A list of the most recent deficiencies for Cambridge Place. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-18 | 2024-02-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-18 | 2024-02-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-18 | 2024-02-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-18 | 2024-02-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-18 | 2024-02-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-18 | 2024-02-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-18 | 2024-02-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-18 | 2024-02-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-18 | 2024-02-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-18 | 2024-02-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-11 | 2024-01-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-11 | 2024-01-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-11 | 2024-01-08 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-11 | 2024-01-08 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-12-11 | 2024-01-08 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-11 | 2024-01-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-11 | 2024-01-08 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-12-11 | 2024-01-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-11 | 2024-01-08 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-12-11 | 2024-01-08 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-12-11 | 2024-01-08 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-11 | 2024-01-08 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-12-11 | 2024-01-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-11 | 2024-01-08 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-12-11 | 2024-01-08 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-12-11 | 2024-01-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-11 | 2024-01-08 | Y |
| Keep all essential equipment working safely. | Health | 2023-12-11 | 2024-01-08 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-09-18 | 2023-10-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-11 | 2022-09-10 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-06 | 2022-05-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-04-06 | 2022-05-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-06 | 2022-05-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-04-06 | 2022-05-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-06 | 2022-05-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-04-06 | 2022-05-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-06 | 2022-05-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-04-06 | 2022-05-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-06 | 2022-05-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-06 | 2022-05-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-06 | 2022-05-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-06 | 2022-05-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-17 | 2022-04-19 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-17 | 2022-04-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-17 | 2022-04-19 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-17 | 2022-04-19 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-03-17 | 2022-04-19 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-17 | 2022-04-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-17 | 2022-04-19 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-03-17 | 2022-04-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-17 | 2022-04-19 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-04-06 | 2022-04-15 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-04-06 | 2022-04-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-04-06 | 2022-04-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-04-06 | 2022-04-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-04-06 | 2022-04-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-09-01 | 2021-09-30 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-08-27 | 2020-09-26 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-08-27 | 2020-09-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-08-27 | 2020-09-26 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-08-27 | 2020-09-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-08-27 | 2020-09-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-08-27 | 2020-09-26 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2020-02-20 | 2020-03-24 | N |
