the nurse before the resident was sent to the hospital. The facility unsubstantiated the abuse allegation, but the investigation was incomplete because witness statements lacked dates and times, one phone statement lacked the staff member’s last name and title, no statement was obtained from a staff member identified as present during the incident, and there was no documentation that non-interviewable residents were physically assessed for abuse. The DON and Administrator confirmed these gaps during interview, and the facility policy required interviews and written statements from the resident, accused, and witnesses.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of its resources. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standards for resource management as outlined in regulatory guidelines. No specific details regarding individual residents, staff actions, or particular events leading to this deficiency are provided in the report.
LPN Pre-Poured Medications and Slept During Shift
Penalty
Summary
The facility failed to ensure care and services were provided within acceptable standards of quality when an LPN was observed pre-pouring resident medications and was also observed sleeping multiple times during the shift. Review of the LPN’s timecard showed she worked a 17.75-hour shift, and photographs taken during the shift showed her standing at the medication cart with the drawer open and multiple medication cups prepared with loose pills already placed in them. The facility’s medication administration policy stated medications are to be administered at the time they are prepared and are not to be pre-poured in advance or for more than one resident at a time. Interviews confirmed the medication practice. A CNA stated the LPN grouped medication administration times together so she only had one medication pass, and residents questioned their medications while the LPN told them the medications were correct and gave them anyway. The LPN confirmed she was the nurse in the photograph and said she had occasionally pre-poured medication to get a jump start on the day. The DON stated she was not aware the LPN was pre-pouring medications and that staff should not pre-pour medications for later administration. The report also documented repeated observations of the LPN asleep while on duty. A resident posted photographs on Facebook showing the LPN asleep on a couch in the common area, and additional pictures and videos showed her asleep at multiple times during the overnight shift. The self-reported incident investigation included statements that the LPN was found sleeping when staff needed medication room keys, that a lab technician could not wake her, and that a resident reported waiting almost six hours for pain medication. Other staff stated they had previously observed the LPN sleeping on the unit and that she had worked multiple shifts over 16 hours. The DON confirmed the LPN had worked several 16-hour shifts and that staff had reported her sleeping and not administering medications or assessing residents.
Failure to Provide Safe, Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #100, who was admitted with a history of urinary tract infections and other medical conditions, including neurocognitive disorder with Lewy bodies, dementia, prostate cancer, obstructive uropathy, and an indwelling urinary catheter. During an observation, Resident #100 was seen sitting in a wheelchair in the lobby/TV area with another resident. The resident's indwelling urinary catheter tubing was lying on the floor without a barrier under the wheelchair, and yellow urine was visible in the uncovered collection drainage bag. The Assistant Director of Nursing verified the observation and acknowledged that the drainage bag should have been covered. This incident was noted as a deficiency in maintaining resident dignity, as outlined in the facility's policy on Resident Rights.
Failure to Provide Necessary Nail Care
Penalty
Summary
The facility failed to provide necessary nail care for a resident, leading to a deficiency in maintaining the resident's ability to perform activities of daily living. The resident, who was admitted with diagnoses including Alzheimer's disease, acute kidney failure, anxiety disorder, and delusions, was observed to have long, jagged fingernails with brown debris underneath. Despite being scheduled for showers twice a week, the resident's fingernails were not trimmed or cleaned, which was contrary to the facility's policy of promoting cleanliness and observing the condition of residents' skin during showers. The resident expressed a desire to have his nails cut, as he did not have clippers and found his nails to be thick and tough. The resident's request for nail care was communicated to an LPN, who verified the condition of the nails and promised to assist. The facility's policy did not include specific guidelines for nail care, and the deficiency was noted during a complaint investigation. The lack of a specific nail care policy and the failure to address the resident's needs in a timely manner contributed to the deficiency.
Failure to Provide Necessary Nail Care
Penalty
Summary
The facility failed to ensure that dependent residents received necessary nail care, as evidenced by the case of a resident who was observed with long, jagged nails and a brown substance underneath them. This resident, who was cognitively intact but required substantial assistance with bathing and hygiene, was admitted with multiple diagnoses including heart failure and a non-traumatic brain injury. Despite being dependent on staff for self-care, there was no documented evidence that nail care was provided during a shower given by hospice staff. The facility's policy on showers and tub baths emphasized cleanliness and the observation of skin condition, including cleaning debris from under fingernails. However, the policy did not allow for trimming nails unless instructed by a supervisor, and there was no specific nail care policy available for review. The Assistant Director of Nursing confirmed the observation of the resident's unkempt nails, highlighting a lapse in the facility's adherence to its own hygiene procedures.
