Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cambridge Place during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, an acute lumbar fracture, and multiple mental health diagnoses did not receive ordered pain management when a daily Lidocaine 5% patch was not administered for an extended period because it was marked as unavailable, without notifying the physician. Additionally, after a fentanyl transdermal patch dose was changed, the previous patch was left in place and the new patch was not applied for several days, while an RN acknowledged knowing the old patch remained and did not contact the pharmacy or MD. During this time, the resident required PRN oxycodone for pain, and was observed unable to converse and staring blankly when questioned.
Insufficient staffing led to inconsistent weekend activities, long call-light wait times, and delayed care. PBJ data showed repeated excessively low weekend staffing, while interviews revealed that direct care staff were busy with resident care, the secured unit sometimes had only one or two staff members, and the activity director worked only weekdays. The Resident Council reported that weekend activity groups were often not covered and that delayed care on weekends was a normal occurrence.
Food Storage and Kitchen Sanitation Deficiencies: Kitchen observations found multiple unlabeled and undated food items stored in refrigerators and a freezer, including meats, dairy, eggs, desserts, and prepared foods. Staff also observed heavy ice buildup in the freezer, peeling wallpaper and paint, missing linoleum in several areas, and specks around an undated flour and sugar bin. Dietary staff verified the findings and noted staff had already discussed the labeling issue with the night cook.
Staff provided meals to residents on Styrofoam plates and bowls instead of regular dinnerware during meal services, citing staff shortages as the reason. This practice was not in accordance with facility policy, which prohibits single-use disposable dining ware except in emergencies, and was confirmed by dietary and administrative nursing staff.
A deficiency was cited when a nursing home area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
Weekend Activities Not Provided Consistently: The facility failed to provide direct, interactive weekend activities based on resident preferences. Activity calendars showed only an activity cart for self-led use on Saturdays and a televised church service on Sundays, with no other weekend activities listed. Staff interviews confirmed the activity director worked weekdays only, direct care staff were expected to cover weekend activities, and resident council reported staffing shortages, delayed care, and long call-light wait times on weekends.
Expired stock medications were found in the East med room, including Docusate sodium, ASA, Vitamin B12, and Ibuprofen. An LPN verified the drugs should have been disposed of, and an admin nurse stated that night shift and each nurse administering meds should check for expired medications. The facility policy required routine inspection of med rooms for outdated medications.
A facility failed to offer, obtain informed declination for, or document a physician contraindication for pneumococcal vaccination, including PVC20, for five reviewed residents. Their records lacked evidence of signed consent or declination, and none had been offered or received the vaccine since admission. An Administrative Nurse stated immunization status was checked on admission and consent forms were provided, but also confirmed there was no system in place to identify who needed which pneumonia vaccine while the DON was on medical leave.
A resident who recently had a total knee replacement and was receiving therapy did not have access to a call light from her bed after moving rooms. Multiple observations and staff interviews confirmed the call light was left hanging on the wall, out of reach, despite facility policy requiring bedside accessibility.
Staff did not consistently follow Enhanced Barrier Precautions (EBP) when providing care to a resident with a urinary catheter, including failing to wear gloves or gowns during high-contact activities and handling an uncovered catheter bag and tubing that were left on the floor. Despite EBP indicators and available PPE, staff acknowledged lapses in protocol, resulting in noncompliance with the facility's infection control policies.
Failure to provide Medicare ABN forms for skilled therapy services. The facility did not provide the completed SNFABN, Form CMS-10055, to three residents or their representatives before discharge, and the residents’ Part A Medicare discharge papers did not show documentation that the notice was given. The facility’s policy required informing Medicare beneficiaries of potential liability for payment and issuing the notice before services that may not be covered by Medicare.
A resident with pulmonary HTN, atrial fibrillation, anxiety, and dementia had a care plan that addressed BBW medications but did not include interventions for antihypertensive therapy or Metoprolol-specific monitoring. The MAR showed the resident received Metoprolol when HR was below ordered hold parameters on multiple occasions, and staff interviews confirmed confusion about whether to follow BP or HR parameters and that the care plan did not reflect the medication monitoring needs.
Failure to monitor an ordered fluid restriction for a resident with CKD stage 4, edema, hypo osmolality, and daily diuretic use. The care plan and MD order required 1800 cc/day with fluids divided between meals, free fluids, and night fluids, but the TAR lacked documentation on multiple day and evening shifts. Staff interviews showed confusion about the resident’s fluid allowance, and a water pitcher was observed at the bedside with fluid remaining.
