Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 The Enclave At Cambridge during CMS and state inspections, most recent first.
Incomplete comprehensive care plans were identified for multiple residents. A resident with PTSD lacked a plan addressing triggers and re-traumatization, another resident with poor dentition had no dental care plan despite broken and missing teeth, a resident with severe pain had no pain management plan, and another resident with multiple diagnoses had an incomplete care plan that did not include several MDS-identified care areas.
A resident with moderate cognitive impairment and incontinence was repeatedly observed eating meals with urinals containing urine left on the tray table beside his food. Despite care plan interventions addressing the risk of cross-contamination and the need to keep urinals off the table, staff did not remove the urinals during meal times, compromising the resident's dignity.
Failure to provide adaptive equipment for mobility needs affected two residents. One resident with intact cognition reported difficulty using the toilet because no bathroom handrails or toilet adaptive equipment were present, and the Maintenance Director confirmed wall-mounted equipment had been removed during construction and not replaced. Another cognitively intact resident with CVA-related weakness and chronic pain reported needing bed side rails for turning and safety; the care plan and bed rail assessment referenced side rails, but the DON confirmed they were not in place until later, and the Maintenance Director said they were installed after the resident requested them.
Failure to report new onset pain after a fall: A resident with multiple chronic conditions, including AFib, Alzheimer's disease, chronic pain, and a mechanical heart valve on Coumadin, had an unwitnessed fall with bruising to the lower back. Although the resident initially denied pain and the NP was notified, later that day the resident complained of generalized pain and received Bio-Freeze to both knees without documentation of provider notification. The MAR documented pain scores with routine analgesic use, but did not identify the pain location or character, and the ADON confirmed no provider notification occurred.
Two residents with intact cognition and discharge-home goals were given NOMNCs that did not identify which skilled services were ending. One notice was signed the day before coverage ended and the other on the last covered day, and the SSD confirmed both residents were not given the required 48-hour notice.
Failure to Timely Report Alleged Misappropriation: A resident alleged that a wallet with cash and personal documents was missing from a drawer, and the issue was investigated and later found unsubstantiated. The allegation was reported to staff, but the Abuse Coordinator was not notified until later, delaying the SRI to the state agency. The resident had multiple medical diagnoses and was moderately cognitively impaired.
Incomplete transfer/discharge documentation for a resident sent from a provider visit to the ED. The resident had acute respiratory failure w/ hypoxia, hemiplegia/hemiparesis, hyperkalemia, DM2, weakness, and a BIMS of 11. The chart lacked the reason for the ER evaluation, the receiving hospital/facility, the admission date, and any transfer/discharge summary. The ADON confirmed the resident was hospitalized from the appointment, but the record did not include the required notice, bed-hold/return info, or communication to the receiving provider.
Toenails Not Kept at Desirable Length: A resident who required substantial to maximum assistance with personal hygiene had long toenails that were observed by an LPN and confirmed by the resident, who said they needed trimmed badly and had not seen a podiatrist in a while. Staff gave conflicting statements about who handled ancillary services and podiatry scheduling, and the podiatrist had recently been in the building.
Failure to comprehensively assess and monitor skin alterations affected three residents. One resident with diabetic foot wounds and a heel ulcer had no documented comprehensive assessment of the toes and heel for weeks, despite outside wound care notes and weekly skin checks. Another resident with venous/arterial ulcers and MASD had buttock skin changes observed, but the WNP did not assess the area. A third resident had multiple purple bruises on the arms and legs that were not documented in the chart.
A resident with multiple chronic conditions and a coccyx pressure ulcer had an incomplete initial wound assessment and delayed treatment documentation. The admission assessment noted a suspected DTI on the coccyx without measurements, a progress note did not address the wound, and the physician order for wound care was not entered until later. The ADON later stated she had measured the wound on paper, but the measurements and full wound details were not entered into the EMR or hard chart.
Failure to supervise residents during smoking sessions. A resident with stroke, cognitive impairment, multiple comorbidities, and a smoking care plan requiring supervision was taken outside with another resident who also needed supervision. A CNA lit cigarettes, then left both residents unsupervised while one was actively smoking to go back inside for different cigarettes, which the CNA later confirmed. The facility smoking policy required direct supervision at all times for residents needing monitoring.
Failure to provide timely incontinence care: A resident who was dependent for all care and on a toileting program was not routinely checked or changed as directed. Staff reported two-hour rounding, but the resident said she was usually checked only once at night, was observed with a strong urine odor, and was taken to lunch without being checked for incontinence or offered toileting assistance.
