Cambridge Place
CAMBRIDGE PLACE in MARYSVILLE, KS — inspection on August 26, 2025.
Found 14 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on observation, interview, and record review, the facility failed to promote care in a manner to maintain and enhance dignity and respect when staff used Styrofoam plates and bowls instead of regular dinnerware for meal service.
This placed the residents of the facility at risk for impaired dignity.
Findings included:- On 08/24/25 at 12:30 PM, observation during the lunch meal service revealed that staff provided Styrofoam plates for meatloaf, mashed potatoes, and carrots, and used Styrofoam bowls for the strawberry cake. On 08/25/25 at 08:45 AM, observation during the breakfast meal service revealed that staff provided Styrofoam plates for scrambled eggs, toast, and either sausage or bacon, and provided Styrofoam bowls for cereal.On 08/24/25 at 12:55 PM, Dietary Staff (DS) BB stated that the facility used the Styrofoam plates and bowls because the kitchen was short-staffed and did not have enough help to clean the dishes.On 08/26/25 at 10:30 AM, Administrative Nurse D verified that staff should not have used Styrofoam plates and bowls for daily meal service.
Administrative Nurse D stated she verified with dietary staff that the reason they use them for the two meals was due to a lack of staff.The facility's Dining Room Standards policy, dated 2020, documented staff would ensure that an attractive, cheerful dining room was maintained with comfortable sound, lighting, furnishings, temperature, and adequate space.
The policy documented that single-use disposable dining ware was not permitted except for emergencies.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Cambridge Place
1100 N 16th Marysville, KS 66508
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation and interview, the facility failed to provide accommodation of needs for one sampled resident, Resident (R) 66, who had a call light on her wall that was unreachable from her bed.
This deficient practice placed R66 at risk for preventable accidents and injuries.
Findings included:- On 08/24/25 at 10:30 AM, observation revealed R66 sat in a wheelchair in her room. R66's call light hung on the wall.
The call light was unreachable by R66 when she was in bed.On 08/24/25 at 03:00 PM, observation revealed R66 sat in a wheelchair in her room. R66's call light hung on the wall and was unreachable to R66 when she was in bed. On 08/25/25 at 03:08 PM, Certified Nurse's Aide (CNA) MM stated the resident liked to propel herself up and down the halls in her wheelchair and sit in the hall and dining room area. On 08/24/25 at 02:00 PM, Licensed Nurse (LN) I stated the resident was mobile in her wheelchair and had recently had a total knee replacement and was getting therapy, but could not safely ambulate independently. LN I stated every resident should have an accessible call light.On 08/24/25 at 03:15 PM, Administrative Nurse E stated R66 had moved from a room down the hall about one month ago.
Administrative Nurse E had not known R66 did not have a call light bedside her bed.
Administrative Nurse E verified that the resident should have a permanent call light to access from their bed, and R66 did not have access to one. On 08/26/25 at 10:30 AM, Administrative Nurse D verified that a resident's call light should be accessible to the resident in bed and should not be across the room from the bed.The facility's Call lights: Accessibility and Timely Response policy, dated 09/09/20, documented the facility would ensure it was adequately equipped with a call light at each resident's bedside and bathing area to allow residents to call for assistance, and the call lights would directly relay to a staff member or centralized location to ensure appropriate response.
Staff would be educated on the proper use of the resident call light system, including how the system works, and ensure residents' access to the call light.
The policy documented with each staff interaction in the resident's room or bathroom, the staff would ensure the call light was within reach of the resident and secured.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Cambridge Place
1100 N 16th Marysville, KS 66508
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited CAMBRIDGE PLACE in MARYSVILLE, KS for a deficiency under regulatory tag F-F0582 during a standard health inspection conducted on 2025-08-26.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of CAMBRIDGE PLACE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-07.
Federal health inspectors cited CAMBRIDGE PLACE in MARYSVILLE, KS for a deficiency under regulatory tag F-F0657 during a standard health inspection conducted on 2025-08-26.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of CAMBRIDGE PLACE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-07.
Federal health inspectors cited CAMBRIDGE PLACE in MARYSVILLE, KS for a deficiency under regulatory tag F-F0679 during a standard health inspection conducted on 2025-08-26.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide activities to meet all resident's needs.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of CAMBRIDGE PLACE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-07.
provide her with the appropriate socks.
