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CAMBRIDGE PLACE Inspection Report, Violations & Safety Grade (MARYSVILLE, Kansas)

1100 N 16TH, MARYSVILLE, Kansas 66508

Phone: 7855625321

CMS Overall:2/5

Overview & Bed Count

Certified Beds
91
Avg Residents/Day
76.7
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Marshall
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall2/5
Health2/5
Staffing2/5
Quality4/5

Nurse Staffing Check

MetricThis FacilityKansas AvgDifference
RN Hours per Resident per Day0.650.73-0.08
Total Nurse Hours per Resident per Day3.424.13-0.71
CMS Staffing Rating2/53.5/5-
Nursing Staff Turnover51.2%48%-

Health Citation History

42 health citations on record

DateCategoryDescriptionSeverity
2026-04-13Quality of Life and Care DeficienciesProvide safe, appropriate pain management for a resident who requires such services.D – Moderate Harm Potential
2025-08-26Nursing and Physician Services DeficienciesProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.F – Moderate Harm Potential
2025-08-26Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2025-08-26Resident Rights DeficienciesHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.E – Moderate Harm Potential
2025-08-26Quality of Life and Care DeficienciesProvide activities to meet all resident's needs.E – Moderate Harm Potential
2025-08-26Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.E – Moderate Harm Potential
2025-08-26Pharmacy Service DeficienciesEnsure 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.E – Moderate Harm Potential
2025-08-26Infection Control DeficienciesDevelop and implement policies and procedures for flu and pneumonia vaccinations.E – Moderate Harm Potential
2025-08-26Resident Rights DeficienciesReasonably accommodate the needs and preferences of each resident.D – Moderate Harm Potential
2025-08-26Resident Rights DeficienciesGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.D – Moderate Harm Potential
2025-08-26Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2025-08-26Quality of Life and Care DeficienciesProvide enough food/fluids to maintain a resident's health.D – Moderate Harm Potential
2025-08-26Quality of Life and Care DeficienciesProvide safe, appropriate dialysis care/services for a resident who requires such services.D – Moderate Harm Potential
2025-08-26Pharmacy Service DeficienciesEnsure each resident’s drug regimen must be free from unnecessary drugs.D – Moderate Harm Potential
2025-08-26Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2023-12-11Nutrition and Dietary DeficienciesEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.F – Moderate Harm Potential
2023-12-11Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2023-12-11Administration DeficienciesElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.F – Moderate Harm Potential
2023-12-11Infection Control DeficienciesProvide and implement an infection prevention and control program.F – Moderate Harm Potential
2023-12-11Environmental DeficienciesKeep all essential equipment working safely.E – Moderate Harm Potential
2023-12-11Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D – Moderate Harm Potential
2023-12-11Freedom from Abuse, Neglect, and Exploitation DeficienciesRespond appropriately to all alleged violations.D – Moderate Harm Potential
2023-12-11Resident Rights DeficienciesProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.D – Moderate Harm Potential
2023-12-11Resident Assessment and Care Planning DeficienciesCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedD – Moderate Harm Potential
2023-12-11Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2023-12-11Quality of Life and Care DeficienciesProvide care and assistance to perform activities of daily living for any resident who is unable.D – Moderate Harm Potential
2023-12-11Quality of Life and Care DeficienciesProvide 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.D – Moderate Harm Potential
2023-12-11Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2023-12-11Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2023-12-11Quality of Life and Care DeficienciesTry 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.D – Moderate Harm Potential
2023-12-11Quality of Life and Care DeficienciesProvide medically-related social services to help each resident achieve the highest possible quality of life.D – Moderate Harm Potential
2023-12-11Pharmacy Service DeficienciesEnsure 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.D – Moderate Harm Potential
2023-12-11Administration DeficienciesArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.D – Moderate Harm Potential
2022-03-17Nutrition and Dietary DeficienciesEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.E – Moderate Harm Potential
2022-03-17Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2022-03-17Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2022-03-17Resident Rights DeficienciesImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.D – Moderate Harm Potential
2022-03-17Resident Assessment and Care Planning DeficienciesAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.D – Moderate Harm Potential
2022-03-17Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2022-03-17Pharmacy Service DeficienciesEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.D – Moderate Harm Potential
2022-03-17Pharmacy Service DeficienciesImplement 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.D – Moderate Harm Potential
2022-03-17Administration DeficienciesArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.D – Moderate Harm Potential