Failure to maintain fluid restriction for a resident receiving dialysis. A resident with ESRD, CVA, hemiplegia, and severe cognitive impairment had a care plan listing dialysis 3x/week and a 2 L fluid restriction, but the physician order initially lacked a fluid restriction. A standing order fax asked about the restriction, and the physician later responded that the resident should be on a 2000 ml fluid restriction. The resident was observed drinking water in the dining room, and an admin nurse confirmed the dialysis schedule and the missing initial fluid restriction order.
Failure to Hold Metoprolol per Ordered Parameters: A resident with pulmonary HTN, A-fib, anxiety, and dementia received Metoprolol ER even when the HR was below the physician’s hold parameter of 60 bpm. The care plan did not include specific guidance for the antihypertensive medication, and staff interviews showed the CMA focused on BP rather than HR, despite the MAR documenting multiple administrations outside ordered parameters.
Failure to Administer and Manage Ordered Pain Medications
Penalty
Summary
The facility failed to provide ordered pain management for a resident with severe cognitive impairment and multiple mental health diagnoses, including dementia, psychotic disturbance, mood disturbance, and anxiety, as well as an acute lumbar vertebral fracture. The resident’s care plan directed staff to assess pain each shift, treat reported pain in a timely manner, and evaluate effectiveness. Physician orders included a daily Lidocaine 5% patch to the lower back and a fentanyl transdermal patch for moderate to severe pain. Record review showed that the resident did not receive the ordered Lidocaine patch for a 12‑day period because it was documented as not available, with no evidence that staff notified the physician or took further action. During this time, the resident’s MDS documented that she received scheduled and PRN pain medications and daily opioid use, but the MAR showed the Lidocaine patch was not administered for multiple consecutive days. The facility also failed to properly manage the resident’s fentanyl transdermal patch orders. After the physician discontinued a 25 mcg fentanyl patch and ordered a 12 mcg replacement, the previous 25 mcg patch remained on the resident’s left shoulder and the new 12 mcg patch was not applied for several days. A nurse later acknowledged knowing the old fentanyl patch was still in place and that the replacement patch was not available, but chose to leave the old patch on and did not contact the pharmacy or physician. The MAR documented that the resident required oxycodone for pain rated at five during this period. Observation showed the resident sitting in a wheelchair, unable to carry on a conversation and staring blankly when asked questions. The clinical record lacked evidence that the physician was notified that the ordered pain medications, including the Lidocaine and fentanyl patches, were not administered as prescribed.
Insufficient Weekend Staffing and Inconsistent Resident Activities
Penalty
Summary
The facility failed to ensure sufficient staffing to meet resident needs and to have a licensed nurse in charge on each shift. The facility had a census of 58 residents, and the sample included 14 residents. A review of the Payroll-Based Journal staffing data from 04/01/22 through 03/31/25 showed the facility triggered for Excessively Low-Weekend Staffing for FY 2024 Quarter Four, FY 2025 Quarter One, and FY 2025 Quarter Two. During interviews, Certified Medication Aide R stated that staff were often busy completing resident care, and group activities might not always be completed on Saturdays and Sundays. She also stated the secured unit sometimes had only one or two staff members and that staff often had difficulty providing supervision while performing care. The Resident Council reported that weekend activities were inconsistent because of low staffing, that the activity director only worked weekdays, that direct care staff were already struggling to complete resident care, and that there were not enough staff to cover weekend activity groups. The council also reported long call-light wait times and delayed care on weekends as normal occurrences. Activity Staff ZZ stated she only worked weekdays and that direct care staff were expected to assist with scheduled weekend activities, while Administrative Nurse D stated she did not feel the facility had issues with low weekend staffing. The facility policy stated it was to provide sufficient and competent staff to ensure completion of care and services for all residents in accordance with resident care plans and the facility assessment.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one kitchen. During observation of the kitchen on 08/24/25, a three-door refrigerator contained multiple unlabeled and undated food items, including pepperoni, hard-boiled eggs, chocolate chip cookies, sliced ham, square yellow cheese, sliced onions, shredded yellow cheese, turkey salad, apple cobbler cake, lime Jello with apples, chicken strips, and creamed corn. The same observation also found an untied blue plastic bag with diced chicken and an unlabeled, undated bag of whole kernel corn in a chest-type freezer, along with approximately 3/4 inch of ice buildup around the inside of the freezer. A two-door refrigerator also contained an unlabeled, undated plastic bag with six saltine crackers with peanut butter in the middle. On 08/25/25, additional kitchen observations identified peeling wallpaper border behind the back of the oven and three-sink area, a chest-type deep freeze with approximately three-quarters-inch-thick ice buildup, missing pieces of linoleum under the dishwasher and in the walking area entering the dishwashing area, a wall with bubbling and peeling paint by a two-door refrigerator, and a missing piece of linoleum in front of the three-sink area. An undated flour and sugar bin also had numerous different-sized blackish-gray specks around the outside. Dietary staff verified the findings and stated staff had talked to the night cook about not labeling and dating food items, that the freezer would be defrosted that week, that the facility had talked about replacing the linoleum, and that the wallpaper border had been peeling for a while and the peeling paint was caused by a water leak.
