Altercare Cambridge: Pain Medication Delayed 10 Hours - OH
The June 22nd incident at Altercare Cambridge began when Resident #50 requested her pain medication around 5:13 PM, the time it was actually due. Staff told her it wouldn't be available until 8:00 PM, a three-hour delay based on incorrect information about her prescription schedule.
She finally received medication at 7:47 PM from the Assistant Director of Nursing, who arrived at the facility around 7:00 PM that evening. But that would be her last dose until 5:21 AM the following morning, creating a gap of nearly 10 hours between medications prescribed to be given every four hours.
"She requested pain medication on night shift on 06/22/25, she waited several hours and no one brought her pain medication," the resident told state inspectors in August. "Their pain continued to get worse as she waited and it got pretty bad due to how long they had been waiting."
The resident had undergone surgery a couple weeks prior after falling and breaking something. She described being "in a lot of pain" and said the delay made her condition significantly worse.
A certified nursing assistant working that shift confirmed staff was giving the resident incorrect information about her medication schedule. CNA #888 told inspectors that staff was "telling Resident #50 her pain medication was due every eight hours however Resident #50 pain medication was due every four hours at that time."
The nursing assistant also confirmed the resident's account of the prolonged wait. "On 06/22/25 on night shift into 06/23/25 Resident #50 was upset because she had asked for pain medication several hours prior and still had not received any," CNA #888 told inspectors.
Two days later, during a physical therapy session, the resident recounted her ordeal to a physical therapist assistant. She told PTA #999 that "on the night of 06/22/25 into 06/23/25 she requested pain medication and had been waiting a long time, at least six hours."
The physical therapist assistant immediately reported the incident to administration and filed a formal statement about what the resident had disclosed.
The Assistant Director of Nursing acknowledged multiple failures in the medication administration. She confirmed that on June 22nd at 8:00 PM, she wrote a note stating the resident's pain medication was "just then due," when it had actually been due at 5:13 PM, approximately three hours earlier.
The ADON admitted she "did not get to the building until about 7:00 PM on 06/22/25" and was "not on the floor the entire night shift." She described the resident as someone who "was very on top of her pain medication, she always knew when it was due, and she took it right when it was due."
State inspectors found no documentation that staff attempted any non-pharmacological pain management techniques during the 10-hour gap between medications. The facility's own pain management policy, revised just a month before the incident, specifically requires staff to consider non-pharmacological interventions when possible.
The policy states that "pain is whatever the resident says it is" and acknowledges that "intense pain can result from even minor procedures or surgery." It requires staff to "administer as needed pain medication as ordered" and follow "professional standards of practice."
The resident's experience contradicted these written standards. Despite having recent surgery and a documented pattern of taking pain medication consistently when due, she was forced to endure escalating pain while staff provided incorrect information about her prescription schedule.
The violation occurred during a complaint investigation that encompassed four separate complaint numbers, suggesting broader concerns about medication administration at the facility. State inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents.
But for Resident #50, the impact was immediate and personal. A routine medication request turned into an overnight ordeal of untreated pain, compounded by staff confusion about basic prescription schedules and the absence of supervisory oversight during critical hours.
The incident highlights the vulnerability of post-surgical residents who depend entirely on nursing home staff for pain management, particularly during night shifts when fewer supervisors are present to ensure proper medication administration.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Altercare Cambridge Inc. from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ALTERCARE CAMBRIDGE INC. in CAMBRIDGE, OH was cited for violations during a health inspection on August 26, 2025.
The June 22nd incident at Altercare Cambridge began when Resident #50 requested her pain medication around 5:13 PM, the time it was actually due.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.