Cambridge Post Acute Care Center: Infection Control Failures - GA
The inspection, conducted September 24, 2025, began with an observation at 11:42 a.m. as LPN AA entered the room of a resident identified in the report as R15 to perform a dressing change. A sign on the door signaled that enhanced barrier precautions were in effect, requiring gowns for high-contact care. Neither LPN AA nor the wound technician working alongside her put one on.
The nurse removed soiled packing from a wound on R15's right hip. She did not change her gloves. With those same gloves, she applied Dakin's solution to gauze and covered the wound with a fresh dressing. Still wearing the same gloves, she reached into her pocket, pulled out a marker, dated the dressing, and returned the marker to her pocket.
She did it again at the sacral wound. Same gloves. Same pocket. Same marker.
When she moved to the left hip, she finally changed her gloves. But she did not wash her hands first. The Director of Nursing later told the inspector that glove changes do not substitute for hand hygiene, and that she expected staff to sanitize their hands whenever they changed gloves. That did not happen.
When the inspector asked LPN AA afterward why she had worn a gown for a different resident before the dressing change but not for R15, she said she forgot. She acknowledged she had ignored the sign posted on R15's door. Her explanation was that there were no PPE supply boxes or a cart at the doorway to serve as a visual reminder. The wound technician confirmed that gowns were required for this type of care and that neither of them had worn one.
The Infection Preventionist and Staff Development Nurse, interviewed at 12:33 p.m. the same day, said staff received frequent training on enhanced barrier precautions and gown use during high-contact care for residents with wounds or catheters. The training covered both protecting residents and reducing the risk of spreading infection between sites and between patients.
The Director of Nursing, interviewed two minutes later, said her expectations were clear: consistent hand hygiene, sanitizing hands with every glove change, and following enhanced barrier precautions for any resident with a wound, central line, or catheter.
What the inspection captured was something different. A nurse who acknowledged she saw the warning sign and ignored it. A marker touched with contaminated gloves, pocketed, and carried out of the room. Three wound sites treated without the hand hygiene that the facility's own nursing director described as non-negotiable.
The marker, now in LPN AA's pocket, would presumably go with her to the next room.
CMS cited the violation under F0880, infection prevention and control, with a harm level of minimal harm or potential for actual harm, affecting a few residents.
R15's wounds remained open.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cambridge Post Acute Care Center from 2025-09-25 including all violations, facility responses, and corrective action plans.
Additional Resources
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 27, 2026 · Our methodology
CAMBRIDGE POST ACUTE CARE CENTER in SNELLVILLE, GA was cited for violations during a health inspection on September 25, 2025.
The inspection, conducted September 24, 2025, began with an observation at 11:42 a.m.
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.