Fire Safety Citation History

41 fire safety citations on record

DateCategoryDescriptionSeverity
2025-08-26Emergency Preparedness DeficienciesDevelop and maintain an Emergency Preparedness Program (EP).F – Moderate Harm Potential
2025-08-26Emergency Preparedness DeficienciesEstablish policies and procedures for volunteers.F – Moderate Harm Potential
2025-08-26Construction DeficienciesUse approved construction type or materials.F – Moderate Harm Potential
2025-08-26Egress DeficienciesAdd 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.F – Moderate Harm Potential
2025-08-26Egress DeficienciesHave properly located and lighted "Exit" signs.F – Moderate Harm Potential
2025-08-26Smoke DeficienciesHave a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.F – Moderate Harm Potential
2025-08-26Smoke DeficienciesInstall corridor and hallway doors that block smoke.F – Moderate Harm Potential
2025-08-26Smoke DeficienciesInstall smoke barrier doors that can resist smoke for at least 20 minutes.F – Moderate Harm Potential
2025-08-26Services DeficienciesHave properly installed electrical wiring and gas equipment.F – Moderate Harm Potential
2025-08-26Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.F – Moderate Harm Potential
2025-08-26Miscellaneous DeficienciesHave restrictions on the use of highly flammable decorations.F – Moderate Harm Potential
2025-08-26Gas, Vacuum, and Electrical Systems DeficienciesEnsure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.F – Moderate Harm Potential
2025-08-26Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.F – Moderate Harm Potential
2025-08-26Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.D – Moderate Harm Potential
2023-12-11Emergency Preparedness DeficienciesConduct testing and exercise requirements.F – Moderate Harm Potential
2023-12-11Smoke DeficienciesProvide properly protected cooking facilities.F – Moderate Harm Potential
2023-12-11Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.F – Moderate Harm Potential
2023-12-11Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2023-12-11Smoke DeficienciesInstall corridor and hallway doors that block smoke.F – Moderate Harm Potential
2023-12-11Services DeficienciesHave properly installed electrical wiring and gas equipment.F – Moderate Harm Potential
2023-12-11Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.F – Moderate Harm Potential
2023-12-11Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.F – Moderate Harm Potential
2023-12-11Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.F – Moderate Harm Potential
2023-12-11Gas, Vacuum, and Electrical Systems DeficienciesHave proper medical gas storage and administration areas.F – Moderate Harm Potential
2022-03-17Emergency Preparedness DeficienciesDevelop and maintain an Emergency Preparedness Program (EP).F – Moderate Harm Potential
2022-03-17Emergency Preparedness DeficienciesInclude a process for Emergency Preparedness collaboration.F – Moderate Harm Potential
2022-03-17Emergency Preparedness DeficienciesAddress subsistence needs for staff and patients.F – Moderate Harm Potential
2022-03-17Emergency Preparedness DeficienciesEstablish emergency prep training and testing.F – Moderate Harm Potential
2022-03-17Emergency Preparedness DeficienciesEstablish staff and initial training requirements.F – Moderate Harm Potential
2022-03-17Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2022-03-17Smoke DeficienciesFollow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.F – Moderate Harm Potential
2022-03-17Miscellaneous DeficienciesProvide a written emergency evacuation plan.F – Moderate Harm Potential
2022-03-17Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.F – Moderate Harm Potential
2022-03-17Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.F – Moderate Harm Potential
2022-03-17Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.F – Moderate Harm Potential
2022-03-17Egress DeficienciesInstall emergency lighting that can last at least 1 1/2 hours.E – Moderate Harm Potential
2022-03-17Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.E – Moderate Harm Potential
2022-03-17Smoke DeficienciesInstall corridor and hallway doors that block smoke.E – Moderate Harm Potential
2022-03-17Smoke DeficienciesInstall smoke barrier doors that can resist smoke for at least 20 minutes.E – Moderate Harm Potential
2022-03-17Services DeficienciesHave properly installed electrical wiring and gas equipment.E – Moderate Harm Potential
2022-03-17Miscellaneous DeficienciesHave posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.E – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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