Cambridge Post Acute Care Center

F-F760

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 27 115771 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32513

Residents Affected - Some Based on record review, interviews, and review of the policy titled Pharmacy Services, the facility failed to ensure medications were administered as ordered for two of three residents (R) (Resident R17 and Resident R25) reviewed for medication administration. Specifically, Resident R17 missed 20 doses of her inhaler (Xopenex) and Atorvastatin 13 times, as ordered; and Resident R25 missed seven doses of Pregabalin (Lyrica-can be used for nerve pain). The deficient practice had the potential for adverse consequences and events due to not receiving ordered and scheduled medications timely.

Findings included:

A review of the undated policy titled Pharmacy Services, revealed the facility will provide Pharmacy Services

in accordance with state and federal regulations. Procedure: Number 5. The facility will provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biological to meet the needs of each resident.

Review of the policy titled Medication Delivery Expectations dated April 2022, revealed the policy is to ensure all residents will receive their medications as ordered and to ensure if medications are not received, center immediately intervenes, and medications received within 4 hours. Protocol: A. Notify the pharmacy of medication that has not been received. Pharmacy has someone on call 24 hours a day, so it is never acceptable to document that a medication is 'not available.' It is the center's responsibility to ensure medications are administered. D. If medication is not available, call the pharmacy and request medication to be delivered STAT [as soon as possible] either from your facility pharmacy or community back-up pharmacy. H. Notify the physician if medication will be given late or obtain an order for different start times, if appropriate.

1. A review of the clinical record revealed Resident R17 was admitted to the facility on [DATE REDACTED] with diagnoses including chronic obstructive pulmonary disease (COPD), diastolic congestive heart failure (CHF) and asthma.

A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/10/2024, revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated she was cognitively intact.

A review of the June 2024 Medication Administration Record (MAR) revealed the following medication orders:

1. Xopenex Inhaler two puffs every six hours related to COPD ordered 5/11/2024. According to the June 2024 MAR, the inhaler was not administered (as indicated by the code 13) eight times, and on two occasions, at 6:00 pm, the documentation was left blank.

2. Atorvastatin 40 milligrams (mg) one tablet at bedtime for elevated cholesterol ordered 3/1/2024. According to the June 2024 MAR, the Atorvastatin was coded as 13 which indicated not administered eight times.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 27 115771 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 A review of the May 2024 MAR revealed:

Level of Harm - Minimal harm or 1. Xopenex Inhaler - was not administered (as indicated by the code 13) 10 times. potential for actual harm 2. Atorvastatin - was not administered five times. Residents Affected - Some

During a group resident council meeting on 7/2/2024 at 10:15 am, the residents were asked if they received their medications on time. Resident R17 stated, They run out of my medications. They don't care if they are missing pills.

2. A review of the clinical record revealed Resident R25 was admitted to the facility on [DATE REDACTED] with diagnoses including diabetes and neuralgia (intense, intermittent pain in the nerves.)

A review of the quarterly MDS assessment with an ARD of 4/18/2024 revealed Resident R25 had a BIMS score of 12 out of 15, which indicated she was moderately impaired in cognition.

A review of the June 2024 MAR revealed the following medication order:

1. Pregabalin (Lyrica-used for nerve pain) 50 mg one capsule every 12 hours ordered 4/24/2024. According to the June 2024 MAR, the Lyrica was coded as 13-not administered seven times; however, on 6/5/2024, the documentation showed that the medication was not administered due to surgery.

During a group resident council meeting on 7/2/2024 at 10:15 am, Resident R25 stated, The nurse brings me my pills and I don't even know what they are for. It takes two to three days to get medications when they reorder.

Interview on 7/8/2024 at 1:13 pm, the Nurse Practitioner (NP) was asked whether of not she knew if medications were not being administered on time to residents. The NP stated, Yes, I am sorry to say it is true.

Interview on 7/8/2024 at 3:30 pm, the Director of Nursing (DON) stated the insurance companies are asking for prior authorizations for some medications, and we keep signing them 100 times over. It's been a struggle.

Interview on 7/9/2024 at 1:56 pm, the Pharmacy Consultant stated, The nurses should be able to call the pharmacy and get the medication they need. They can go onto the website and order medication there also.

