Cambridge Health And Rehabilitation Center
Cambridge Health and Rehabilitation Center in Richmond, TX — inspection on February 26, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
pm, she said housekeeping were responsible for cleaning resident rooms, mopping, and wiping down
do not clean while food was on the hall.
She said if staff knew that a resident was messy, the
policy dated October 2009 read in part .
Residents are provided with a safe, clean, comfortable and homelike environment . 2.
The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.
These characteristics include: a. cleanliness and order .
675901 02/26/2026
Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469
a fall, the aides are not supposed to move the resident and notify the nurse.
The DON said the aide
leave the general area.
The DON said when a resident had a fall and there were 2 nurses assessing
said when the Kardex shows staff assistance for a resident, the aides should know the resident is 1-person assist.
The DON said the Kardex is charted based on what was in section GG of the MDS.
The DON said there are some days a resident would need less help than other days, more is better.
The DON said if an aide was not familiar with a resident, the charge nurse would give report to the aide, and the aide should know where to access the Kardex.
The DON said she did not think there was a risk when the Kardex was not specific for 1-person or 2-person assist.
Record review of the facility's policy titled Resident Assessment and Associated Processes, dated 04/2025 read in part . It is the policy of this facility that resident will be assessed, and the findings documented in their clinical health record.
Procedure: .Comprehensive assessment: includes the completion of the MDS (Minimum Data Set) as well as the CAA (Care Area Assessment) process, followed by development and/or review of the comprehensive care plan. an accurate comprehensive assessment will be made of the resident's needs, strengths, goals, life history, and preferences, using the RAI (Resident Assessment Instrument) and will include at least the following: physical functioning and structural problem .
Record review of the facility's policy titles Comprehensive Person-Centered Care Planning, dated 04/2025 read in part . it is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial need that are identified in the comprehensive assessment .
675901 02/26/2026
Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469
both arms and both legs, she checked her head and did vitals.
She said she did not document because
room to go back to her hall and came back to Resident #1's room to assist with the Hoyer lift. LVN C
A, and CNA B helped Resident #1 back to bed using the Hoyer lift. LVN C did not recall Resident #1 voicing any pain while getting transferred back to her bed.
During an interview with RN A, he said when he got to Resident #1's room, Resident #1 was in a seated position. RN A said he checked Resident #1's vital signs and checked her head and body. RN A said Resident #1 was complaining of shoulder pain. RN A said he notified Resident #1's family member, the doctor and the DON. RN A said there were orders for an x-ray to Resident #1's shoulder.
During an interview with LVN B on 2/4/26 at 4:46 PM, she said from what she could recall, it was reported to her that Resident #1 had fallen. LVN B said she was asked to follow up for pain on 1/7/26 for Resident #1's lower extremity, she could not recall which side.
She said she asked Resident #1 if she was in pain, and Resident #1 told her yes.
LVN B said Resident #1's x-ray results came back on a different shift. LVN B said Resident #1's pain to her lower extremity was what prompted the orders for the x-ray.
During an interview with the DOR on 2/4/26 at 2:24 PM, he said before Resident #1 had her fall she was maximum assist x2 for transfers and moderate assist for bed mobility.
The DOR said now Resident #1 is dependent for bed mobility and required 2-person assist.
During an interview with the NP on 2/5/26 at 9:52 AM, she said on 1/6/26 there was an order for x-ray of Resident #1's shoulder put in and that x-ray came back negative.
The NP said it was communicated to her on the morning of 1/7/26 that Resident #1 had a fall and pain in her leg.
The NP said she ordered x-rays to lower extremities, and those x-rays came back negative.
During an interview with the DON on 2/5/26 at 1:00 PM, she said Resident #1 initially complained of shoulder pain, then on the second day she complained of pain to bilateral hips, knees, and legs.
The DON said after the fall, Resident #1 was medicated with Tylenol, and it was effective.
The DON said Resident #1's baseline is alert and oriented.
The DON said Resident #1 was feeding off of her roommate and constantly asking for pain meds at the same time her roommate asked for pain meds.
The DON said the NP was at the facility once a week and there were no orders to send Resident #1 to the hospital.
During an interview with the Administrator on 2/5/26 at 3:30 PM, she said the expectation of staff for residents having pain was to make sure they are managing the resident's pain, medicating the resident, and if the pain was not manageable, contact the doctor.
The Administrator said when she spoke to the doctor, the doctor told her if there was no indication of a fracture then they managed the pain.
The Administrator said on 1/15/26, the daughter found out Resident #1 fell and insisted she go to the hospital. Resident #1 did not want to go to the hospital because the pain was manageable. Resident #1 was sent to the hospital on 1/15/26.
The Administrator said Resident #1 is now a 2-person assist, and staff had done a skill check on peri care and bed baths.
Record review of the facility's policy titled Fall Management System, dated 04/2025 read in part . It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs .
675901 02/26/2026
Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469
could be someone can come behind that nurse and give the same medication again.
Record review of
direction and supervision of the residents' attending physicians or the Medical Director of the facility,
and responsibilities: . perform administrative duties regarding assigned residents, such as completing medical forms, reports, evaluations, studies, charting .
Record review of the facility's policy titled Documentation, dated 05/2007 read in part . the resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition .