Inspection Reports for Cambridge Nursing & Rehabilitation Center
2020 Cambridge Dr, Lexington, KY 40504, United States, KY, 40504
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 8, 2025
Visit Reason
This document is the annual inspection survey completed for Cambridge Nursing & Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 22, 2024
Visit Reason
The inspection was conducted due to a complaint regarding inadequate supervision and monitoring of residents at risk for elopement, specifically focusing on Resident 1 who exited the facility unsupervised.
Complaint Details
The complaint investigation focused on Resident 1 who was ordered to have 15 minute checks due to high elopement risk but was found outside the facility unsupervised after the checks were discontinued without the APRN's order. Staff failed to respond timely to alarms indicating the resident's exit. The investigation also included infection control breaches affecting residents with Covid-19 and other infections.
Findings
The facility failed to ensure adequate supervision for residents at risk of elopement, resulting in Resident 1 exiting the facility unsupervised. Additionally, deficiencies were found in infection prevention and control practices affecting multiple residents, including improper use of PPE, failure to follow isolation protocols, and inadequate staff response to infection control guidelines.
Deficiencies (2)
Failure to provide adequate supervision and monitoring for residents at risk of elopement, resulting in Resident 1 exiting the facility unsupervised.
Failure to maintain an infection prevention and control program, including improper use of PPE, failure to follow isolation precautions, and inadequate hand hygiene.
Report Facts
Residents sampled: 10
Residents affected: 4
15 minute checks duration: 8
Fall risk assessment dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN1 | Advanced Practice Registered Nurse | Ordered 15 minute checks for Resident 1 and stated she did not discontinue the order |
| RN1 | Registered Nurse | Present at nurses' station during Resident 1 elopement incident; assessed resident after exit |
| East Hall Unit Manager | Unit Manager | Interviewed regarding Resident 1's elopement and staff response to alarms |
| DON | Director of Nursing/Infection Preventionist | Provided statements on expectations for staff response and infection control practices |
| Housekeeper 1 | Housekeeper | Heard door alarm and observed Resident 1 outside facility |
| Housekeeper 2 | Housekeeping Supervisor | Interviewed regarding laundry and garbage handling practices related to infection control |
| SRNA4 | State Registered Nurse Aide | Observed breaching PPE protocol in Covid positive room |
| LPN5 | Licensed Practical Nurse | Interviewed about Resident 1's condition and infection control practices |
| Interim Administrator | Interim Administrator | Provided statements on staff expectations and infection control training |
| Regional President of Operations | Regional President of Operations | Provided statements on expectations for staff response to alarms and infection control adherence |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure adequate supervision and monitoring of residents at risk for elopement and infection prevention and control deficiencies.
Complaint Details
The complaint investigation focused on the incident where Resident 1, a high elopement risk resident, exited the facility unsupervised on 08/02/2024. The investigation also included infection control practices for residents with COVID-19 and other communicable diseases.
Findings
The facility failed to provide adequate supervision for a high-risk resident who eloped unsupervised, and failed to maintain an effective infection prevention and control program, including improper use of PPE, failure to enforce isolation precautions, and inadequate staff response to alarms.
Deficiencies (2)
Failure to ensure adequate supervision and monitoring of residents at risk for elopement, resulting in a resident exiting the facility unsupervised.
Failure to provide and implement an infection prevention and control program, including breaches in PPE use, improper handling of contaminated linens and garbage, failure to enforce isolation precautions, and inadequate staff adherence to CDC guidelines.
Report Facts
Residents sampled: 42
Residents affected: 4
Residents affected: 1
Dates of 15 minute checks: 15 minute checks initiated 07/22/2024 and discontinued 07/30/2024; reinitiated 08/02/2024 with no documentation after 08/15/2024
Distance resident wandered: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Advanced Practice Registered Nurse (APRN) 1 | Advanced Practice Registered Nurse | Ordered 15 minute checks for Resident 1 and stated she did not discontinue the order |
| East Hall Unit Manager | Unit Manager | Interviewed regarding resident elopement incident and staff response to alarm |
| Registered Nurse (RN) 1 | Registered Nurse | Interviewed about alarm response and resident assessment after elopement |
| State Registered Nurse Aide (SRNA) 7 | State Registered Nurse Aide | Interviewed about resident wandering behavior and supervision |
| Licensed Practical Nurse (LPN) 5 | Licensed Practical Nurse | Interviewed about resident's condition and care plan updates |
| Kentucky Medication Aide (KMA)/SRNA3 | Medication Aide/State Registered Nurse Aide | Interviewed about resident wandering behavior |
| Housekeeper 1 | Housekeeper | Observed alarm and assisted in locating resident after elopement |
| Housekeeper 2 | Housekeeper | Observed removing garbage bags without gloves or hand hygiene |
| Director of Nursing/Infection Preventionist (DON/IP) | Director of Nursing/Infection Preventionist | Interviewed about infection control policies and staff compliance |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed about infection control training and expectations |
| Interim Administrator | Interim Administrator | Interviewed about facility operations and expectations for staff compliance |
| Regional President of Operations | Regional President of Operations | Interviewed about oversight and expectations for infection control and alarm response |
| State Registered Nurse Aide (SRNA) 4 | State Registered Nurse Aide | Observed improper donning and doffing of PPE and handling of contaminated items |
| Licensed Practical Nurse (LPN) 3 | Licensed Practical Nurse | Interviewed about infection control during nebulizer treatment |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 24, 2020
Visit Reason
The inspection was conducted to assess the facility's compliance with safety standards related to accident hazards, food sanitation, infection control, and proper use of assistive devices such as transfer poles.