The Pharmacy Consultant was asked if he was aware of medications not being available due to prior authorizations by insurance companies or Medicare. The Pharmacy Consultant stated, No, I have not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 27 115771 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32513 potential for actual harm Based on record review, interviews, and review of the policy titled, Diabetes Care-Insulin Administration and Residents Affected - Some Administration of Drugs, the facility failed to ensure staff administered insulin as ordered for three of five residents (R) (Resident R15, Resident R11, Resident R5) reviewed for insulin administration. Specifically, there were multiple discrepancies in the blood sugar (BS) documentation and insulin sliding scale orders, as well as multiple days and times with no documentation that insulin was administered. This failure placed the residents at risk of hypoglycemia, hyperglycemia, and a diminished quality of life.

Findings included.

Review of the policy titled Diabetes Care-Insulin Administration, dated April 2022, revealed the policy is that special precautions should be followed in the administration of insulin. Policy Interpretation and Implementation: Number 2. Insulin dosage should be drawn only by personnel licensed to administer such drug and must be administered by the person drawing the injection. Number 3. The type of insulin, dosage requirements, strength, and method of administration should be verified to assure that it corresponds with the order on the medication sheet and the physician's order. Number 4. Any discrepancies should be reported to

the Charge Nurse or designee. Number 5. The resident's physician should be notified of any discrepancies or adverse drug reactions.

Review of the policy titled, Administration of Drugs, dated April 2022 revealed Policy Interpretation and Implementation: Number 2. Drugs must be administered in accordance with the written orders of the attending physician. Number 9. The nurse administering the drug must record such information on the resident's eMAR (electronic medication administration record) immediately after administration. Number 12. Should a drug be withheld, refused, or given other than at the scheduled time, the nurse should give the appropriate chart code inside the eMAR that states the reason for not administering that drug. Number 13.

The nurse should enter an explanatory note in the progress notes for eMAR when drugs are withheld, refused, or given other than at scheduled times. The physician should be notified of drugs that are withheld and/or repeated refusal of drugs.

1. Review of the clinical record revealed Resident R15 was admitted to the facility on [DATE REDACTED] with a diagnosis of diabetes.

Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/10/2024 revealed Resident R15 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Section N documented resident was administered insulin seven of seven days of the look back period.

Review of Resident R15's care plan revised on 6/27/2024 revealed resident has a diagnosis of diabetes. Interventions to care include administer diabetes medication as ordered and monitor/document for side effects and effectiveness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 27 115771 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Review of the June 2024 Medication Administration Record (MAR) revealed an order for Novolog (short-acting) insulin via sliding scale, .Inject as per sliding scaled .0-160 = 1 unit; 161-200 = 2 units; 201-240 Level of Harm - Minimal harm or = 3 units; 241-280 = 4 units; 281-300 = 5 units; 301-340 = 6 units before meals and at bedtime . The order potential for actual harm was dated 6/4/2023.

Residents Affected - Some Review of the June 2024 MAR revealed that the blood sugar (BS) was documented between 0-160 and the insulin was not administered per the sliding scale a total of 16 times. According to the sliding scale orders,

the resident should have been administered one unit of insulin for blood sugar level of 0-160; it was documented as not administered/BS within parameters. Further review revealed blood sugar (BS) was greater than 160 on three occasions, but no insulin was administered - documented as not administered/BS within parameters. On 6/14/2024 at 11:30 am, BS was recorded as 363, but no insulin was given - documented as not administered/BS within parameters. On 6/26/2024 at 9:00 pm, the BS was documented as 347 however, there was no documentation that insulin was administered, per the sliding scale.

Review of the July 2024 MAR from 7/1/2024 to 7/3/2024 revealed, the BS indicated insulin should have been administered four times (7/1/2024 at 11:30 am and 4:30 pm, 7/2/2024 at 6:30 am and 11:30 am) but was not documented as administered.

2. Review of the clinical record revealed Resident R11 was admitted to the facility on [DATE REDACTED] and discharged on [DATE REDACTED]. Resident R11 had a diagnosis of diabetes.

Review of the admission MDS with an ARD of 10/11/2023 revealed Resident R11 had a BIMS score of nine out of 15 which indicated she was moderately impaired in cognition. Section N documented resident was administered insulin four of seven days of the look back period.

Review of the November 2023 MAR revealed the following orders:

1. Accu check AC [before meals] QID [four times daily] before meals and at bedtime with order date of 10/11/2023.

2. Novolog (Insulin Aspart) inject per sliding scale: 0-250 = 0 units; 251-280 = 4 units; 281-320 = 5 units; 321-360 = 6 units; 361-400 = 7 units; [PHONE NUMBER] = 0 units. less than 60 = 0 units give glucose gel, greater than 400 call MD, NP [nurse practitioner] for further orders. Order date was 10/6/2023 and discontinued on 11/17/2023.

