Federal inspectors found the 136-bed facility violated basic safety and health requirements during a July complaint investigation. Two residents never received education about or offers for pneumonia and COVID-19 vaccines, despite facility policies requiring both. Meanwhile, stray cats had taken over the entrance area, leaving residents like R16 unable to enjoy outdoor time with her sister.
"I would love to go outside, but now it's too hot and the stench is horrible," resident R14 told inspectors. "There are cats all over there and people just throw their trash down anywhere."
The vaccination failures involved residents with dementia and cognitive impairment. R18, who has Alzheimer's disease and dementia, never received the pneumonia vaccine or education about it since admission. Her medical record showed no documentation that she received the shot or refused it.
R19, admitted with stroke and vascular dementia but scoring normally on cognitive tests, never got information about COVID-19 vaccines or boosters. No consent forms or refusal documentation existed in his file either.
Licensed Practical Nurse Unit Manager HH admitted she knew nothing about R18's pneumonia vaccination status. When asked about R19's COVID vaccine, she said, "I don't remember anything about COVID vaccines, so I am guessing he did not receive the vaccine. I don't know why."
The Infection Control Preventionist told inspectors vaccination tracking wasn't her responsibility. "I don't do anything with this, it's the Unit Managers responsibility," she said.
Administrator acknowledged awareness of problems but said he "did not know the extent." The Director of Nursing confirmed R19 had neither received the COVID-19 vaccine nor signed a declination form.
Outside the building, conditions deteriorated to the point where residents stopped using outdoor spaces entirely. R16 explained that she and her sister "used to sit out on the porch area, but there's cat hair all over the place and a strong odor that smells like pee."
R17 was more direct: "I don't go outside anymore. I would like to but there's so many cats. I don't like cats."
Inspectors observed obvious cat hair on outdoor furniture cushions under the covered porch and detected a strong cat urine odor. Two cats jumped from bushes near the entrance during the inspection. An Activity Assistant revealed one resident enjoyed feeding the stray cats, but other residents avoided the area because of hair and smell.
Inside room C14, wallpaper peeled away from bathroom walls with dark, detaching edges at the bottom. Large brown water spots stained ceiling tiles throughout the resident's room.
Garbage and debris littered common areas used by residents, staff and visitors. Inspectors found tissues, paper, disposable cups and a face mask scattered across the parking lot, sidewalk and covered entrance porch, despite a trash bin near the front door.
The Administrator confirmed the environmental problems, explaining that a maintenance employee "usually picks up all the outdoor trash in the morning." The Environmental Director called the trash "unsightly to the facility" and noted that visitors arrive most frequently in early morning and after work hours, when the debris would be most visible.
The Activity Assistant promised to relocate cat feeding to a less-used entrance and arrange pressure washing to reduce hair and odor from the outdoor seating area.
Cambridge Post Acute Care's policies required pneumonia vaccination status to be determined and documented for each resident upon admission, with education provided about benefits and side effects. COVID-19 policies mandated education about benefits, risks and side effects before offering vaccines, with documentation of either vaccination or refusal.
The facility's maintenance policy required keeping buildings and grounds "in good repair and free from hazards" while maintaining "grounds, sidewalks, parking lots, etc. in good order."
R14 summed up the compound effect of the facility's failures: residents who might benefit from outdoor time and social interaction were trapped inside by conditions the facility allowed to persist, while basic preventive healthcare went undocumented and unaddressed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cambridge Post Acute Care Center from 2024-07-09 including all violations, facility responses, and corrective action plans.
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