Respiratory care was not properly managed for two residents. One resident with chronic respiratory failure, COPD, and heart failure had continuous oxygen ordered, but his humidification bottle was empty and he reported it had been empty for a week. Another resident with acute respiratory failure with hypoxia had no active oxygen order in the chart, while the concentrator was set at 4 L and he was not wearing his nasal cannula; RN confirmed the order could not be found and the resident was supposed to be on 2 L.
Failure to assess and implement trauma informed care for a resident with PTSD, dementia, depression, anxiety, bi-polar disorder, and DM. The resident’s MDS showed cognitive intactness and a PTSD dx, but the care plan did not address the cause of PTSD, triggers for re-traumatization, or interventions to reduce re-traumatization risk. Record review found no assessment of PTSD causes or triggers, and the SS Director verified no such assessment or care plan had been completed.
A resident with Parkinson's disease and muscle weakness had upper dentures only and reported sore gums from chewing, but no one had offered dental services. The SSD said nurses add residents to the dental list, while the DON said the social worker was responsible for signing residents up upon admission and was unaware this had not been done.
A facility failed to resubmit a PASARR for a resident after a new diagnosis of anxiety was added to their medical record. The resident had existing diagnoses of dementia, cerebrovascular accident, and bipolar disorder. An LPN confirmed that a new PASARR should have been submitted following the new diagnosis.
A resident with multiple diagnoses was not provided with a walker or enrolled in a restorative program despite physical therapy recommendations. Observations showed the resident using a wheelchair, and interviews confirmed the lack of follow-through on therapy recommendations, leading to a deficiency in maintaining the resident's ability to perform activities of daily living.
The facility failed to maintain a pest-free environment, affecting two residents who experienced issues with flies and gnats in their rooms. One resident reported a long-standing problem with flies, and both residents were provided with flyswatters. During wound care, pests were observed on and around a resident. The DON confirmed awareness of the issue, and the exterminator suggested using bleach as a treatment.
Incomplete Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed for four residents reviewed. Resident #38, admitted with diagnoses including muscle wasting and atrophy, spondylosis, hypercalcemia, anxiety disorder, anemia, depression, and hyperlipidemia, had a care plan that addressed nutrition risk and a separate plan noting sadness, anxiety, and despair related to illness losses, but no additional completed care plan items were present. The MDS indicated intact cognition and identified care areas to be included in the care plan for communication, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, pressure ulcer, and psychotropic drug use. The MDS nurse confirmed the comprehensive care plan was not completed. Resident #4, admitted with GERD, nausea, and dysphagia, was observed with missing, broken, and decayed teeth and reported needing dental evaluation for extractions and dentures, yet the comprehensive plan of care contained no dental care plan. Resident #2, admitted with dementia, diabetes, depression, anxiety disorder, bipolar disorder, and PTSD, had an MDS showing intact cognition and PTSD, but the care plan did not address the cause of PTSD, triggers for re-traumatization, or interventions to reduce re-traumatization. Resident #5, admitted with stroke affecting the right side, diabetes, hypertension, anxiety, lung disease, bipolar disorder, aphasia, bilateral amputations, and significant cognitive impairment, had pain rated 9/10 on the MDS with pain affecting sleep and ADLs, but the initial care plan did not include pain management; this was later verified by the MDS coordinator.
Failure to Preserve Resident Dignity During Meals Due to Urinals Left Beside Food
Penalty
Summary
A deficiency was identified when a resident was observed dining with urinals containing urine placed on the tray table beside his food. Multiple observations over two days confirmed that the resident's urinals, each half full, were left on the bedside or tray table during meal times, including during breakfast and lunch. The presence of urinals next to food was confirmed by a registered nurse, who acknowledged that this was inappropriate. The resident involved had a history of acute respiratory failure, hemiplegia, diabetes, muscle weakness, and moderate cognitive impairment, requiring assistance with activities of daily living and incontinence care. The care plan noted the risk of infection or cross-contamination due to the resident keeping urinals on the bedside table with food and other items, and interventions included education and encouragement to keep urinals off the table. Despite these interventions, staff did not ensure the removal of urinals from the dining area, resulting in a failure to preserve the resident's dignity during meals.