3. Humalog (Insulin Lispro) inject per sliding scale: 0-200 = 0 units; 201-240 = 3 units; 241-280 = 4 units; 281-320 = 5 units; 321-360 = 6 units; 361- 400 = 7 units; [PHONE NUMBER] = 0 units and notify MD for further orders. Order date was 11/17/2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 27 115771 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Review of the November 2023 MAR revealed the following discrepancies in the BS amount from the accu check number documented and the sliding scale on 11/1/2023 - accu check recorded as 232, sliding scale Level of Harm - Minimal harm or BS documented as 234; NA [not applicable] was used on the sliding scale 28 times but documented on the potential for actual harm accu check section; the accu check documentation identified that insulin needed to be administered but was not documented as administered on the sliding scale for 11/3/2023 at 9:00 pm BS was 319, should have Residents Affected - Some received five units and 11/17/2023 at 9:00 pm BS was 243, should have received four units; the BS on 11/25/2023 at 11:30 am, showed a BS of 261, however, on the sliding scale, the BS was documented as 231 and three units of insulin was administered. There was no documentation that the BS was obtained or insulin administered on 11/21/2023 at 6:30 am or 11/30/2023 at 4:30 pm.

Review of the December 2023 MAR revealed the following orders:

1. Accu check AC [before meals] QID [four times daily] before meals and at bedtime with order date of 10/11/2023.

2. Humalog (Insulin Lispro) inject per sliding scale: 0-200 = 0 units; 201-240 = 3 units; 241-280 = 4 units; 281-320 = 5 units; 321-360 = 6 units; 361- 400 = 7 units; [PHONE NUMBER] = 0 units and notify MD for further orders. Order date was 11/17/2023.

Review of the December 2023 MAR revealed the following discrepancies: The BS documentation differed between the accu check and the sliding scale five times (12/2/2023 at 9:00 pm, 12/9/2023 at 9:00 pm, 12/13/2023 at 6:30 am, 12/18/2023 at 4:30 pm, 12/26/2023 at 4:30 pm); there was no documentation that the BS was obtained or insulin administered, five times (12/13/2023 at 4:30 pm, 12/15/2023 at 4:30 pm, 12/19/2023 at 11:30 am and 4:30 pm, 12/29/2023 at 4:30 pm); the accu check documentation showed one number and the sliding scale showed another number and insulin was administered per the sliding scale, two times (12/16/2023 accu check at 9:00 pm BS was documented as 210, sliding scale revealed BS documented as 341 and six units insulin administered; 12/26/2023 accu check BS at 4:30 pm was documented as 220, sliding scale revealed BS documented as 307 and five units insulin administered); accu check showed one number and the sliding scale showed another number and no insulin was administered one time (12/2/2023); the accu check documentation and the sliding scale documentation showed that insulin should have been administered, but was not, one time (12/25/2024 at 4:30 pm).

3. Review of the clinical record revealed Resident R5 was originally admitted to the facility on [DATE REDACTED] and discharged

on [DATE REDACTED] and had a diagnosis of diabetes.

Review of the admission MDS with an ARD of 7/5/2023 revealed Resident R5 had a BIMS score of 15, which indicated he was cognitively intact. Section N documented resident was administered insulin seven of seven days of the look back period.

Review of Resident R5's care plan revised on 6/21/2023 revealed resident has a diagnosis of diabetes. Interventions to care include administer diabetes medication as ordered and monitor/document for side effects and effectiveness; Fasting Serum Blood Sugar/accu checks as ordered by the doctor; monitor/document/report to doctor signs/symptoms of hypoglycemia such as sweating, tremors, increased heart rate, slurred speech, lack of coordination and staggering gait.

Review of the January 2023 MAR revealed the following orders:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 27 115771 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 1. Novolog insulin, inject per sliding scale: 0-250 = 0 units; 251-280 = 4 units; 281-320 = 5 units; 321-360 = 6 units; 361-400 = 7 units; [PHONE NUMBER] = 0 units call MD, NP for further orders. Order date 11/16/2022 Level of Harm - Minimal harm or and discontinued on 8/2/2023. potential for actual harm

Review of the January 2023 MAR revealed the following discrepancies: The BS documentation on 1/4/2023 Residents Affected - Some at 11:30 am was 253, there is no evidence insulin was administered according to the sliding scale orders; on 1/28/2023 the BS was documented as 397 and there was no documentation of insulin having been administered-documented as not administered/BS within parameters.