Use of Disposable Dinnerware Compromises Resident Dignity
Penalty
Summary
Staff served meals to residents using Styrofoam plates and bowls instead of regular dinnerware during both lunch and breakfast meal services. Observations confirmed that meatloaf, mashed potatoes, carrots, strawberry cake, scrambled eggs, toast, sausage or bacon, and cereal were all served on disposable Styrofoam ware. Dietary staff stated that the use of disposable plates and bowls was due to being short-staffed and lacking sufficient help to clean dishes. The facility's Dining Room Standards policy, dated 2020, specifies that single-use disposable dining ware is not permitted except in emergencies. Administrative nursing staff verified that Styrofoam ware should not have been used for daily meal service and confirmed the reason for its use was staff shortages.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Weekend Activities Not Provided Consistently
Penalty
Summary
The facility failed to provide direct, interactive activities based on resident preferences on weekends for a census of 77 residents, with 18 residents sampled. Review of the June 2025, July 2025, and August 2025 activity calendars showed that residents only had access to an activity cart on Saturdays for self-led activities, and the only Sunday activity listed was a televised church service. No other weekend activities were listed for residents. During interviews, the Resident Council reported on 08/26/25 that the facility lacked consistent weekend activities because of a lack of staff present, stating that the activity director only worked weekdays and direct care staff were already struggling to complete care and did not have enough staff to cover weekend activity groups. The council also reported long call-light wait times and delayed care on weekends. On 08/25/25, a CMA stated staff were often busy completing resident care and group activities may not always be completed on Saturdays and Sundays. An Activity Staff member stated she only worked weekdays and direct care staff were expected to provide scheduled weekend activities, while residents could use the activities cart if they chose. The facility policy stated it would provide activities that meet residents' needs and interests to support physical, mental, and psychosocial well-being.
Expired Medications Found in Medication Room
Penalty
Summary
The facility failed to dispose of expired medications in a timely manner. During observation of the East medication room, expired stock medications were found, including one bottle of Docusate sodium with an expiration date of 11/27/24, one bottle of ASA with an expiration date of 01/23/25, one bottle of Vitamin B12 with an expiration date of 03/07/25, and one bottle of Ibuprofen with an expiration date of 06/05/25. The facility had a census of 44 residents at the time of the survey. Licensed Nurse G verified that the expired drugs should have been disposed of. Administrative Nurse D stated that the night shift should check the medication cart for expired medications and that each nurse administering medications should check for expired medications and dispose of them if they have expired. The facility policy stated that medication rooms were to be routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels.
Failure to Document Pneumococcal Vaccine Offer, Consent, or Contraindication
Penalty
Summary
The facility failed to offer, obtain an informed declination for, or document a physician contraindication for pneumococcal vaccination, including PVC20, for five reviewed residents: R3, R16, R34, R35, and R49. Record review showed that each of these residents’ clinical records lacked evidence that the facility or the resident representative received or signed consent to receive, or informed declination of, the pneumococcal vaccine, including PVC20. For each resident, the electronic health record showed admission to the facility on [DATE], and none had been offered or received a pneumococcal vaccine, including PVC20, since admission. During interview on 08/25/25 at 12:10 PM, Administrative Nurse D stated that immunization status was assessed on admission by checking the CMS website to determine prior vaccinations, after which an order would be sent to the physician and the vaccine administered at the facility. Administrative Nurse D also verified that the facility would provide consent forms with vaccine information to the resident and/or DPOA for signature. She further verified that the DON was on medical leave and that there was no system in place to identify who needed which pneumonia vaccine. The facility’s Pneumococcal Vaccine policy dated 01/31/22 stated that residents would be offered pneumococcal immunization in accordance with current CDC guidelines, assessed on admission, provided vaccine information, and asked to sign consent prior to administration.
