A list of the most recent deficiencies for Embassy of Cambridge. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-29 | 2023-10-20 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-21 | 2023-06-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-21 | 2023-06-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-16 | 2023-03-07 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-02-16 | 2023-03-07 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-16 | 2023-03-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-16 | 2023-03-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-16 | 2023-03-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-16 | 2023-03-07 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-02-16 | 2023-03-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-16 | 2023-03-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-16 | 2023-03-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-16 | 2023-03-07 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-16 | 2023-03-07 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-16 | 2023-03-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-16 | 2023-03-07 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-02-16 | 2023-03-07 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-02-16 | 2023-03-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-16 | 2023-03-07 | 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 | 2023-02-16 | 2023-03-07 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-16 | 2022-09-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-16 | 2022-09-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-08-16 | 2022-09-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-16 | 2022-09-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-16 | 2022-09-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-08-16 | 2022-09-06 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-08-16 | 2022-09-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-16 | 2022-09-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-16 | 2022-09-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-16 | 2022-09-06 | N |
| 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 | 2022-08-16 | 2022-09-06 | N |
| Provide or obtain dental services for each resident. | Health | 2022-08-16 | 2022-09-06 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-08-16 | 2022-09-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-16 | 2022-09-06 | N |
| Report COVID19 data to residents and families. | Health | 2022-08-16 | 2022-09-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-16 | 2022-09-06 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-08-10 | 2022-09-06 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-08-10 | 2022-09-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-10 | 2022-09-06 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-08-10 | 2022-09-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-10 | 2022-09-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-10 | 2022-09-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-10 | 2022-09-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-01-20 | 2022-02-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-19 | 2021-09-15 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-07-08 | 2021-07-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-18 | 2021-04-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-29 | 2021-04-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-18 | 2021-04-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-08 | 2021-04-20 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-10-24 | 2020-01-20 | 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 | 2019-10-24 | 2020-01-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-24 | 2020-01-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-24 | 2020-01-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-24 | 2020-01-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-10-24 | 2020-01-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-24 | 2020-01-07 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-10-24 | 2020-01-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-24 | 2020-01-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-24 | 2020-01-07 | N |
| Provide or obtain dental services for each resident. | Health | 2019-10-24 | 2020-01-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-10-24 | 2020-01-07 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-10-21 | 2020-01-06 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-10-21 | 2020-01-06 | 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 | 2019-10-21 | 2020-01-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-21 | 2020-01-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-21 | 2020-01-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-21 | 2020-01-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-09-20 | 2018-10-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-09-20 | 2018-10-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-09-20 | 2018-10-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-20 | 2018-10-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-20 | 2018-10-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-09-20 | 2018-10-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-20 | 2018-10-12 | N |
| 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 | 2018-09-20 | 2018-10-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-20 | 2018-10-12 | 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 | 2018-09-20 | 2018-10-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-09-20 | 2018-10-12 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-09-20 | 2018-10-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-20 | 2018-10-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-09-20 | 2018-10-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-09-20 | 2018-10-12 | N |
| 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 | 2018-09-20 | 2018-10-12 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2018-09-20 | 2018-10-12 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2018-09-20 | 2018-10-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-20 | 2018-10-12 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-09-20 | 2018-10-12 | N |
| Use approved construction type or materials. | Fire Safety | 2018-09-20 | 2018-10-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-01 | Not Fixed | N |
