SNELLVILLE, GA - A February 2025 inspection at Cambridge Post Acute Care Center uncovered critical deficiencies in respiratory equipment maintenance and medication administration that placed residents with chronic lung conditions at risk.
Contaminated Oxygen Equipment Posed Respiratory Risks
Inspectors documented pervasive failures in maintaining oxygen concentrators for multiple residents with serious respiratory conditions. Four residents requiring supplemental oxygen had equipment with severely contaminated filters that went uncleaned despite facility protocols requiring weekly maintenance.
Resident 6, who had been prescribed oxygen at 2 liters per minute with orders to maintain saturation above 90 percent, had an oxygen concentrator with a filter covered in thick dark brown substance. Additionally, the oxygen flow was set at 3 liters—50 percent higher than the prescribed dose. This error was confirmed by nursing staff during the inspection.
Resident 98, admitted with chronic obstructive pulmonary disease with acute exacerbation, faced similar conditions. Physician orders specifically required weekly cleaning of respiratory supplies and filters. However, observations on consecutive days revealed the oxygen concentrator filter contained a thick gray fuzzy substance, indicating prolonged neglect of basic maintenance requirements.
Resident 64, who had asthma with specific monitoring instructions for shortness of breath, also had contaminated equipment. The resident's oxygen concentrator filter showed the same thick gray buildup observed over multiple days.
Contaminated oxygen equipment creates multiple health hazards for residents with compromised respiratory function. Dirty filters reduce oxygen flow efficiency, potentially causing residents to receive inadequate oxygen levels despite appearing to be on supplemental therapy. The buildup of dust, debris, and biological contaminants in filters can introduce bacteria, mold spores, and other pathogens directly into the airways of vulnerable patients. For residents with COPD or asthma, exposure to these contaminants can trigger acute exacerbations, increased mucus production, and potentially life-threatening breathing difficulties.
The facility's Director of Nursing stated that Sunday night shift nurses were responsible for respiratory equipment maintenance, with unit managers expected to conduct Monday morning rounds to verify completion. However, inspectors found that Licensed Practical Nurse DD confirmed during her Monday rounds that multiple oxygen concentrators had dirty filters, indicating the oversight system had failed.
Medication Administration Errors Created Treatment Risks
The inspection revealed a medication error rate of 7.69 percent—significantly above the allowable 5 percent threshold. Licensed Practical Nurse AA made two critical errors while administering medications to Resident 35, who has type 2 diabetes and irritable bowel syndrome.
The nurse administered Linzess oral capsules at 290 micrograms per capsule when the physician's order specified 145 micrograms per capsule. This resulted in the resident receiving double the prescribed dose. When questioned, the nurse stated she had not checked the dosage printed on the medication bottle label before administration, violating the facility's own three-check policy for verifying the right resident, medication, dosage, time, and route.
The same nurse also failed to properly prime an insulin pen before administering a dose to Resident 35. According to manufacturer guidelines and standard nursing practice, insulin pens must be primed with 2 units before dialing the prescribed dose to ensure accurate delivery and remove air from the needle. The nurse acknowledged she was unaware of this requirement.
Improper insulin pen technique can result in residents receiving significantly less than their prescribed insulin dose. If air remains in the needle or the pen mechanism is not properly engaged, the full dose may not be delivered into the subcutaneous tissue. For diabetic residents, receiving inadequate insulin can lead to persistent hyperglycemia, increasing risks of diabetic ketoacidosis, delayed wound healing, infections, and long-term complications affecting kidneys, nerves, and blood vessels.
The Director of Nursing confirmed that nurses should follow manufacturer guidelines for insulin administration and that failure to prime pens could result in decreased insulin doses and adverse outcomes. She noted that recent education on insulin administration had been provided and planned additional training on medication administration procedures.
Infection Control Failures in Patient Care Areas
Inspectors identified widespread infection control violations affecting 11 of 69 shared resident rooms across all four facility wings. Personal care items including wash basins, bedpans, and urinals were found unlabeled, unbagged, or sitting directly on bathroom floors.
In Room D5, inspectors observed one basin sitting directly on the floor without a protective bag or resident label. Two bedpans and two additional basins were found in bags but without identifying labels. Room B16 contained three unlabeled and unbagged urinals. Room C15 had an unlabeled, unbagged basin on the floor.
Facility policy specifically requires that residents' names be written on wash basins, which must be stored in clean plastic bags in the resident's bathroom, closet, or nightstand. The Infection Control Preventionist acknowledged during the inspection that Certified Nursing Assistants were responsible for ensuring all items were properly bagged, labeled, and stored off floors, but confirmed the violations observed.
Unlabeled and improperly stored personal care equipment creates significant cross-contamination risks in shared bathroom spaces. When items are not clearly designated for individual residents, staff may inadvertently use one resident's basin or bedpan for another resident, potentially transferring infectious organisms. Equipment stored directly on floors—particularly bathroom floors—can harbor dangerous pathogens including antibiotic-resistant bacteria, C. difficile spores, and other healthcare-associated infection agents.
Additional Issues Identified
The inspection documented that Resident 105, admitted with asthma and cough variant asthma, also had an oxygen concentrator with a dirty built-in filter containing thick dark brown substance observed on consecutive days. Facility staff confirmed awareness of the weekly respiratory equipment maintenance schedule but failed to implement it consistently across multiple units.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cambridge Post Acute Care Center from 2025-02-10 including all violations, facility responses, and corrective action plans.
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