Failure to Provide Adaptive Equipment for Mobility Needs
Penalty
Summary
The facility failed to provide necessary adaptive equipment to promote mobility for two residents. Resident #47, who had diagnoses including encephalopathy, type 2 diabetes mellitus with hyperglycemia, atherosclerotic heart disease with angina pectoris, essential hypertension, hyperlipidemia, vitamin D deficiency, convulsions, and a personal history of transient ischemic attack, had a BIMS score of 13, indicating intact cognitive function. During interview and observation, the resident stated she had difficulty getting on and off the toilet because there were no handrails in her bathroom, and observation confirmed there were no handrails beside or near the toilet and no adaptive toilet equipment present. The Maintenance Director confirmed that no adaptive equipment or handrails were available in the bathroom because recent construction had required removal of wall-mounted assistive equipment and it had not been replaced. Resident #33, who had diagnoses including cerebral infarction, limitation of activities due to disability, muscle weakness, major depressive disorder, and chronic pain, was cognitively intact and receiving PT and OT. The care plan identified a fall risk with an intervention for 1/2 side rails as enablers, and a bed rail assist device assessment documented that side rails were in place. However, the resident reported concern with mobility and stated she had side rails in her previous room, had asked for them in her current room, and did not receive them until later. The DON confirmed the resident did not have side rails until the day before the interview and stated the siderails had been removed after the resident was assessed not to need them, while the Maintenance Director confirmed the side rails were placed on the bed after being told the resident had requested them.
Failure to Report New Onset Pain After a Fall
Penalty
Summary
The facility failed to report new onset of pain to the medical provider after a resident had an unwitnessed fall. Resident #10 was admitted with multiple diagnoses including diabetes, bipolar disorder, atrial fibrillation, Alzheimer's disease, heart failure, degenerative joint disease of the thoracic spine, an artificial heart valve requiring chronic blood thinner therapy, morbid obesity, and chronic pain. The quarterly MDS showed the resident was dependent for all care and required assistance with wheelchair navigation. The most recent pain assessment documented chronic mild pain to the sacral region and use of scheduled and as-needed pain medication. On 08/18/25 at 7:15 A.M., the resident had an unwitnessed fall in the room with bruising to the right lower back. At that time, the resident denied pain or discomfort and the nurse practitioner was notified. Later that same day at 9:52 P.M., nursing documentation showed the resident complained of generalized pain and Bio-Freeze was applied to both knees, but there was no documentation that the medical provider was notified of this new onset of pain after the fall. The MAR for August 2025 documented pain scale ratings with routine pain medication administration, but did not specify the location or character of the pain. During interview, the ADON confirmed there was no provider notification for the pain and stated the facility did not have an official fall policy, only an undated and unsigned Fall Checklist kept at nurses' stations.
NOMNC forms lacked required service details and 48-hour notice
Penalty
Summary
The facility failed to ensure residents were given proper Notice of Medicare Non-Coverage (NOMNC) information for the end of skilled services and failed to ensure the notices identified which skilled services were being discontinued. Review of NOMNC forms, interviews, and policy showed that two residents were affected. One resident was admitted with diagnoses including other specified disorders of muscle and muscle weakness, had intact cognition, and wanted to discharge home. His care plan reflected discharge planning goals, but the NOMNC stated only that Medicare services would end and did not specify what type of Medicare services were ending; the notice was signed by the resident one day before the listed end date. A second resident was admitted with diagnoses including unspecified convulsions and other lack of coordination, had intact cognition, and was also planning to discharge home. His care plan identified the stay as short term with discharge home planned, but the NOMNC only stated the last day covered for skilled services and did not identify which skilled services were ending; it was signed on the same day the coverage ended. During interview, the Social Service Director stated she had residents sign NOMNCs the day she received them and was not sure of the required time frame. She confirmed both residents were not given 48-hour notice of the end of skilled services and that the NOMNCs did not specify which services were ending.
Failure to Timely Report Allegation of Misappropriation
Penalty
Summary
The facility failed to timely report an allegation of misappropriation involving one resident. The resident alleged that a wallet containing $420.00, identification, and a social security card was missing from a nightstand drawer after having it earlier the same day. A search of the resident’s room was started that evening, and the allegation was later investigated and found to be unsubstantiated; law enforcement was contacted and the resident was refunded $420.00. The resident had been admitted with diagnoses including infection of an internal hip prosthesis, heart failure, anxiety disorder, and chronic pain syndrome, and the MDS described the resident as moderately cognitively impaired. The allegation was made to facility staff, and an investigation was initiated, but the Abuse Coordinator was not notified until two days later. The Administrator confirmed that the SRI was not filed timely because the allegation of misappropriation was reported to staff on one day and not brought to management until later, at which point the SRI was filed with the state agency. The facility policy required the Administrator or DON to be immediately notified of suspected abuse and required suspected abuse to be reported immediately, no later than 24 hours when there was no serious bodily injury.