Inadequate Infection Control for Indwelling Catheter
Penalty
Summary
The facility failed to maintain adequate infection control practices for a resident with an indwelling urinary catheter. The resident, who had a history of urinary tract infections and other medical conditions, was observed with the catheter tubing lying on the floor under their wheelchair. This observation was made in the lobby/TV area across from the nursing station, and the Assistant Director of Nursing verified the improper placement of the tubing at the time of observation. The tubing was subsequently changed due to its contact with the floor. The facility's infection control program, as outlined in their policy dated November 2020, was intended to implement prevention measures to control healthcare-associated infections. However, the incident involving the resident's catheter tubing on the floor indicates a lapse in adhering to these infection control practices. Interviews with the Assistant Director of Nursing and a Licensed Practical Nurse confirmed that the catheter tubing should not have been in contact with the floor, highlighting a deficiency in maintaining proper infection prevention measures.
Inaccurate Nurse Staffing Information Posting
Penalty
Summary
The facility failed to post accurate nurse staffing information as required by the Benefits Improvement and Protection Act (BIPA). On December 30, 2024, observations at the reception area and two nursing stations revealed that the BIPA Report indicated a census of 46 residents, while the actual census was 49, as confirmed by the Daily Census Report. The Administrator acknowledged that the BIPA Report, printed on December 27, 2024, to cover the weekend, was outdated and did not reflect the current census. This discrepancy was verified through interviews with the Administrator and a receptionist, confirming that the posted BIPA Reports did not accurately represent the daily census, potentially affecting all 49 residents in the facility.
Inaccurate PASRR Documentation for Resident
Penalty
Summary
The facility failed to ensure the accuracy of a Pre-Admission Screening and Resident Review (PASRR) document for a resident, which did not reflect the use of anti-anxiety medication and a psychiatric hospitalization. The resident, who was admitted with diagnoses including metabolic encephalopathy, Alzheimer's disease, major depressive disorder, delusional disorder, dementia with psychotic disturbance, and panic disorder, was found to be severely cognitively impaired and receiving anti-anxiety medication as per the Minimum Data Set (MDS) 3.0 assessment. However, the PASRR document inaccurately indicated no anti-anxiety medication was being used and failed to note a prior inpatient psychiatric hospitalization. The resident's physician orders confirmed the prescription of Xanax 0.5 mg to be administered three times daily, and the medication administration record showed the medication was given as ordered. Additionally, the resident's medical record documented a psychiatric hospitalization due to increased confusion, paranoia, delusions, and other symptoms. During an interview, the Social Services Designee acknowledged the inaccuracies in the PASRR document.
Failure to Change and Document Oxygen Tubing
Penalty
Summary
The facility failed to ensure that oxygen tubing was changed weekly and documented as administered in the medical record for a resident using supplemental oxygen. Observations of the resident over several days revealed that the oxygen tubing and nasal cannula were not dated, indicating a lack of routine replacement. The resident, who has chronic obstructive pulmonary disease, Parkinson's disease, and a history of cerebrovascular accident, uses supplemental oxygen daily while in bed. Despite physician orders for supplemental oxygen as needed, there was no order for routine replacement of the oxygen tubing. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the oxygen tubing was supposed to be changed weekly by a contracted company, but there was no documentation to verify this had occurred. The facility's policy required changing the oxygen tubing and nasal cannula every seven days, but this was not adhered to, as evidenced by the lack of documentation in the medical record and Medication Administration Record (MAR). The deficiency affected the resident's care, as the facility did not follow its policy or ensure proper documentation of oxygen therapy administration.
Inadequate Communication and Fluid Restriction Management for Dialysis Resident
Penalty
Summary
The facility failed to ensure consistent communication between the facility and the dialysis center regarding a resident's hemodialysis treatments. The medical record for the resident, who was diagnosed with end-stage renal disease, dependence on renal dialysis, pulmonary hypertension, and congestive heart failure, was missing dialysis visit notes for 13 out of 14 treatments in the past 30 days. These notes were supposed to include vital information such as pre-weight, dry weight, vital signs, medications administered, and how the resident tolerated the treatment. Interviews with the resident and staff confirmed the lack of communication and documentation, with the facility relying on occasional phone calls from the dialysis center for updates. Additionally, the facility failed to ensure the resident's medical record accurately reflected the current order for a fluid restriction. The resident had a physician's order for a 1,500 ml/day fluid restriction, but the care plans and meal ticket were inconsistent, with one care plan indicating a 1,200 ml/day restriction. The resident was observed with a can of pop and a full Styrofoam cup of water in her room, and she was unsure if she was on a fluid restriction. Interviews with staff revealed a lack of awareness about the resident's fluid restriction, with the STNA providing the same amount of water as other residents. The Director of Nursing and an RN verified the discrepancies in the resident's care plans, physician's orders, and meal ticket regarding the fluid restriction. They acknowledged the lack of communication and documentation from the dialysis center and confirmed that the resident's current order was for a 1,500 ml/day fluid restriction. The staff's lack of awareness and the inconsistencies in documentation contributed to the deficiency in providing safe and appropriate dialysis care for the resident.