Review of the February 2023 MAR revealed the following discrepancies: There was no documentation of an accu check documented or insulin administered three times (2/12/2023 at 6:30 am, 2/13/2024 at 6:30 am, 2/26/2023 at 6:30 am). On 2/9/2023 at 9:00 pm, the BS was documented as 40 however, there was no documentation in the medical record to indicate the physician was notified or the condition of the resident.

Interview on 7/8/2024 at 1:18 pm, the Nurse Practitioner (NP) revealed she has taken care these residents and stated, it's been a struggle for me also. My expectation would be that insulin is given for the amount needed based on the blood sugar reading on the machine, and they are to call me if it's over 400, and document correctly.

Interview on 7/8/2024 at 3:30 pm, the Director of Nursing (DON) stated, I was not aware of the extent of the insulin administration problems. This information has surprised me. The DON further stated, My expectation is that insulin is documented and administered according to the physician orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 27 115771 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 32513 Residents Affected - Few Based on observations, interviews, and review of the policy titled Pharmacy Services, the facility failed to ensure expired insulin vials were removed from two of five medication carts. This failure placed the residents at risk of being administered ineffective medications. The census was 136.

Findings included.

Review of the undated policy titled Pharmacy Services, revealed it is the policy of the facility to provide Pharmacy Services in accordance with State and Federal regulations. Procedure: Number 10. Drugs and biologicals used in the facility will be labeled in accordance with currently accepted professional principals, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

1. Observation and interview on 7/5/2024 at 4:35 am, the B-Hall medication cart was inspected with Licensed Practical Nurse (LPN) JJ and revealed one opened and used vial of Lantus (long-acting) insulin with an open date of 6/1/2024. LPN JJ was asked when Lantus insulin expires, and she replied, after 28 days. LPN JJ confirmed that the insulin vial had been used after the 28-day expiration date.

2. Observation and interview on 7/5/2024 at 5:01 am, the C-Hall medication cart was inspected with LPN II and revealed one opened and used vial of Novolog (short-acting) insulin without an open or use by date. LPN II confirmed that the insulin vial did not contain an open date and therefore, she did not know when the medication would expire. LPN II confirmed that the insulin had been administered to the resident.

Interview on 7/9/2024 at 1:56 pm, the pharmacist stated, I do cart monitoring monthly, checking to see if any insulins have expired. This has been an ongoing problem at this facility. The pharmacist further stated, The nurses' are supposed to check the medication carts for the expired medications.

Interview on 7/9/2024 at 2:20 pm, the DON stated expired medications should not be available for use on medication carts. She stated they should be removed immediately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 27 115771 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32513 potential for actual harm Based on observations, record review, interviews, and review of the policy titled Enhanced Barrier Residents Affected - Some Precautions, the facility failed to ensure enhanced barrier precautions (EBP) and transmission-based precautions (TBP) were implemented for two residents (R) (Resident R19 and Resident R20) of four residents reviewed for infection control. Specifically, the facility failed to have personal protective equipment (PPE) supplies readily available and accessible for use by staff when providing high-contact care. This failure had the potential to expose residents to infections due to cross-contamination.

Findings include:

Review of the policy titled Enhanced Barrier Precautions revised March 30, 2024, documented Enhanced Barrier Precautions (EBP) are infection control interventions designed to reduce transmission of resistant organisms. Procedure: Number 1. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of (Multi Drug Resistant Organisms (MDRO) to staff hands and clothing. Number 4. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities:

a. Dressing

b. Bathing/showering

c. Transferring

d. Providing hygiene

e. Changing linens

f. Changing briefs or assisting with toileting

g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy

h. Wound care: any skin opening requiring a dressing

1. Review of the clinical record revealed Resident R19 was readmitted to the facility on [DATE REDACTED] with diagnoses including cerebral vascular accident (CVA) with right-sided paralysis, seizures, and vascular dementia.

