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Deficiency Records for Embassy of Cambridge
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.
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? |
|---|---|---|---|---|
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-09-06 | 2024-09-20 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-09-06 | 2024-09-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-06 | 2024-09-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-09-06 | 2024-09-20 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-09-06 | 2024-09-20 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-09-06 | 2024-09-20 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-09-06 | 2024-09-20 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-09-06 | 2024-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-06 | 2024-09-20 | 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 | 2024-09-06 | 2024-09-20 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-09-06 | 2024-09-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-09-06 | 2024-09-20 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2024-09-06 | 2024-09-20 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-09-06 | 2024-09-20 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2024-09-06 | 2024-09-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-09-06 | 2024-09-20 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-09-06 | 2024-09-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-21 | 2024-06-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-05-21 | 2024-06-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-21 | 2024-06-13 | 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 | 2024-05-21 | 2024-06-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-21 | 2024-06-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-21 | 2024-06-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-05-21 | 2024-06-13 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-05-21 | 2024-06-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-21 | 2024-06-13 | N |
| 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 | 2024-05-21 | 2024-06-13 | 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 | 2024-05-21 | 2024-06-13 | N |
| Provide or obtain dental services for each resident. | Health | 2024-05-21 | 2024-06-13 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-05-21 | 2024-06-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-21 | 2024-06-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-21 | 2024-06-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-05-21 | 2024-06-13 | 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 | 2024-05-15 | 2024-06-13 | 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 | 2024-05-15 | 2024-06-13 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-05-15 | 2024-06-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-05-15 | 2024-06-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-15 | 2024-06-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-15 | 2024-06-13 | N |
| Have an externally vented heating system. | Fire Safety | 2024-05-15 | 2024-06-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-15 | 2024-06-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-12 | 2024-04-16 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-04-12 | 2024-04-16 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-04-12 | 2024-04-16 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-04-12 | 2024-04-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-04-12 | 2024-04-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-04 | 2024-04-16 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-04 | 2024-04-16 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-03-04 | 2024-04-16 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-03-04 | 2024-04-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-04 | 2024-04-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-04 | 2024-04-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-01 | 2024-04-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-22 | 2024-02-16 | Y |
| 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 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 |
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