The resident required two-person physical assistance for all care according to their assessment dated July 21st. The nursing assistant admitted during a November 6th phone interview that she never checked the care plan before providing care and was unaware of the two-person requirement.
"I did not get report from the 7:00 AM-3:00 PM shift regarding Resident #2's plan of care," the nursing assistant told investigators.
Another nursing assistant who had cared for the resident for three years described them as "a FULL complete" - bedridden and requiring two-person assistance for all care. This CNA said the resident "could not turn on their own as they were immobile" and she always cared for them with her hallway partner.
On the day of the fall, this experienced nursing assistant was about to leave the unit when she observed the resident on the floor bleeding. Two other nursing assistants were in the room. She went to the nursing station and informed the nurse.
The facility's investigation concluded that the first nursing assistant "performed tasks properly per protocols" and blamed the fall on the resident moving their arm, which "shifted their weight and they loss trunk balance, landing on the floor."
But when federal surveyors pressed the Director of Nursing about whether nursing assistants should follow care plans, she admitted: "Yes. The CNAs should have followed the plan of care."
The nursing assistant also told investigators that the resident did not have side rails in use during the incident.
Cambridge Rehabilitation's investigation took 13 days to complete, closing on September 18th. By the time federal surveyors arrived on November 6th for their complaint inspection, 62 days had elapsed since the fall.
The Director of Nursing told surveyors she "did not look at the MDS coding yet and could not comment on the plan of care" when first asked about the resident's care requirements at 2:00 PM.
Five minutes later, after reviewing the coding with surveyors, she acknowledged that nursing assistants should have followed the established care plan requiring two-person assistance.
The facility provided no written statement from the experienced nursing assistant who discovered the bleeding resident on the floor, despite her three years of caring for this person and her detailed knowledge of their care needs.
When surveyors asked for documentation of in-service education following the incident, the Director of Nursing provided training materials dated August 22nd regarding activities of daily living. The nursing assistant involved in the September 5th fall was not in attendance at this training.
The resident's assessment clearly documented their complete dependence on staff. They could not assist with turning or rolling from side to side and required two-person physical assistance for all care activities.
The nursing assistant who caused the fall admitted she was unaware of these requirements despite the documentation being available on the resident's care plan and Kardex - the summary of daily care needs that nursing staff use for reference.
Federal surveyors cited Cambridge Rehabilitation for failing to ensure residents receive proper care according to their assessed needs. The violation carried a determination of minimal harm or potential for actual harm affecting few residents.
The facility's root cause analysis blamed the resident for rolling out of bed during the care procedure, but investigators found the real cause was a nursing assistant working alone with someone who required two-person assistance according to their documented care plan.
The experienced nursing assistant's account contradicted the facility's conclusion. She described a resident who was completely immobile and always required her hallway partner's assistance for any care activities.
Cambridge Rehabilitation completed its internal investigation while the resident's care requirements remained unchanged - still needing two-person assistance for all activities, still unable to turn independently, still completely dependent on staff for basic care.
The September 5th incident occurred during what should have been routine incontinence care and linen changing. Instead, it became a fall with bleeding because one nursing assistant worked alone with a resident whose care plan specifically prohibited solo assistance.
Sixty-two days later, when federal surveyors arrived to investigate the complaint, facility leadership still could not immediately explain what care this resident required or why their nursing assistant had ignored the established protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cambridge Rehabilitation and Healthcare Center from 2025-11-06 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Cambridge Rehabilitation and Healthcare Center
- Browse all NJ nursing home inspections