Review of the significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/14/2024 documented Resident R19 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated he was cognitively intact for daily decision-making. Section M documented that Resident R19 had one unstageable pressure ulcer (a pressure ulcer that had full or partial thickness of dead tissue).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 27 115771 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of the Wound Evaluation and Management Summary dated 5/2/2024 revealed Resident R19 had three pressure sores: left lower extremity, right lower extremity, and right sacrum. Resident R19 is being followed by wound Level of Harm - Minimal harm or physician weekly. potential for actual harm

Observation on 7/1/2024 at 8:15 am, Licensed Practical Nurse (LPN) CC was observed providing wound Residents Affected - Some care to Resident R19. LPN CC was not observed to be wearing a gown. The signage for EBP was located on the floor, behind the door and was not readily visible for staff/visitors. In addition, there was no trash receptacle near

the door to place the soiled gowns and gloves in before leaving the room.

Interview on 7/1/2024 at 8:25 am, LPN CC stated I saw the enhanced barrier precaution sign on the floor, but did not know the precautions were for Resident R19 or his roommate. She further stated that she did not know Resident R19 required EBP when providing wound care.

2. Review of the clinical record revealed Resident R20 was admitted to the facility on [DATE REDACTED] with diagnoses including pneumonia, open wounds, and multiple rib fractures.

Observation on 7/1/2024 at 10:30 am, Certified Nurse Aide (CNA) FF was placing PPE and a TBP sign for contact precautions, on the door for Resident R20. CNA FF was asked why Resident R20 needed to have TBP. She stated, I think he has MRSA (Methicillin-Resistant Staph Aureus-a bacteria that is resistant to most antibiotics and can spread by touching people with unclean hands or unclean surfaces).

Interview on 7/1/2024 at 4:03 pm, Unit Manager (UM) was questioned about CNA FF placing the PPE/door signage for Resident R20 seven days after he was admitted to the facility. The UM stated resident was admitted from

the hospital with a PICC (Peripherally inserted central catheter-used to give intravenous medications) line.

During further interview, the UM revealed resident was not placed on EBP precautions at the time of admission and should have been, due to his wounds and PICC line access. She stated she was not aware that Resident R20 had MRSA until she reviewed his discharge paperwork. She replied, I was not told this by the hospital, when he transferred.

Interview on 7/2/2024 at 7:47 am, Resident R20 revealed the staff started wearing gowns and gloves yesterday. He stated when he was admitted to the facility last Monday, they were not wearing using any protective equipment.

Interview on 7/2/2024 at 10:35 am, the Infection Control Preventionist (ICP) was asked regarding there not being EBP signage on the residents' doors, to alert staff of the requirements when caring for them. The ICP stated, I was told to put the signage inside the room, by the sharps container. The ICP was informed about

the observation of the signage for Resident R19 having been on the floor and behind the door, and LPN CC revealing

she did not know if the requirements were for Resident R19 or his roommate. The ICP stated, I was out last week.

During further interview, she revealed that the UM was responsible for ensuring EBP and TBP signage is readily visible and PPE was accessible for the staff/visitors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 27 115771 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32513 potential for actual harm Based on record review, interviews, and review of the policy titled Antibiotic Stewardship, the facility failed to Residents Affected - Many assess and determine clinical indications for use of antibiotics utilizing the McGreer Criteria, failed to implement systematic protocols to monitor, decrease use, and measure effectiveness of antibiotics and create an action plan to lower the use of antibiotics for two of three sampled residents (R) (Resident R16 and Resident R17).

Findings included.

Review of the policy titled Antibiotic Stewardship, dated April 2022, revealed the policy is the center will develop an Antibiotic Stewardship program to monitor antibiotics and determine true infections as part of the Infection Prevention and Control Program. Procedure: Program Overview: Number 1. The center will establish a multidisciplinary Antibiotic Stewardship Program that defines optimal antibiotic use and provides guidance for optimal antibiotics prescribed. Number 4. The members of the antibiotic stewardship committee should develop, endorse or adopt established guidelines for use by center staff for appropriate identification and observation of infections and treatment guidelines. Number 5. Essential data to be reviewed by the committee should include:

a. Antibiotic orders

b. Clinical documentation supporting resident condition and

observation

c. Supplemental information from:

i. Infection surveillance logs

ii. Microbiology testing

iii. Other tests used to confirm infection, such as imaging

iv. Trends in infections

v. Trends by prescriber

Number 8. Resident Assessment and Communication of Change in Condition. When the center staff suspects a resident has an infection, the nurse should complete an evaluation of the resident to determine if

the resident's status meets minimum criteria for initiating antibiotics such as: the McGeer criteria.

