Cambridge Place

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure Resident (R) 1 received her pain medication as ordered to help alleviate her pain. This deficient practice placed R1 at risk of pain and emotional distress from being in pain.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure sufficient staffing. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and delayed care. Findings Included:- A review of the facility's Payroll-Based Journal (PBJ - Staffing Data Report) from 04/01/22 through 03/31/25 indicated the facility triggered for Excessively Low-Weekend Staffing for Fiscal Year (FY) 2024 Quarter Four (07/01/24 - 09/30/24), FY 2025 Quarter One (10/01/24 - 12/31/24), and FY 2025 Quarter Two (01/01/25 - 03/31/25). On 08/25/25 at 10:21 AM, Certified Medication Aide (CMA) R stated that staff often would be busy completing care for the residents, and group activities may not always be completed on Saturdays and Sundays. [...]

Inspectors wroteThe facility had a census of 77 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one kitchen. This deficient practice placed the residents who received their meals from the facility's kitchens at risk for foodborne illness.

Inspectors wroteThe facility had a census of 72 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to promote care in a manner to maintain and enhance dignity and respect when staff used Styrofoam plates and bowls instead of regular dinnerware for meal service. This placed the residents of the facility at risk for impaired dignity.

Inspectors wroteThe facility identified a census of 77 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide direct, interactive activities based on resident preferences on weekends. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation. Findings Included:- A review of the facility's Activity Calendars for June 2025, July 2025, and August 2025 was completed. A review of the calendars indicated the residents only had access to an activity cart on Saturdays for self-led activities. The calendars noted that the residents were only provided a televised church service on Sundays. No other activities were listed for weekends for the residents. [...]

Inspectors wroteThe facility identified a census of 77 residents. The sample included 18 residents, with 13 reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area and out of reach of nine cognitively impaired, independently mobile residents. The facility additionally failed to provide adequate supervision and ensure Resident (R) 44's fall prevention interventions were followed, resulting in multiple non-injury falls. This placed the affected residents at risk for preventable accidents. Findings Included: - On 08/24/25 at 09:00 AM, an initial walkthrough of the facility was completed. An inspection of the main nurse's station area revealed a storage closet propped open by a cloth sling rope. [...]

Inspectors wroteThe facility had a census of 44 residents. Based on observation, interview, and record review, the facility failed to dispose of expired medications in a timely manner. This deficient practice placed residents at risk of receiving ineffective medication.

Inspectors wroteThe facility had a census of 77 residents. The sample included 18 residents, with five residents reviewed for immunizations, Resident (R) 3, R16, R34, R35, and R49, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, obtain an informed declination, or a physician documented contraindication for the pneumococcal vaccination, including the PVC20 per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the residents at risk for pneumococcal infection and related complications.

Inspectors wroteThe Facility had a census of 77 residents. The sample included 18 residents, with one reviewed for the environment. Based on observation and interview, the facility failed to provide accommodation of needs for one sampled resident, Resident (R) 66, who had a call light on her wall that was unreachable from her bed. This deficient practice placed R66 at risk for preventable accidents and injuries.

Inspectors wroteThe facility had a census of 77 residents. Based on record review and interview, the facility failed to provide Resident (R) 9, R11, and R12, or their representative, the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055. This placed the resident at risk of uninformed decisions about their skilled services.

Inspectors wroteThe facility had a census of 77 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to revise the care plan for one sampled resident, Resident (R) 47, which included interventions for antihypertensive (a class of medication used to treat high blood pressure) medications. This placed the residents at risk for physical decline, other related complications, and at risk for unnecessary medications.

Inspectors wroteThe facility had a census of 77 residents. The sample included 18 residents, with one reviewed for hydration. Based on observation, record review, and interview, the facility failed to consistently monitor Resident (R) 70's physician-ordered fluid restriction. This placed the resident at risk of complications related to fluid overload.