Incomplete Transfer and Discharge Documentation
Penalty
Summary
The facility failed to ensure complete transfer or discharge information for one resident who was hospitalized after an outpatient provider requested emergency room evaluation. Resident #12 was admitted with diagnoses including acute respiratory failure with hypoxia, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, hyperkalemia, type 2 diabetes mellitus, muscle weakness, and muscle wasting. The resident’s MDS showed a BIMS score of 11, indicating moderate problems with thinking and memory, and the resident used a walker, required partial to moderate assistance for mobility, had one-sided lower extremity impairment, and was occasionally incontinent of urine and frequently incontinent of bowel. Progress notes showed the facility was notified that the resident was sent from an appointment to the emergency room, but the record did not document the reason for the evaluation. Later that evening, the facility was informed by the ED that the resident would either be admitted or transferred to another facility due to anemia and elevated cardiac enzymes, but there was no further documentation identifying where the resident was admitted or the date of admission. The medical record did not contain transfer or discharge documentation, and the ADON confirmed that the resident was admitted to the hospital from a physician appointment. The facility policy required written transfer or discharge notice, bed-hold and return policy information in emergency transfers, nursing documentation of orientation and preparation, and communication of transfer or discharge information to the receiving facility or provider.
Toenails Not Kept at Desirable Length
Penalty
Summary
Provide care and assistance with activities of daily living for residents unable to do so was not met when the facility failed to ensure a resident’s toenails were kept at a desirable length. Resident #38 was admitted with diagnoses including muscle wasting and atrophy and spondylosis. Her MDS indicated cognition was intact, she had no behaviors, and she required substantial to maximum assistance with personal hygiene. During interview, the resident stated her toenails were bad and that she had not seen a podiatrist in a while. On observation, the resident was seated in the therapy gym and the LPN looked at her feet and confirmed her toenails were long. The resident told the nurse her nails needed trimmed badly and agreed to have them filed down until she could see a podiatrist. The LPN stated the podiatrist had been at the facility the previous week and said nursing staff could clean and file nails but not actually cut them. The SSD stated the podiatrist had been in the building on two recent days and said there would have been enough time to get the resident on the list to be seen, while the admission staff stated she did not offer ancillary services upon admission and the SSD was in charge of that; the SSD then stated she was not in charge of ancillary services.
Failure to comprehensively assess and monitor skin alterations
Penalty
Summary
The facility failed to ensure skin alterations were comprehensively assessed and monitored for three residents. Resident #1 had multiple foot wounds and a right heel wound related to diabetes, gangrene, osteomyelitis, and limited mobility. Outside wound provider notes documented gangrene of the left great toe, traumatic ulceration of the right great toe, and later a new diabetic ulcer on the right heel. Although weekly skin assessments and ongoing treatment were documented, there was no evidence of a comprehensive assessment of the right and left great toes or the right heel from 11/29/25 through 12/17/25. Staff confirmed the resident’s feet were not comprehensively measured or assessed in December, and the resident refused one dressing removal because the wound center appointment had been cancelled and the dressing had already been changed. Resident #8 had documented venous and arterial ulcers and was also identified as having shearing and MASD to the buttocks. The care plan and orders included weekly skin assessment and treatment to the buttocks, and treatment records showed moisture barrier ointment had been applied three times daily since 02/14/25. However, the weekly skin assessment and the visiting wound nurse note did not show a comprehensive assessment of the MASD on the buttocks. On observation, the resident had red blanchable areas on both buttocks, and nursing staff confirmed the wound nurse had only looked at the resident’s feet and had not assessed the buttocks. Staff also confirmed there was no comprehensive assessment after the MASD was noted to determine whether the area was improving or worsening. Resident #35 had no documented skin impairments in nursing notes, orders, treatment records, or skin checks, yet observation showed multiple round, purple bruises on both arms and legs. The DON confirmed there was no indication in the resident’s records of bruising. Additional observation and interview with the DON again confirmed multiple purple scattered bruises on the resident’s bilateral arms. The record did not show that the bruising had been documented as a skin issue.