Call Light Inaccessible to Bedbound Resident
Penalty
Summary
A deficiency was identified when a resident's call light was found to be inaccessible from her bed. Observations on multiple occasions showed that the call light was hanging on the wall and could not be reached by the resident while she was in bed. The resident, who had recently undergone a total knee replacement and was receiving therapy, was mobile in her wheelchair but could not safely ambulate independently. Interviews with staff confirmed that the call light should have been accessible to the resident at all times, especially when in bed. Further investigation revealed that the resident had moved rooms about a month prior, and administrative staff were unaware that the call light was not properly installed at the bedside in the new room. The facility's policy required that call lights be accessible at each resident's bedside and that staff ensure accessibility during every interaction. Despite this policy, the resident did not have access to a call light from her bed, as verified by both administrative and nursing staff.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Facility staff failed to implement proper infection prevention and control measures, specifically Enhanced Barrier Precautions (EBP), for a resident with an indwelling urinary catheter. Multiple observations revealed that staff did not consistently don gloves or gowns when performing high-contact care activities, such as emptying the urinary catheter bag or handling the catheter and tubing. On several occasions, staff entered the resident's room and assisted with care or handled the catheter bag without wearing gloves or gowns, despite the presence of EBP indicators and available personal protective equipment (PPE). The urinary catheter bag and tubing were also observed uncovered and placed on the floor, and staff picked them up without gloves. The facility's policies required the use of EBP, including targeted gown and glove use during high-contact care activities for residents with devices such as urinary catheters. Staff interviews confirmed awareness of EBP indicators, but also acknowledged lapses in following protocol, such as forgetting to wear a gown or failing to use gloves when handling the catheter bag. The facility's own policies emphasized the importance of these precautions to prevent the transmission of multidrug-resistant organisms and reduce infections, but these were not consistently followed during the survey period.
Failure to Provide Medicare ABN for Skilled Therapy Services
Penalty
Summary
The facility failed to provide Resident 9, Resident 11, and Resident 12, or their representatives, with the completed Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form 10055. The report states that the Medicare ABN form 10055 informs the beneficiary that Medicare may not pay for future skilled therapy services and gives the beneficiary options to receive the listed services, decline them, or receive them while being responsible for payment if Medicare does not pay. Review of the residents’ Part A Medicare discharge papers showed that the facility did not provide the ABN form 10055 disclosing the cost of continuing skilled services. On 08/26/25 at 12:15 PM, Administrative Staff A verified that the facility lacked documentation showing the ABN form 10055 had been provided to the discharged residents. The facility’s Advanced Beneficiary Notices policy, dated 11/01/19, states that the facility shall inform Medicare beneficiaries of potential liability for payment and issue a liability notice before providing services that may not be covered by Medicare, using the SNFABN, Form CMS-10055. The policy also states the notice shall be provided within two days of the last anticipated service to allow the resident or representative time to decide whether to receive the services and assume financial responsibility.
Care plan lacked interventions for antihypertensive medication monitoring
Penalty
Summary
The facility failed to revise the comprehensive care plan for one sampled resident, R47, to include interventions related to antihypertensive medication use. R47 had diagnoses of pulmonary hypertension, atrial fibrillation, anxiety, and dementia with behavioral disturbance. The quarterly MDS documented moderately impaired cognition and need for partial assistance with several activities of daily living, and also showed that R47 received antipsychotic, antidepressant, and diuretic medications daily. The care plan dated 06/24/25, initiated on 03/10/23, documented that R47 received medications with black box warnings and instructed staff to administer medications as ordered and refer to the eMAR, but it did not include further direction related to antihypertension medications or specifically address Metoprolol. The physician ordered Metoprolol ER 25 mg by mouth in the morning for atrial fibrillation and hypertension, with instructions to hold the medication if systolic blood pressure was less than 100 mmHg or heart rate was less than 60 bpm. The MAR showed that R47 received Metoprolol on multiple dates in July and August 2025 when the heart rate was below the ordered parameters. During interview, a CMA stated she focused on blood pressure and did not usually worry about heart rate, while an LN and an administrative nurse stated staff should follow the physician's orders and that the care plan should reflect the antihypertension medication and what staff should monitor for. The facility policy stated the comprehensive care plan would be reviewed and revised as necessary when a resident experienced a status change.