Inspectors wroteThe facility had a census of 77 residents. The sample included 18 residents, with two reviewed for dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing fluid restriction implementation for Resident (R) 4, who received dialysis treatment. This placed the resident at risk for complications and health decline.

Inspectors wroteThe facility had a census of 77 residents. The sample included 18 residents, with one reviewed for hydration. Based on observation, record review, and interview, the facility failed to hold blood pressure medication per the physician's ordered parameters for one resident, Resident (R) 47. This placed R47 at risk of low blood pressure and pulse side effects, and at risk of receiving unnecessary medication.

Inspectors wroteThe facility had a census of 77 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to provide enhanced barrier precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R) 13. The facility staff failed to don (put on) gloves when emptying R13's urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). The facility staff also failed to wear gloves when picking up an uncovered urinary catheter bag from the floor. This deficient practice placed the residents at risk for possible exposure to infection.

Inspectors wroteThe facility had a census of 79 residents. The sample included two kitchens and 18 residents. Based on observation, record review, and interview the facility failed to provide the services of a full time certified dietary manager for the 79 residents who resided in the facility and received their meals from the kitchen.

Inspectors wroteThe facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for all the residents who received their meals from the facility's two kitchens. This placed all residents at risk for food borne illness.

Inspectors wroteThe facility had a census of 79 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 79 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to provide infection control measures for residents' oxygen tubing when not in use and failed to implement a surveillance plan for water borne pathogens. This deficient practice placed the residents of the facility at risk for infections.

Inspectors wroteThe facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to ensure one of two kitchens walk-in freezer was in safe operating condition, when the freezer door continued to build up with ice and fail to completely shut. This placed the residents of one of two buildings who received their meals from that kitchen at risk for foodborne illness.

Inspectors wroteThe facility had a census of 79 residents. The sample included 18 residents with one reviewed for abuse. Based on observation, record review, and interview the facility failed to ensure staff identified and reported allegations of potential abuse to the administrator of the facility immediately. This placed the residents at risk for ongoing abuse and/or mistreatment.

Inspectors wroteThe facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to investigate Resident (R)69's unwitnessed fall in the bathroom which resulted in swelling and bruising. This deficient practice placed R69 at risk for unidentified and continued abuse, neglect and/or mistreatment.

Inspectors wroteThe facility had a census of 79 residents. The sample included 18 residents with one reviewed for discharge to the hospital. Based on observation, interview, and record review, the facility failed to notify the ombudsman of the facility-initiated discharge of Resident (R) 81, placing R81 at risk for discharges without oversight of the ombudsman office.

Inspectors wroteThe facility had a census of 79 residents. The sample included 18 residents with one reviewed for respiratory care. Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for Resident (R) 25's use of supplemental oxygen. This deficient practice placed R25 at risk for respiratory complications related to uncommunicated care needs.

Inspectors wroteThe facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to review and revise Resident (R) 284's Care Plan with effective interventions for staff to follow when R284 had behaviors. This placed R284 at risk for unmet care needs.

Inspectors wroteThe facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility staff failed to provide necessary services for one of four residents reviewed for activities of daily living (ADLs), when Resident (R) 74 requested staff assistance with repositioning and they told her she would have to wait, then did not return until 41 minutes later to assist her. This placed R74 at risk for impaired mobility and decreased comfort.

Inspectors wroteThe facility had a census of 79 residents, The sample included 18 residents with one reviewed for range of motion (ROM). Based on observation, interview, and record review, the facility failed to provide neck stretching exercises for Resident (R) 15 to prevent further decline in her neck range of motion as discussed during her quarterly care plan meeting. This placed the resident at risk for decreased or impaired comfort.

Inspectors wroteThe facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to provide an environment free from accident hazards when Resident (R) 67's bedrail exceeded the acceptable safety dimension to prevent entrapment. This placed the resident at risk for accidents and preventable injury.