The plan noted R44 had an unwitnessed non-injury fall in front of the nurse's station on 06/03/25.
The plan noted that staff were re-educated that R44 required supervision and/or touch assistance while ambulating. R44's EMR under Progress Notes revealed a Communication with Providers note completed on 09/03/24.
The note indicated staff were alerted by the secured unit's patio door alarm and found R44 outside on the patio floor of the enclosed patio.
The note revealed R44 was assessed by nursing and brought back inside. On 08/26/25 at 07:41 AM, R44 slept in her bed.
Her bed was in the lowest position with a fall mat on the floor next to her bed. R44's front-wheeled walker was positioned next to her recliner. R44's walker did not have a bright-colored ribbon tied to it. An inspection of her room revealed the non-skid sock signage was placed above her room's dresser behind a flowerpot. On 08/26/25 at 09:00 AM, Certified Medication Aide (CMA) R stated R44 used both her walker and wheelchair due to her decline in abilities and being placed on hospice care (end-of-life comfort care).
She stated R44 was a fall risk due to her weakness and cognitive impairment.
She stated staff were expected to ensure her fall interventions were followed and in place. CMA R stated the unit sometimes only had one or two staff members and often had difficulties providing supervision while performing care. On 08/26/25 at 12:24 PM, Administrative Nurse D stated all staff had access to review the care plan and ensure the interventions were in place.
She stated new interventions would be discussed by the interdisciplinary team, and staff would be informed by the nurse.
The facility's Accidents and Supervision policy (undated) indicated the facility promoted an environment that remains free from accident hazards.
The policy indicated the facility appropriately assessed and implemented interventions to prevent falls and minimize complications if falls occurred.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Cambridge Place
1100 N 16th Marysville, KS 66508
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited CAMBRIDGE PLACE in MARYSVILLE, KS for a deficiency under regulatory tag F-F0692 during a standard health inspection conducted on 2025-08-26.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide enough food/fluids to maintain a resident's health.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of CAMBRIDGE PLACE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-07.
Federal health inspectors cited CAMBRIDGE PLACE in MARYSVILLE, KS for a deficiency under regulatory tag F-F0698 during a standard health inspection conducted on 2025-08-26.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of CAMBRIDGE PLACE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-07.
Federal health inspectors cited CAMBRIDGE PLACE in MARYSVILLE, KS for a deficiency under regulatory tag F-F0725 during a standard health inspection conducted on 2025-08-26.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of CAMBRIDGE PLACE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-07.
Federal health inspectors cited CAMBRIDGE PLACE in MARYSVILLE, KS for a deficiency under regulatory tag F-F0757 during a standard health inspection conducted on 2025-08-26.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure each resident’s drug regimen must be free from unnecessary drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of CAMBRIDGE PLACE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-07.
Federal health inspectors cited CAMBRIDGE PLACE in MARYSVILLE, KS for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-26.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: 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.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of CAMBRIDGE PLACE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-07.
Federal health inspectors cited CAMBRIDGE PLACE in MARYSVILLE, KS for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-26.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of CAMBRIDGE PLACE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-07.
changing linens, changing briefs or assisting with toileting, device care or use with central lines (a long, thin tube inserted into a large vein in the neck, chest, or groin that reaches a major vein near the heart) urinary catheters, feeding tubes (tube for introducing high-calorie fluids into the stomach), tracheostomy(opening through the neck into the trachea through which an indwelling tube may be inserted), ventilator tube (a medical device that connects a person's windpipe to a ventilator machine, delivering air, oxygen, and medications directly into their lungs to help them breathe when they cannot do so effectively on their own), hemodialysis catheters (a procedure where impurities or wastes are removed from the blood), Peripherally Inserted Central Catheter (PICC) line (a long, thin tube inserted into a vein in the upper arm that is guided to a large central vein near the heart), midline (a long, thin, flexible tube inserted into a peripheral (outside, surface, or surrounding area of an organ, other structure, or field of vision) vein in the arm, typically for administering medications or fluids) catheters, and wound care: any skin opening requiring a dressing.
Facility ID:
Federal health inspectors cited CAMBRIDGE PLACE in MARYSVILLE, KS for a deficiency under regulatory tag F-F0883 during a standard health inspection conducted on 2025-08-26.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Develop and implement policies and procedures for flu and pneumonia vaccinations.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of CAMBRIDGE PLACE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-07.