Cambridge Post Acute: Wrong Oxygen Doses Given - GA
Federal inspectors found Cambridge Post Acute Care Center administered oxygen at 3 liters per minute instead of the prescribed 2 liters to a resident identified as R6. The patient had been admitted with diagnoses including asthma, dependence on supplemental oxygen, and malignant neoplasm of unspecified bronchus or lung.
The physician's order dated October 26, 2024 specified continuous oxygen at 2 liters per minute via nasal cannula. But when inspectors observed the resident on February 8 at 10:58 a.m. and again on February 9 at 8:45 a.m., they found the oxygen flowing at 3 liters per minute both times.
The facility's own policy states that "oxygen therapy is administered to the resident only upon the written order of a licensed physician." The policy was dated April 2022, nearly three years before the violations occurred.
Three other residents faced different risks from contaminated equipment. Inspectors found dirty filters in oxygen concentrators serving residents R98, R64, and R105. The facility failed to maintain clean filters despite having 19 residents receiving respiratory treatments.
Contaminated filters can harbor bacteria and other pathogens that residents then inhale directly into their lungs. For elderly patients already requiring oxygen support, dirty equipment creates additional risks for respiratory infections and medical complications.
The inspection occurred on February 10, 2025, but the oxygen dosage error had persisted for over three months since the physician's order in October. The resident with lung cancer continued receiving 50 percent more oxygen than prescribed throughout this period.
Federal regulators classified the violations as having "minimal harm or potential for actual harm" but noted the deficient practices "had the potential to put residents at risk for increased respiratory infections, medical complications and potentially life-threatening complications."
The findings affected four of the facility's 19 residents receiving respiratory treatments, representing more than 20 percent of those requiring oxygen therapy or related care.
Oxygen therapy requires precise administration because too little oxygen can cause dangerous drops in blood oxygen levels, while too much can suppress breathing in some patients or cause other complications. For residents with lung conditions like cancer or asthma, proper dosing becomes even more critical.
The inspection report did not indicate whether staff had documented the incorrect oxygen flow rates in medical records or whether anyone had noticed the discrepancy during routine monitoring.
Cambridge Post Acute Care Center operates at 2020 McGee Road in Snellville. The facility must submit a plan of correction to address the respiratory care violations, though the inspection report did not specify a timeline for compliance.
The oxygen safety violations occurred despite the facility having written policies requiring adherence to physician orders for oxygen therapy. The policy had been in place for nearly three years before inspectors documented the failures.
For the resident with lung cancer, the higher oxygen dose continued undetected through multiple shifts and staff rotations. The patient's complex medical conditions made proper oxygen administration particularly important for preventing complications.
The dirty filter problem affected three separate oxygen concentrators, suggesting systematic maintenance failures rather than isolated incidents. Clean filters are essential for preventing contaminated air from entering residents' respiratory systems.
Federal inspectors found the violations during a routine survey of the facility's compliance with Medicare and Medicaid participation requirements. The inspection covered multiple areas of care and safety beyond respiratory treatments.
The resident receiving incorrect oxygen doses had been dependent on supplemental oxygen before admission, making proper equipment operation and dosing essential for their ongoing health and survival.
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
- View all inspection reports for Cambridge Post Acute Care Center
- Browse all GA nursing home inspections
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
CAMBRIDGE POST ACUTE CARE CENTER in SNELLVILLE, GA was cited for violations during a health inspection on February 10, 2025.
The patient had been admitted with diagnoses including asthma, dependence on supplemental oxygen, and malignant neoplasm of unspecified bronchus or lung.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at CAMBRIDGE POST ACUTE CARE CENTER?
- The patient had been admitted with diagnoses including asthma, dependence on supplemental oxygen, and malignant neoplasm of unspecified bronchus or lung.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in SNELLVILLE, GA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from CAMBRIDGE POST ACUTE CARE CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 115771.
- Has this facility had violations before?
- To check CAMBRIDGE POST ACUTE CARE CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.