Inspectors wroteThe facility had a census of 79 residents, The sample included 18 residents with one reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to provide Resident (R) 25's supplemental oxygen at the physician ordered rate through the nasal canula and with the use of a non-invasive ventilator. This deficient practice placed R25 at risk for complications resulting from the incorrect rate of oxygen administered.

Inspectors wroteThe facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to assess the actual bedrail prior to use to assure safety for Resident (R) 67. This placed the resident at risk for injury.

Inspectors wroteThe facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed provide adequate medically related social services to meet Resident (R) 284's mental and behavioral health needs. This placed the resident at risk for decreased quality of care and life.

Inspectors wroteThe facility had a census of 79 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to discard Resident (R)32's outdated insulin (hormone which allows cells throughout the body to uptake glucose) flex pen. This deficient practice placed the affected resident at risk for ineffective medications.

Inspectors wroteThe facility had a census of 79 residents. The sample included 18 residents with two reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)46. This placed R46 at risk for inappropriate end of life cares.

Inspectors wroteThe facility identified a census of 42 residents with seven residents reviewed for restorative therapy. Based on record review, observation, and interview, the facility failed to provide Resident (R) 1, R2, R3, and R4. with the restorative therapy services to maintain or improve mobility with the maximum practicable independence. The deficient practice placed R1, R2, R3, and R4 at risk for an avoidable decline in range of motion and mobility.

Inspectors wroteThe facility had a census of 77 residents. The sample included 18 residents. Based on observation, record review and interview, the facility failed to correctly prepare a pureed diet for three residents. This placed the residents at risk for not receiving adequate nutrition and choking.

Inspectors wroteThe facility had a census of 77 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 77 residents in the facility, who received their meals from one of the two facility kitchens. This placed the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 77 residents. The sample included 18 residents. Based on observation, interview and record review, the facility failed to use a proper disinfection agent on the facility's multi use glucometer (an instrument which measures the amount of glucose (sugar) in your blood). This placed the residents in one of two facility buildings at risk for blood borne pathogens (any organism that can produce disease) when staff obtained blood sugar tests of residents.

Inspectors wrote- R22's Physician Order Sheet (POS), dated 01/20/22, documented diagnoses of long-term use of anticoagulant (commonly known as blood thinner), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), presence of cardiac pacemaker (implanted device to regulate the beating of the heart) pulmonary hypertension (high blood pressure that affects the arteries in the lungs and heart), and atrial fibrillation (rapid, irregular heart beat). The admission Minimum Data Set (MDS), dated [DATE], documented R22 had intact cognition, required extensive assistance of one staff for activities of daily living (ADLs), had no skin ulcers, and received an anticoagulant and diuretic (medication to promote the formation and excretion of urine) daily. [...]

Inspectors wroteThe facility had a census of 77 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for Resident (R) 22 placing the resident at risk for improper care and continued skin injury.

Inspectors wroteThe facility had a census of 77 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to complete the weekly skin assessment to document Resident (R) 22's skin condition which developed on 03/11/22. This placed the resident at risk for further skin issues.

Inspectors wroteThe facility had a census of 77 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist's recommendations were addressed by the facility and physician for a 14 day stop date or physician's rationale for extended use for PRN (as needed) psychotropic medication (medications that affect a person's mental state) for Resident (R) 21 and provide an appropriate diagnosis for an antipsychotic medication (medication used to treat major emotional conditions and mental illness) for R4. This placed the residents at risk to receive unnecessary psychotropic medications and adverse medication side effects.

Inspectors wrote- R4's Physician Order Sheet (POS), dated 03/11/22, documented diagnoses of Parkinson's disease (disorder of the central nervous system that affects movement), major depressive disorder, single episode (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and dementia (group of thinking and social symptoms that interferes with daily functioning). R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, and a mood score of one. The MDS documented R4 was independent with eating and required extensive staff assistance for all other activities of daily living (ADLs). [...]

Inspectors wroteThe facility had a census of 77 residents. The sample included 18 residents with two reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 40 and R25. This placed R40 and R25 at risk for inappropriate end of life cares.