Cambridge Place: Fall Prevention Failures for Hospice Resident - KS
The inspection was completed August 26, 2025. It was a complaint survey.
The resident, identified in inspection records as R44, was described as cognitively impaired and physically weakened, conditions that had worsened enough that she had been placed on hospice, the level of care reserved for people in the final stage of life. She used both a walker and a wheelchair. Her care plan required staff to provide supervision and touch assistance while she walked, to make sure her walker had a bright-colored ribbon tied to it, and to ensure she wore non-skid socks. These were not suggestions. They were interventions the facility's own interdisciplinary team had put in writing after she fell.
The fall on June 3, 2025 happened in front of the nurse's station. The one in September 2024 was worse: staff were alerted by a patio door alarm and found her on the floor of an enclosed patio outside the secured unit. She had made it through the door and gone down before anyone reached her.
When inspectors checked her room at 7:41 in the morning on August 26, her bed was in the lowest position and a fall mat was on the floor beside it. Those pieces were in place. The walker was not next to her. It was positioned by her recliner, on the other side of the room. No ribbon. The non-skid sock sign, the one meant to catch a caregiver's eye before R44 stood up and took a step, was sitting above the dresser behind a flowerpot. An inspector had to look for it to find it.
A certified medication aide identified as CMA R was interviewed at 9:00 that morning. She confirmed R44 was a fall risk because of her weakness and cognitive impairment. She said staff were expected to make sure fall interventions were followed and in place. Then she said something that cuts to the center of the problem: the unit sometimes had only one or two staff members on, and they often had difficulty providing supervision while they were performing care.
One or two people. A locked unit. Residents who need touch assistance to walk.
The administrative nurse, identified as Administrative Nurse D, was interviewed at 12:24 in the afternoon. She said all staff had access to the care plan and could review the interventions themselves. She said new interventions were discussed by the interdisciplinary team and communicated to staff by the nurse.
The care plan existed. The interventions were documented. Staff knew about them. The ribbon was not on the walker. The sign was behind the flowerpot.
The deficiency was cited at a level of minimal harm or potential for actual harm, which in the language of federal inspections means no documented injury resulted from what inspectors found that day. That rating does not account for the fall in June, or the one on the patio in September of the year before, or what might have happened on any morning when R44 woke up, reached for a walker with no ribbon, and took a step without anyone close enough to catch her.
She was on hospice. She was already at the end. The interventions her care team wrote down existed, in part, because falling at that stage of decline carries consequences that cannot be undone.
The flowerpot was still in front of the sign when inspectors left.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cambridge Place from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
CAMBRIDGE PLACE in MARYSVILLE, KS was cited for violations during a health inspection on August 26, 2025.
The inspection was completed August 26, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.