Cambridge Place

In the surveyor’s words

From the most serious findings on record at Cambridge Place, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF725Aug 26, 2025

  The 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). […]

• No harm, potential for more than minimal, widespreadF812Aug 26, 2025

  The 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.Findings included:- On 08/24/25 at 09:21 AM, observation in the kitchen revealed a three-door refrigerator had the following:An unlabeled, undated 1/2 full 10-pound (lb.) package of pepperoni.An unlabeled, undated plastic bag with five hard-boiled eggs.An unlabeled, undated pan with 17 square chocolate chip cookies.An unlabeled, undated plastic bag of sliced ham.An unlabeled, undated plastic bag of square… […]

• No harm, potential for more than minimal, widespreadF801Dec 11, 2023

  The 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. Findings included: - On 12/06/23, review of the noon meal consisted of roast beef, buttered noodles, seasoned squash, dinner roll, and assorted deserts. On 12/06 /23 at 10:56 AM, observation revealed Dietary Staff BB in the kitchen overseeing the preparation of the noon meal. On 08/29/23 at 04:25 PM, Dietary Staff BB verified she was not a certified dietary manager. […]

• No harm, potential for more than minimal, widespreadF812Dec 11, 2023

  The 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. Findings included: - On 12/05/23 at 08:27AM observation in the first of two kitchens revealed the following: The walk-in refrigerator had a cracked eggshell, an approximately one-half inch(in) by three in. wide piece of plastic wrap on the floor, and numerous different size pieces of paper underneath the bottom shelf. The white chest freezer had approximately one-quarter in. […]

• No harm, potential for more than minimal, widespreadF851Dec 11, 2023

  The 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. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal year (FY) 2023 Quarter 1 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple (5) dates. Review of the facility licensed nurse payroll data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. […]