Cambridge Post Acute: PICC Line Safety Failures - GA
The resident, identified in inspection records only as RB, told inspectors he first alerted nursing staff on the evening of September 17, 2025, that the tape securing his PICC line was peeling away and he was afraid the line would come out. It came out the following morning. He went without his intravenous medications for two full days while the facility arranged reinsertion.
A new PICC line was placed on the afternoon of September 19. No chest x-ray was ordered afterward to confirm the line had seated correctly. The line was used to deliver medications daily from that point forward.
The Assistant Director of Nursing confirmed to inspectors on September 25 that no follow-up chest x-ray had been done after the September 19 insertion and that the line had been in use every day since. The owner of the outside company that inserted the line said their nurse always requested that the facility call the physician and get an x-ray order, because the insertion nurse had no authority to write orders or contact the facility's provider directly. Nobody had.
The dressing on that same line went unchanged for days. When inspectors observed RB on September 23, he had gauze packed under a transparent dressing with no date or time written on it. RB said the dressing had not been changed since the line was inserted on September 19. The medication administration record showed a dressing change had occurred on September 22. RB denied it had ever been touched.
When inspectors returned on September 24, RB said the dressing still had not been changed, and that staff had told him it would only be changed when the tape came off on its own.
The dressing change that inspectors observed that afternoon, performed by a registered nurse identified as RN HH, had its own problems. The nurse broke the sterile field by touching RB's arm with one hand while cleaning with the other. The StatLock stabilization device was not replaced. The antibacterial disk around the insertion site was left in place rather than changed. The nurse wore a mask but no gown, despite an isolation sign on the room door.
Cambridge Post Acute was not new to PICC line complaints. A telephone interview with a prior resident, identified as RA and connected to a separate complaint, produced a blunt summary: a nurse had told her the facility was not equipped to handle PICC lines.
The Director of Nursing, interviewed on September 24, described what she expected her staff to do when a PICC line became unusable. The nurse was to call the physician immediately, request an alternative route for the medication, and if no alternative existed, treat reinsertion as a stat procedure, meaning immediate, with the doctor notified about the timeline. She also expected dressing changes to happen on schedule.
What actually happened with RB did not match any part of that description. He warned staff the tape was failing. Nobody intervened. The line came out. He went two days without IV medication. A new line went in without a confirmatory x-ray. The dressing sat unchanged for days. When a nurse finally changed it, she contaminated the sterile field and left components in place that should have been replaced.
RN GG, interviewed on September 24, described the facility's response when a PICC line came out: call the doctor, get an x-ray order before reinsertion, then another x-ray after. "We just wait until the PICC is inserted to restart the antibiotic," she said.
Nobody described ordering a post-insertion x-ray on September 19. Nobody could explain why the line was in daily use without one.
RB was still in his bed at Cambridge Post Acute when inspectors completed their visit on September 25, his medications running through a line whose position had never been confirmed.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 13, 2026 · Our methodology
CAMBRIDGE POST ACUTE CARE CENTER in SNELLVILLE, GA was cited for violations during a health inspection on September 25, 2025.
It came out the following morning.
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.