Failure to Follow Contact Precautions for a Resident
Penalty
Summary
The facility failed to adhere to appropriate transmission-based precautions for a resident on contact precautions. Resident #253, who was admitted with diagnoses including enterocolitis due to Clostridium difficile, sepsis, pneumonia, and chronic obstructive pulmonary disease, was required to remain in his room under contact precautions due to a highly transmissible disease. Despite this, an observation revealed that the Activity Coordinator (AC) #192 was in Resident #253's room, sitting on the edge of the resident's bed while wearing a protective gown and gloves. However, the gown was improperly secured, leaving a three to four-inch opening that allowed AC #192's pants to come into contact with the bed linens. During an interview, AC #192 acknowledged the resident's contact precautions for C-Diff and admitted that she should not have been sitting on the resident's bed with her personal clothing exposed and in contact with the bed linens. This incident highlights a lapse in following the necessary infection prevention protocols, as the staff member's actions did not align with the required precautions for a resident with a highly transmissible disease.
Failure to Ensure Privacy of Resident's Medical Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of Resident #40's personal and medical records. During an observation on 04/16/24 at 7:22 A.M., it was noted that the medication cart was left unattended outside room [ROOM NUMBER] with Resident #40's information visible on the computer screen. This lapse in protocol allowed any passerby to view the resident's private health information. Resident #40 had a complex medical history, including muscle weakness, chronic obstructive pulmonary disease, diabetes, hypertension, rheumatoid arthritis, major depressive disorder, anxiety disorder, respiratory failure, polyneuropathy, glaucoma, vitamin D deficiency, congestive heart failure, low back pain, irritable bowel syndrome, ulcerative colitis, diverticulitis, intervertebral disc degeneration, chronic pain syndrome, and adult failure to thrive. An interview with Registered Nurse #110 confirmed that she had left Resident #40's private health information up on the computer screen while attending to the resident in their room. The facility's undated HIPAA policy clearly states that protected health information should not be left in locations where it could be seen by unauthorized individuals and that unattended medical records should be kept behind the nurse's station. This incident was identified as an incidental finding during the investigation of Complaint Number OH00152284.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure medications were not left unattended on top of the medication cart and failed to ensure the medication cart was locked while unattended. This incident had the potential to affect three cognitively impaired and independently mobile residents out of 21 on the Rodeo Unit. The facility census was 49. During an observation, the medication cart was found outside a room, unlocked, with a plastic medicine cup containing 12 tablets for a resident. The medications included aspirin, Buspar, Carafate, vitamin D3, Dicyclomine, Duloxetine, Hydroxychloroquine, Lasix, Leflunomide, Lyrica, Pantoprazole, and Sulfasalazine. The nurse verified she had left the cart unlocked and the medication unattended because the resident wanted to take the medication after eating. The facility's policy on medication administration, dated 05/20, stated that the medication cart should be kept closed and locked when out of sight of the medication nurse or aide, and no medication should be kept on top of the cart. Additionally, privacy was to be maintained for all resident information when not in use. This deficiency was identified as an incidental finding during the investigation of a complaint.
Failure to Perform Proper Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure staff performed proper hand hygiene during medication administration, affecting two residents out of four observed. Specifically, a Registered Nurse administered medication to one resident and then proceeded to prepare and administer medication to another resident without washing her hands in between. This pattern continued as the nurse prepared and administered medication to a third resident without washing her hands prior, although she did wash her hands after the administration. An interview with the Registered Nurse confirmed that she had not washed her hands after administering medication to the first resident, before and after administering medication to the second resident, and prior to administering medication to the third resident. The facility's hand washing policy, dated November 2020, and the medication administration policy, dated May 2020, both required staff to wash their hands before preparing or handling medications and after coming into direct contact with a resident. This deficiency was identified during the investigation of a complaint.
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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) |
|---|---|---|---|---|
| Embassy Of Cambridge | 1.3 mi | ★★★★★ | 3 | 0 |
| The Enclave At Cambridge | 4.4 mi | ★★★★★ | 20 | 0 |
| Continuing Healthcare At Beckett House | 9.6 mi | ★★★★★ | 2 | 0 |
| Riverside Manor Nrsg & Rehab Ctr | 14.4 mi | ★★★★★ | 4 | 0 |
| Lafayette Pointe Nursing & Rehab Ctr | 16.8 mi | ★★★★★ | 1 | 0 |
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