Care Citations

EMBASSY OF CAMBRIDGE

1471 WILLS CREEK VALLEY DRIVE, CAMBRIDGE, OH, 43725 · 7404394437

On the CMS record

Overall rating (CMS)
2 / 5
Health inspection rating
1 / 5
Staffing rating
1 / 5
Certified beds
95
Ownership type
For profit - Corporation
Chain
EMBASSY HEALTHCARE

Inspection findings on record (91)

Quoted exactly as CMS published them. We do not rewrite findings.

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity E · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity E · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0676 · scope/severity D · potential for more than minimal harm

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0698 · scope/severity D · potential for more than minimal harm

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0756 · scope/severity D · potential for more than minimal harm

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0759 · scope/severity D · potential for more than minimal harm

Ensure medication error rates are not 5 percent or greater.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity D · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0585 · scope/severity D · potential for more than minimal harm

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity D · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Administration Deficiencies

Tag 0835 · scope/severity D · potential for more than minimal harm

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0697 · scope/severity G · actual harm

Provide safe, appropriate pain management for a resident who requires such services.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0585 · scope/severity F · potential for more than minimal harm

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0606 · scope/severity F · potential for more than minimal harm

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0802 · scope/severity F · potential for more than minimal harm

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0803 · scope/severity F · potential for more than minimal harm

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0809 · scope/severity F · potential for more than minimal harm

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0602 · scope/severity E · potential for more than minimal harm

Protect each resident from the wrongful use of the resident's belongings or money.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0550 · scope/severity D · potential for more than minimal harm

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0610 · scope/severity D · potential for more than minimal harm

Respond appropriately to all alleged violations.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0626 · scope/severity D · potential for more than minimal harm

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0755 · scope/severity D · potential for more than minimal harm

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0807 · scope/severity D · potential for more than minimal harm

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0725 · scope/severity F · potential for more than minimal harm

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0727 · scope/severity F · potential for more than minimal harm

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.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0804 · scope/severity F · potential for more than minimal harm

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0557 · scope/severity D · potential for more than minimal harm

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0602 · scope/severity D · potential for more than minimal harm

Protect each resident from the wrongful use of the resident's belongings or money.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0610 · scope/severity D · potential for more than minimal harm

Respond appropriately to all alleged violations.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0622 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0623 · scope/severity D · potential for more than minimal harm

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0625 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0644 · scope/severity D · potential for more than minimal harm

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0755 · scope/severity D · potential for more than minimal harm

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0800 · scope/severity D · potential for more than minimal harm

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0807 · scope/severity D · potential for more than minimal harm

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity D · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0919 · scope/severity D · potential for more than minimal harm

Make sure that a working call system is available in each resident's bathroom and bathing area.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity G · actual harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0921 · scope/severity F · potential for more than minimal harm

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity E · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0644 · scope/severity D · potential for more than minimal harm

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0657 · scope/severity D · potential for more than minimal harm

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity D · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0692 · scope/severity D · potential for more than minimal harm

Provide enough food/fluids to maintain a resident's health.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0693 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity D · potential for more than minimal harm

Provide safe and appropriate respiratory care for a resident when needed.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0700 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0791 · scope/severity D · potential for more than minimal harm

Provide or obtain dental services for each resident.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0810 · scope/severity D · potential for more than minimal harm

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity D · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity F · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity D · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0759 · scope/severity D · potential for more than minimal harm

Ensure medication error rates are not 5 percent or greater.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0760 · scope/severity D · potential for more than minimal harm

Ensure that residents are free from significant medication errors.

Recorded as corrected on .

— Administration Deficiencies

Tag 0835 · scope/severity D · potential for more than minimal harm

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity J · immediate jeopardy

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0698 · scope/severity D · potential for more than minimal harm

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0759 · scope/severity D · potential for more than minimal harm

Ensure medication error rates are not 5 percent or greater.

Recorded as corrected on .

— Administration Deficiencies

Tag 0835 · scope/severity D · potential for more than minimal harm

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity D · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity D · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity F · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity G · actual harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity F · potential for more than minimal harm

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.

Recorded as corrected on .

— Administration Deficiencies

Tag 0867 · scope/severity F · potential for more than minimal harm

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0885 · scope/severity F · potential for more than minimal harm

Report COVID19 data to residents and families.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity E · potential for more than minimal harm

Ensure each resident receives an accurate assessment.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0558 · scope/severity D · potential for more than minimal harm

Reasonably accommodate the needs and preferences of each resident.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0582 · scope/severity D · potential for more than minimal harm

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0623 · scope/severity D · potential for more than minimal harm

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0645 · scope/severity D · potential for more than minimal harm

PASARR screening for Mental disorders or Intellectual Disabilities

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0685 · scope/severity D · potential for more than minimal harm

Assist a resident in gaining access to vision and hearing services.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity D · potential for more than minimal harm

Provide safe and appropriate respiratory care for a resident when needed.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0757 · scope/severity D · potential for more than minimal harm

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0791 · scope/severity D · potential for more than minimal harm

Provide or obtain dental services for each resident.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0805 · scope/severity D · potential for more than minimal harm

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0921 · scope/severity D · potential for more than minimal harm

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 365770