Snellville facility administered incorrect oxygen levels and failed to maintain clean equipment filters, putting residents at serious respiratory risk.
Cambridge Post Acute Care Center: Oxygen Safety Failures - GA
Snellville facility documented for improper oxygen therapy and equipment maintenance violations that could lead to respiratory complications.
Cambridge Post Acute Care Center in Snellville cited for dangerous oxygen therapy violations affecting multiple residents!
SNELLVILLE, GA - Federal inspectors cited Cambridge Post Acute Care Center for serious oxygen therapy violations that put vulnerable residents at risk for respiratory complications and potentially life-threatening medical emergencies.
Critical Oxygen Dosage Violations
During inspections conducted in February 2025, federal surveyors discovered that facility staff were administering oxygen at incorrect levels to a resident with serious respiratory conditions. The resident, diagnosed with asthma, oxygen dependence, and lung cancer, had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula.
However, inspectors observed staff providing oxygen at 3 liters per minute on multiple occasions - a 50% increase above the prescribed dose. This deviation occurred despite clear facility policies requiring oxygen therapy to be administered only according to written physician orders.
Equipment Maintenance Failures
Inspectors also identified widespread equipment maintenance problems affecting three additional residents receiving respiratory treatments. The oxygen concentrators serving these patients had dirty, clogged filters that had not been properly maintained according to safety standards.
Clean filters are essential for oxygen concentrator function, as contaminated equipment can introduce bacteria and other harmful particles into the oxygen supply. When filters become clogged with dust, debris, and potentially infectious material, the equipment's ability to deliver pure, concentrated oxygen becomes compromised.
Medical Risks and Complications
Incorrect oxygen dosages can cause serious medical complications. Too much oxygen can lead to oxygen toxicity, suppressed breathing drive in certain patients, and interference with the body's natural respiratory mechanisms. For patients with chronic obstructive pulmonary disease or other breathing conditions, excessive oxygen can actually worsen their condition by reducing their natural urge to breathe.
Contaminated oxygen equipment poses significant infection risks. Dirty filters can harbor bacteria, mold, and other pathogens that get delivered directly into patients' respiratory systems. This is particularly dangerous for nursing home residents, who often have compromised immune systems and existing respiratory conditions that make them more susceptible to pneumonia and other serious infections.
Industry Standards and Proper Protocols
According to established medical protocols, oxygen therapy requires precise administration based on individual patient needs. Healthcare facilities must:
- Follow physician orders exactly regarding flow rates and delivery methods - Monitor patients regularly for signs of oxygen toxicity or inadequate oxygenation - Maintain equipment according to manufacturer specifications - Replace or clean filters on scheduled intervals - Document all oxygen administration and equipment maintenance
The facility's own policy, dated April 2022, clearly states that oxygen therapy should only be administered according to written physician orders. This policy aligns with Centers for Medicare & Medicaid Services regulations that require nursing homes to provide medically necessary care according to professional standards.
Widespread System Failures
The violations affected four residents out of 19 receiving respiratory treatments - representing more than 20% of the facility's oxygen therapy patients. This high percentage suggests systematic problems with staff training, supervision, and quality assurance procedures rather than isolated incidents.
Federal inspectors classified these violations as having "minimal harm or potential for actual harm," but noted that the deficient practices put residents at risk for increased respiratory infections, medical complications, and potentially life-threatening situations.
Facility Response Required
Cambridge Post Acute Care Center must submit a plan of correction detailing how they will address these oxygen therapy violations. The facility needs to demonstrate improved staff training on proper oxygen administration, enhanced equipment maintenance procedures, and stronger oversight systems to prevent future occurrences.
Residents and families can contact the facility or Georgia's state survey agency for information about the nursing home's corrective action plan. The facility is located at 2020 McGee Road in Snellville and has faced previous regulatory scrutiny for various care-related violations.
This case highlights the importance of proper respiratory care in nursing home settings, where residents often depend on supplemental oxygen for basic survival. When facilities fail to follow basic safety protocols, vulnerable patients face unnecessary risks that could result in serious medical emergencies or death.
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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