Findings
The facility failed to ensure transfer poles were installed according to Manufacturer's Recommendations for Use, creating potential entrapment hazards for residents. Additionally, food service sanitation practices were inadequate, including improper cleaning of food thermometers and beverage carts. Infection control lapses were observed during medication administration, including failure to perform hand hygiene and contamination of medication capsules.
Deficiencies (3)
Failure to install transfer poles per Manufacturer's Recommendations for Use, risking resident entrapment and falls.
Failure to store, prepare, and serve food under sanitary conditions, including improper cleaning of food thermometers and beverage carts.
Failure to implement proper infection prevention and control during medication administration, including inadequate hand hygiene and contamination of medication.
Report Facts
Residents affected by transfer pole deficiency: 5
Distance of transfer poles from beds: 3
Distance of transfer poles from beds: 3.5
Distance of transfer poles from beds: 4
Distance of transfer poles from beds: 6
Distance of transfer poles from beds: 9
Distance of transfer poles from beds: 10.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed failing to perform hand hygiene between medication administrations and contaminating medication capsule. |
| SRNA #1 | State Registered Nursing Assistant | Cared for Residents #32, #38, #54, #70, #72 and provided statements about transfer pole use and training. |
| SRNA #2 | State Registered Nursing Assistant | Provided statements about transfer pole installation and training. |
| Occupational Therapist (OT) #1 | Occupational Therapist | Provided information on resident transfer assessments and training related to transfer poles. |
| Physical Therapist (PT) #1 | Physical Therapist | Discussed transfer pole recommendations, resident assessments, and staff training. |
| Maintenance Director | Maintenance Director | Responsible for installation of transfer poles and described procedures and lack of MRU awareness. |
| Therapy Manager | Therapy Manager | Described therapy department's assessment and training related to transfer poles. |
| Director of Nursing (DON) | Director of Nursing | Discussed expectations for transfer pole use and lack of awareness of MRU warnings. |
| Administrator | Facility Administrator | Provided statements on expectations for resident safety, transfer pole use, and infection control. |
| Dietary Aide #1 | Dietary Aide | Discussed cleaning practices for beverage carts and thermometer sanitation. |
| Dietary Aide #3 | Dietary Aide | Described cleaning frequency of walls and beverage carts. |
| Dietary Aide #4 | Dietary Aide | Discussed cleaning of beverage carts and walls between meals. |
| Registered Dietitian | Registered Dietitian | Provided information on food thermometer cleaning and sanitation practices. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Discussed hand hygiene expectations and staff training. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Mar 14, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, code status orders, water temperature safety, and infection control practices at Cambridge Nursing & Rehabilitation Center.
Findings
The facility was found deficient in maintaining resident dignity by posting personal care information publicly and labeling clothing in a manner considered undignified. The facility failed to ensure residents' code status orders were consistently documented on Monthly Physician's Orders. Water temperatures in resident rooms exceeded safe limits, posing a scalding risk. Infection control practices were inadequate, with staff failing to perform proper hand hygiene and glove use during resident care.
Deficiencies (4)
Failure to ensure residents were treated with dignity, including posting personal care information on Resident #45's door and labeling Resident #62's clothing externally.
Failure to have active Physician's Orders for residents' code status on Monthly Physician's Orders for Residents #9 and #94.
Water temperatures in resident rooms exceeded 110 degrees Fahrenheit, with some readings up to 122 degrees, posing a risk of scalding.
Failure to implement proper infection prevention and control practices, including inadequate hand hygiene and glove use by staff when providing care to Resident #94.
Report Facts
Residents sampled: 23
Residents affected: 2
Residents affected: 2
Rooms checked for water temperature: 8
Rooms with water temperature >110F: 5
Water temperature max: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA #6 | State Registered Nurse Aide | Interviewed regarding dignity issues with posted signs and clothing labeling |
| SRNA #5 | State Registered Nurse Aide | Interviewed regarding dignity issues with posted signs and clothing labeling |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for resident dignity and code status order issues |
| Administrator | Administrator | Interviewed regarding facility expectations for dignity, code status, water temperature, and infection control |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding dignity issues and water temperature observations |
| RN Supervisor | Registered Nurse Supervisor | Interviewed regarding issues with Monthly Physician's Orders and code status |
| Pharmacist | Pharmacist | Interviewed regarding pharmacy issues with Monthly Physician's Orders and code status |
| SRNA #8 | State Registered Nursing Assistant | Observed and interviewed regarding failure to perform hand hygiene and glove use during resident care |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding infection control expectations and observations of SRNA #8 |
| Maintenance Director | Maintenance Director | Interviewed regarding water temperature monitoring and thermometer calibration |
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