1. Review of the clinical revealed Resident R16 was admitted to the facility on [DATE REDACTED] with diagnoses including diabetes, osteoarthritis, osteophyte of the right shoulder, and cellulitis.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Review of the document provided by the facility titled Infection Control Log for reporting period December 2023, revealed line listing Resident R16 was identified to have a positive urine culture for Escherichia coli and ESBL Level of Harm - Minimal harm or and was started on oral antibiotic from 12/14/2023 through 12/21/2023. There is no evidence of a McGreer potential for actual harm criteria to determine clinical indications for antibiotic use.

Residents Affected - Many Review of the Lab Results Report dated 12/13/2023 revealed a urinalysis specimen was collected on 12/12/2023 for Resident R16 and documented microscopic urinalysis results with white blood cells (WBC) too numerous to count and trace bacteria. A culture and sensitivity was performed and results reported on 12/15/2023 with >100,000 colony-forming unit per milliliter (cfmu/ml) escherichia coli.

Review of the Progress Note dated 12/14/2023 revealed documentation of a Physician Order for Macrobid 100 mg every 12 hours for UTI for seven days.

Review of the Infection Control Resident Tracking Note dated 12/14/2023 documented Resident R16 had a healthcare acquired UTI.

2. Review of the clinical record revealed Resident R17 was admitted to the facility on [DATE REDACTED] with diagnoses including diastolic congestive heart failure (CHF) and asthma.

Review of the document provided by the facility titled Infection Control Log for reporting period May 2024, revealed line listing Resident R17 was identified to have a positive urine culture for Escherichia coli and ESBL and was started on oral antibiotic from 5/9/2024 through 5/14/2024. There is no evidence of a McGreer criteria to determine clinical indications for antibiotic use.

Review of the Physician Visit Note dated 5/6/2024 indicated Resident R17 had symptoms of urinary tract infection (UTI) including burning, difficulty urinating, and frequency.

Review of the Lab Results Report dated 5/7/2024 revealed a urinalysis specimen was collected on 5/6/2024 for Resident R17 and documented microscopic urinalysis results without abnormalities; however, culture results reported on 5/9/2024 revealed >100,000 colony-forming unit per milliliter (cfmu/ml) escherichia coli and proteus mirabilis.

Review of the Progress Note dated 5/9/2024 revealed documentation of a Physician Order for Nitrofurantoin Capsules 100 milligrams (mg) one capsule every 12 hours for UTI for five days.

Review of the Infection Control Resident Tracking Note dated 5/9/2024 documented Resident R17 was confused, had burning upon urination, and retention.

Review of Resident R17's May 2024 Medication Administration Record (MAR) revealed an order date of 5/9/2024 for Nitrofurantoin Macrocrystal 100 milligrams (mg) capsule every 12 hours for UTI for five days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 27 115771 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Interview on 7/9/2024 at 11:05 am, the Infection Control Preventionist (ICP) was asked for documentation for signs and symptoms and the McGreer criteria worksheet Resident R16 and Resident R17. She provided a line listing that Level of Harm - Minimal harm or documented the name of the resident, what antibiotic they were on and dates. There was no documentation potential for actual harm of the signs/symptoms the residents were having when prescribed antibiotics. The ICP stated, I don't know anything about that. The ICP further stated, If there was a problem, then the nurses are supposed to Residents Affected - Many document it and call the doctor to get an antibiotic. I am not doing any infection surveillance as I didn't get any training. The ICP was asked how long she had worked at the facility. She stated, One and half years.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 27 115771 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 32513

Residents Affected - Many Based on record review, interviews, and review of the policy titled Infection Control -Infection Preventionist,

the facility failed to ensure that the person in the role of the Infection Control Preventionist (ICP) adequately assessed, developed, implemented, monitored, and managed the Infection Control and Prevention (IPCP) program, to prevent and control the spread of infections. This failure created the potential for an ineffective infection control program that placed residents at risk for the potential transmission of infections and communicable diseases. The facility census was 136.

Findings included.

Review of the undated policy titled Infection Control-Infection Preventionist, indicated it is the policy of the facility to employ an appropriate qualified professional to establish and maintain an infection control and prevention program designed to prevent the development and transmission of communicable diseases and infections. Procedure: Number 1. The facility will designate a qualified individual as the Infection Preventionist whose primary role is to coordinate and be actively accountable for the facility's infection prevention and control and antibiotic stewardship programs. Number 4. Responsibilities of the Infection Preventionist include but are not limited to:

a. Implementing a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based on the facility assessment.

b. Ensuring written standards, policies, and procedures for the program, which must include, but not limited to.

i. A system of surveillance designed to identify possible communicable diseases or infection before they can spread

to other persons in the facility.

iii. Standard and transmission-based precautions to be followed to prevent spread of infections.

f. Ensuring the implementation of an antibiotic stewardship program consistent with the requirements.