Delayed pressure ulcer assessment and treatment
Penalty
Summary
Facility failed to ensure a timely comprehensive pressure ulcer assessment and treatment for one resident with a pressure ulcer on the coccyx. The resident was admitted with diagnoses including encounter for surgical aftercare following amputation, acquired absence of the right leg above knee, COPD, CHF, and history of cerebral infarction. The baseline care plan noted occasional urinary and bowel incontinence and pain of the coccyx and right knee. The care plan identified a pressure ulcer with interventions to administer ordered treatments and monitor dressing integrity. The nursing admission assessment documented a suspected deep tissue injury on the coccyx, but it did not include wound measurements and listed only padding and protection as treatment. A skilled nursing progress note the next day documented no changes in skin integrity and did not mention the coccyx pressure ulcer. A physician order for wound cleansing, medihoney, calcium alginate, and a dry dressing was not entered until two days after admission, and the wound NP note identified the resident as having an unstageable coccyx pressure ulcer. The treatment administration record showed the ordered dressing change first occurred the following day. The ADON initially stated there was no evidence of a complete assessment with measurements until the wound NP evaluated the resident, then later stated she had completed an initial assessment and measurements on paper, but those measurements were not in the EMR or hard chart. The paper pressure skin condition record showed the coccyx ulcer was first observed on admission day with measurements of 2 cm by 1.3 cm by 0.1 cm, but the wound characteristics and wound bed sections were left blank. The facility policy required initial assessment, documentation, and measurement by the nurse who discovers the area.
Failure to Supervise Residents During Smoking
Penalty
Summary
The facility failed to provide adequate supervision during smoking sessions for two residents. Resident #5 had diagnoses including stroke with right-sided involvement, diabetes, hypertension, anxiety, lung disease, bipolar disorder, aphasia, a left above-knee amputation, and a right below-knee amputation. The resident’s MDS assessment showed moderate to severe cognitive deficit, and the resident was dependent for all care, including bathing and dressing, and required assistance with wheelchair navigation. The most recent smoking safety evaluation indicated Resident #5 required assistance with lighting smoking materials and supervision during smoking, and the care plan stated the resident required supervision while smoking. During an observation, a CNA took Resident #5 and another resident, Resident #47, outside to the smoking area and lit a cigarette for Resident #47 before giving Resident #5 a cigarette. When Resident #5 said the cigarettes were the wrong kind and requested regular cigarettes instead of menthol, the CNA left both residents in the smoking area and went back inside to retrieve different cigarettes. Resident #5 and Resident #47 were left unsupervised while Resident #47 was actively smoking. The CNA later confirmed she had left the two residents alone during the smoking session. The facility smoking policy stated that any resident with restricted smoking privileges requiring monitoring must have direct supervision at all times while smoking.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident who was admitted with diagnoses including diabetes, bipolar disorder, atrial fibrillation, Alzheimer's disease, heart failure, degenerative joint disease of the thoracic spine, an artificial heart valve with chronic blood thinner use, morbid obesity, and chronic pain. The quarterly MDS showed the resident was dependent for all care, including toileting, and was incontinent of bowel and bladder with a toileting program. The active care plan directed toileting assistance and incontinence care every two hours to prevent skin breakdown related to frequent bowel and bladder incontinence. Observation and interviews showed the resident reported staff usually completed a check and change only once at night and did not routinely check during the day. A bedside commode was present in the room, and later the resident was observed in the activities room with a strong odor of stale urine coming from her immediate vicinity. A CNA acknowledged the resident had not been checked or toileted since returning from a doctor's appointment after lunch and that someone else may have provided care. On another observation, the resident was taken to lunch by a CNA without being checked for incontinence or offered toileting assistance, and the CNA stated she thought the resident had already been checked and changed earlier and would be okay until after lunch.
Respiratory Care Orders and Oxygen Equipment Not Properly Managed
Penalty
Summary
Provide safe and appropriate respiratory care for residents when needed was not ensured for two residents reviewed for respiratory care. Resident #8 had diagnoses including chronic respiratory failure, COPD, and heart failure, and his care plan and orders indicated continuous oxygen at 5 LPM. During observation, his oxygen humidification bottle was empty while oxygen was running continuously, and the resident stated the bottle had been empty for a week and that staff told him the facility was out of the special water used for the humidification bottle. A later observation confirmed the humidification bottle was still empty, and RN #306 confirmed the bottle was empty and that tubing had just been changed that morning. Resident #12 had diagnoses including acute respiratory failure with hypoxia, hemiplegia and hemiparesis following cerebral infarction, hyperkalemia, type 2 diabetes mellitus, muscle weakness, and muscle wasting. His care plan stated he required oxygen and that oxygen should be provided as ordered, but the medical record did not contain an active oxygen order. The prior order for oxygen 2 L via nasal cannula had been discontinued, and RN #355 confirmed the active order could not be located and that the resident had likely returned from the hospital without the order being restarted. During observation, the resident's oxygen concentrator was set at 4 L and he was not wearing his nasal cannula.
