Federal inspectors found the same dirty filters on February 8 and again on February 9, documenting that residents with chronic obstructive pulmonary disease and asthma were breathing through equipment contaminated with what staff described as "thick dark brown substance" and "thick fuzzy gray substance."
Resident 98, admitted with COPD requiring oxygen at 2 liters per minute to maintain safe blood oxygen levels, relied on an oxygen concentrator whose filter inspectors found clogged on consecutive days. The physician's orders specifically required weekly changes of respiratory supplies and filter cleaning.
Resident 64, diagnosed with asthma and requiring oxygen as needed to keep saturation above 90 percent, faced the same problem. Inspectors observed the same thick gray contamination in the oxygen concentrator filter on both February 8 at 9:03 am and February 9 at 7:57 am.
The contamination was even worse for Resident 105, who has asthma and cough variant asthma. Her oxygen concentrator's built-in filter was "dirty with a thick dark brown substance" when inspectors checked at 8:32 am on February 8. More than 23 hours later, at 8:03 am on February 9, the same thick brown contamination remained.
Director of Nursing told inspectors that Sunday night shift nurses were responsible for maintaining and cleaning oxygen machine filters weekly. She expected unit nursing managers to make rounds every Monday morning to verify the maintenance had been completed properly.
But those rounds weren't catching the problems.
Licensed Practical Nurse CC confirmed during a February 9 inspection that Resident 6's oxygen concentrator filter was dirty with thick dark brown substance. She also discovered the oxygen tank was set to three liters when the physician had ordered only two liters.
Licensed Practical Nurse DD, who conducted the Monday morning rounds to verify equipment cleaning, acknowledged that multiple oxygen concentrator filters remained dirty with thick contamination. She confirmed the gray substance on Resident 98 and Resident 64's filters, and the dark brown contamination on Resident 105's equipment.
The facility's medication administration problems extended beyond respiratory equipment. Licensed Practical Nurse AA administered wrong medication dosages to a diabetic resident, creating a 7.69 percent error rate that exceeded federal safety standards.
During a February 8 medication pass, LPN AA gave Resident 35 two capsules of Linzess 290 mg when the physician had ordered Linzess 145 mg capsules. She administered 580 mg instead of the prescribed 290 mg for the resident's irritable bowel syndrome.
The same nurse failed to properly prepare insulin for the diabetic resident. When Resident 35's blood sugar required four units of insulin according to the sliding scale order, LPN AA dialed the dose and administered it without priming the insulin pen needle with two units first.
"She was unaware she should prime the needle before dialing the dose on the pen," according to the inspection report.
LPN AA told inspectors she didn't realize the Linzess bottle was labeled as 290 mg capsules and should have checked the dosage before administering the medication. She also admitted she was unaware of the requirement to prime insulin pen needles.
The Director of Nursing explained that failing to prime insulin pens could result in residents receiving decreased insulin doses, potentially causing adverse outcomes. She said a nurse practitioner had recently provided education on insulin administration and planned additional medication training.
Infection control failures affected residents throughout the facility. In 11 of 69 shared rooms, inspectors found basins, urinals and bedpans that were unlabeled and uncovered, violating policies designed to prevent cross-contamination between residents.
Room D5 had one basin sitting directly on the bathroom floor, unbagged and unlabeled. Two bedpans and two additional basins were in plastic bags but bore no resident names. Room D16 had an unlabeled urinal attached to the toilet assistance bar, plus a bedpan and basin in a bag without names.
Three unlabeled and unbagged urinals sat in the Room B16 bathroom. Room C15 had a basin sitting on the floor with no bag or label. Room A15 had an unlabeled basin on the floor plus a bedpan and another basin in a bag without resident identification.
The facility's policy required basins to be labeled with residents' names, placed in clean plastic bags, and stored in bathrooms, closets or nightstands. The Infection Control Preventionist acknowledged that certified nursing assistants were supposed to ensure all items were off floors, properly bagged and labeled.
"She acknowledged several items sitting directly on the floor, unbagged and unlabeled," inspectors wrote.
Only Room B5 followed proper protocol, with two basins and one bedpan labeled with resident names and stored together in a clear plastic bag.
The violations occurred despite facility policies requiring proper equipment maintenance and medication administration. The respiratory equipment policy specifically mandated weekly changes of supplies and tubing, with filter cleaning requirements for oxygen concentrators.
Medication administration policies required nurses to check labels three times to verify the right resident, medication, dosage, time and method of administration before giving medications.
The Director of Nursing told inspectors her expectations were for nurses to follow the five rights of medication administration and ensure medications were given according to physician orders. She said administering incorrect dosages could potentially cause adverse effects for residents.
But the gap between policy and practice left vulnerable residents breathing through contaminated equipment and receiving wrong medication doses while infection control measures failed across multiple rooms.
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.
Additional Resources
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