Review of the CDC (Center for Disease Control) Nursing Home Infection Preventionist Training Course revealed the facility's ICP completed the course on 11/7/2022. The training course included, but not limited to, the following modules:

~ Infection Prevention and Control Program.

~ Infection Surveillance.

~ Principles of Transmission-Based Precautions.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 ~ Outbreaks.

Level of Harm - Minimal harm or ~ Infection Prevention and Antibiotic Stewardship potential for actual harm Considerations During Care Transitions. Residents Affected - Many

Review of the facility's Antibiotic Stewardship Program (ASP) documents, Immunization documents, and Infection Control program documents, revealed the ICP was not adequately assessing, implementing, monitoring, or managing the Infection Control and Prevention (IPCP) program, to prevent and control the spread of infections.

Interview on 7/1/2024 at 2:55 pm, the ICP revealed she had not obtained any updated infection control trainings or education since 11/2022.

Interview on 7/1/2024 at 3:36 pm, the Administrator stated I knew we had some issues but didn't know the extent.

Cross Refer

F-F887

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32513 potential for actual harm Based on record review, interviews, and review of the policy titled Infection Control-Influenza, Pneumococcal Residents Affected - Few and SARS-CoV-2 Immunizations for Residents, the facility failed to provide education, offer, or provide the pneumonia vaccination for one of five sampled residents (R) (Resident R18) reviewed for pneumonia vaccinations.

This deficient practice had the potential to increase the spread of pneumonia among unvaccinated residents.

Findings included.

Review of the policy titled, Infection Control-Influenza, Pneumococcal and SARS-CoV-2 Immunizations for Residents, dated 8/2022 revealed it is the policy of the facility to ensure that the residents receive Influenza, Pneumococcal, and SARS-CoV-2 immunizations, in accordance with state and federal regulations, and national guidelines. Pneumococcal Immunization: Number 1. Pneumococcal immunization status will be determined and documented for each resident upon admission. Number 5. The resident's medical record includes documentation that indicates, at a minimum, the following:

i. That the resident or resident representative was provided education regarding the benefits and potential side

effects of pneumococcal immunization

ii. That the resident either received the pneumococcal immunization or did not receive the pneumococcal

immunization due to medical contraindications or refusal.

Review of the clinical record revealed Resident R18 was admitted to the facility on [DATE REDACTED] with a diagnosis of Alzheimer's disease and dementia.

Review of the annual Minimum Data Set (MDS) assessment dated with an Assessment Reference Date (ARD) of 4/2/2024 revealed Resident R18 had a Brief Interview of Mental Status (BIMS) score of 0.

Review of the Immunizations tab in the electronic medical record (EMR) revealed no documentation that Resident R18 was administered the pneumonia vaccine since admission.

Review of the Miscellaneous tab in the EMR revealed no documentation that a refusal to consent to the pneumonia vaccine was filed in the EMR.

Interview on 7/1/2024 at 12:40 pm, the Infection Control Preventionist (ICP) revealed information regarding resident immunizations is the responsibility of the Unit Managers (UM). The ICP stated, I don't do anything with this, it's the Unit Managers responsibility. During further interview, the ICP stated the UM's ensure the residents vaccination status is determined and documented in the medical record.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Interview on 7/1/2024 at 12:46 pm, the Licensed Practical Nurse (LPN) Unit Manager (UM) HH stated she did not know anything about Resident R18's pneumonia vaccination. During further interview, she stated she would Level of Harm - Minimal harm or check with her daughter regarding the pneumonia vaccine. The UM confirmed that there was no potential for actual harm documentation of a pneumonia vaccine administered or refused, in the EMR since admission for Resident R18.

Residents Affected - Few Interview on 7/1/2024 at 1:36 pm, the Administrator stated, I knew we had some issues, but did not know the extent.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32513

Residents Affected - Few Based on record review, interviews, and review of policy titled Infection Control-Influenza, Pneumococcal and SARS-CoV-2 Immunizations for Residents, the facility failed to ensure one of five sampled residents (R) (Resident R19) reviewed for Covid-19 immunizations, was provided education regarding the benefits, risks, potential side effects associated with the vaccine, was offered the Covid-19 vaccine, or declined the vaccine. This failure had the potential to place the resident at risk of acquiring and/or transmitting Covid-19.