Failure to Monitor Ordered Fluid Restriction
Penalty
Summary
The facility failed to consistently monitor Resident 70’s physician-ordered 1800 cc per day fluid restriction. Resident 70 had diagnoses including chronic kidney disease stage 4, peripheral autonomic neuropathy, edema, and hypo osmolality. The resident’s MDS documented varying cognitive status, need for partial staff assistance with several activities of daily living, and daily diuretic use. The care plan directed staff to follow physician orders for the fluid restriction, document fluid intake every shift, monitor for dehydration and weight changes, and report abnormal findings to the physician. The physician’s orders specified how the 1800 cc fluid restriction was to be distributed across meals, free fluids, and night fluids, and staff were directed to notify the physician of non-compliance and update the care plan. The TAR lacked documentation of staff-monitored fluid restriction on multiple day and evening shifts in June, July, and August 2025. During observation, a pitcher of water was present at the bedside with measurable fluid remaining. Staff interviews showed a CNA was unsure of the amount of fluid the resident was supposed to receive on her shift, a nurse stated staff worked with the kitchen and documented total intake per shift, and an administrative nurse stated staff were expected to follow the physician’s orders and document shift intake in the medical record.
Failure to Maintain Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure ongoing fluid restriction implementation for a resident receiving dialysis. The resident had diagnoses of ESRD, CVA, and hemiplegia, and the admission MDS documented a BIMS score of 6, indicating severe cognitive impairment. The MDS also recorded that the resident received dialysis treatment and required partial to moderate assistance with toilet hygiene, personal hygiene, and showering/bathing. The resident’s dialysis care plan documented dialysis three times weekly and a fluid restriction of 2 liters, with staff to follow the physician’s order. A physician order dated 07/25/25 documented dialysis three times a week and a renal diet, but did not include a fluid restriction. A standing order faxed to the physician asked whether the resident should be on a fluid restriction due to dialysis status, and the physician responded on 07/30/25 that the resident should be on a 2000 ml fluid restriction, which the nurse noted. On 08/25/25, the resident was observed in the dining room with scrambled eggs, oatmeal, and one cup of water. Administrative Nurse D verified the resident received dialysis on Monday, Wednesday, and Friday, and confirmed the physician initially did not have a fluid restriction order.
Failure to Hold Metoprolol per Ordered Parameters
Penalty
Summary
The facility failed to hold Metoprolol ER for one resident when the resident’s heart rate was below the physician-ordered parameter. The resident had diagnoses including pulmonary hypertension, atrial fibrillation, anxiety, and dementia with behavioral disturbance, and the Quarterly MDS documented moderately impaired cognition and need for partial assistance with several activities of daily living. The resident’s care plan noted the use of medications with black box warnings and directed staff to administer medications as ordered, but it did not include specific direction for the resident’s antihypertension medication or related monitoring interventions. The physician ordered Metoprolol ER 25 mg by mouth in the morning for atrial fibrillation and hypertension, with instructions to hold the medication if systolic blood pressure was less than 100 mmHg or heart rate was less than 60 bpm. The MAR showed multiple instances in July and August 2025 when the medication was administered despite heart rates below 60 bpm. During interviews, a CMA stated she focused on blood pressure and did not usually worry about heart rate, while nursing staff stated medications should follow physician orders and that the care plan should reflect the medication’s side effects and monitoring needs. The facility policy required staff to obtain and record vital signs when applicable and hold medication for vital signs outside the physician’s prescribed parameters.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marysville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Frankfort Community Care Home | 15.8 mi | ★★★★★ | 20 | 1 |
| Linn Community Nursing Home | 26.7 mi | ★★★★★ | 7 | 0 |
| Eastridge | 28.7 mi | ★★★★★ | 14 | 1 |
| Good Samaritan Society - Beatrice | 28.8 mi | ★★★★★ | 12 | 0 |
| Life Care Center Of Seneca | 29.7 mi | ★★★★★ | 0 | 0 |
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