Failure to Assess and Plan for PTSD-Related Trauma Informed Care
Penalty
Summary
Facility failed to assess and implement trauma informed care for one resident with diagnoses including dementia, diabetes mellitus, depression, anxiety disorder, bi-polar disorder, and PTSD. The resident’s MDS assessment dated 10/13/25 showed the resident was cognitively intact and had a diagnosis of PTSD. Review of the care plan showed no plan of care addressing the cause of PTSD, triggers that may cause re-traumatization, or interventions to reduce the risk of re-traumatization and provide care for PTSD. Further record review found no assessment had been completed to identify the cause of PTSD or potential triggers that may cause re-traumatization. Social Services Director #364 verified that an assessment of the cause of PTSD and possible triggers had not been completed and that no plan of care had been implemented to minimize the risk of re-traumatization.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to ensure dental services were provided for one resident reviewed for dental care. Resident #14 was admitted with diagnoses including Parkinson's disease and muscle weakness, and an admission assessment documented upper dentures only. An order dated 11/18/25 indicated the resident could receive dental care as needed. During interview, the resident stated his gums were sore from chewing and that no one had offered dental services. The Social Services Director stated nurses add residents to the dental list, while the DON stated residents could be added by emailing the in-house dental company and that it was the social worker's duty to sign residents up for services upon admission. The DON also stated she was not aware the social worker had not been adding residents and added Resident #14 to the dental list at that time.
Failure to Resubmit PASARR for New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) was resubmitted following a new mental health diagnosis for a resident. The resident, who was admitted with diagnoses including dementia, cerebrovascular accident, and bipolar disorder, received a new diagnosis of anxiety. Despite this new diagnosis, there was no evidence of a PASARR resubmission. An interview with an LPN confirmed that a new PASARR should have been submitted for the resident's new diagnosis of anxiety.
Failure to Implement Therapy Recommendations for Resident
Penalty
Summary
The facility failed to implement therapy recommendations 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 heart failure, diabetes, and chronic pain, had been receiving physical therapy services until a discharge note on 11/20/23 recommended the use of a walker and the establishment of a restorative ambulation program. Despite these recommendations, the resident was not provided with a walker or enrolled in a restorative program, as confirmed by multiple observations and interviews with staff and the resident. The resident's quarterly Minimum Data Set indicated that she was not receiving restorative or therapy services, and observations over several days showed her using a wheelchair for ambulation without a walker. Interviews with the resident and various staff members, including the Therapy Director and the head of the restorative program, confirmed that the recommended restorative interventions were not implemented. The resident expressed a desire to walk again and reported that she had not received therapy or a walker since her discharge from physical therapy, which contributed to her current inability to walk.
Pest Control Deficiency in Resident Rooms
Penalty
Summary
The facility failed to ensure it was free of pests, specifically flies and gnats, affecting two residents. Observations revealed multiple instances of flies and gnats in the rooms of the affected residents. One resident reported that flies had been an issue for five years and had a flyswatter on his bed. Another resident had a fly sticky strip in his room, and both residents reported that staff had provided flyswatters. During wound care, flies and gnats were observed flying around and on one of the residents. The Director of Nursing acknowledged the issue and mentioned that the exterminator had been unable to treat the rooms, recommending the use of bleach instead.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 159 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 Cambridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Embassy Of Cambridge | 3.1 mi | ★★★★★ | 3 | 0 |
| Altercare Cambridge Inc. | 4.4 mi | ★★★★★ | 14 | 0 |
| Continuing Healthcare At Beckett House | 8.4 mi | ★★★★★ | 2 | 0 |
| Summit Acres Nursing Home | 18.5 mi | ★★★★★ | 3 | 0 |
| Riverside Manor Nrsg & Rehab Ctr | 18.8 mi | ★★★★★ | 4 | 0 |
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