Findings included.

Review of the facility policy titled, Infection Control-Influenza, Pneumococcal and SARS-CoV-2 Immunizations for Residents, dated 8/2022 revealed it is the policy of the facility to ensure that the residents receive Influenza, Pneumococcal, and SARS-CoV-2 immunizations, in accordance with state and federal regulations, and national guidelines. SARS-CoV-2. Number 1. Before offering the SARs-CoV-2 immunization, each resident and/or resident representative receives education regarding the benefits, risks, and potential side effects of the immunization. Number 2. Each resident is offered SARS-CoV-2 immunization, unless the immunization is medically contraindicated, or the resident as already been immunized. Number 4. The resident and/or resident representative has the opportunity to accept or refuse a SARS-CoV-2 vaccine and change their decision. Number 5. The resident's medical record includes documentation that indicates, at a minimum, the following:

a. The resident or resident representative was provided education regarding the benefits and potential risks associated with SARS-CoV-2 vaccine.

b. If the resident did not receive the SARS-CoV-2 vaccine due to medical contraindications or refusal.

Review of the clinical record revealed Resident R19 was admitted to the facility on [DATE REDACTED] with diagnoses that included cerebral vascular accident and vascular dementia.

Review of the Significant Change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/14/2024 revealed Resident R19 had a Brief Interview of Mental Status (BIMS) score of 14, indicating no cognitive impairment.

Review of the Immunizations tab in the electronic medical record (EMR) revealed no documentation of the SARS-CoV-2 (Covid) vaccine having been offered or administered.

Review of the Miscellaneous' tab in the EMR revealed no documentation of a consent refusal for the Covid vaccine or boosters.

Interview on 7/1/2024 at 12:40 pm, the Infection Control Preventionist (ICP) was asked who was responsible for ensuring residents immunizations are identified and documented in the EMR. The ICP stated, I don't do anything with this, it's the unit managers who do this.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Interview on 7/1/2024 at 12:46 pm, the Licensed Practical Nurse (LPN) Unit Manager (UM) HH, was asked about Resident R19's Covid vaccine information. The UM stated, I don't remember anything about Covid vaccines, so Level of Harm - Minimal harm or I am guessing he did not receive the vaccine. I don't know why. potential for actual harm

Interview on 7/1/2024 at 1:36 pm, the Administrator stated, I knew we had some issues, but did not know the Residents Affected - Few extent.

Interview on 7/1/2024 at 2:12 pm, the Director of Nursing (DON) provided a list of vaccination refusals, and

she confirmed Resident R19 had not been administered the Covid-19 vaccine or signed a declination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 27 115771 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 36462

Residents Affected - Many Based on observations, interviews, and review of the policy titled Maintenance Service, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors. Specifically, the facility failed to address and remove bulking wallpaper and water-stained ceiling tiles from room C14. In addition, the facility failed to maintain the aesthetic appeal of the exterior of the facility and a clean and safe porch area at the entrance of the facility. The census was 136.

Findings included:

Review of the policy titled Maintenance Service dated April 2022 documented Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: Number 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Number 2. The following functions are performed by maintenance, but not limited to:

a. Maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines.

b. Maintaining the building in good repair and free from hazards

h. Maintaining the grounds, sidewalks, parking lots, etc. in good order

i. Providing routinely scheduled maintenance service to all areas.

Observation and interview on 7/1/2024 at 10:30 am, Resident R16 revealed that she and her sister used to sit out on

the porch area, but there's cat hair all over the place and a strong odor that smells like pee.

Interview on 7/1/2024 at 10:45 am, Resident R17 stated I don't go outside anymore. I would like to but there's so many cats. I don't like cats.

Observation on 7/1/2024 at 4:08 pm, revealed the front entrance to the facility, obvious cat hair on the cushions of the outdoor furniture under the porch area. There was also a strong odor of car urine.

Observation and interview on 7/1/2024 at 4:10 pm, with Activity Assistant AA, revealed two cats jumped out from behind the bushes near the front entrance and scurried away. The Activity Assistant AA was informed that cats are a common allergy to many people, especially when the hair sheds often and freely. She stated that one particular resident enjoys feeding the cats, but there are other residents that don't sit outside because of the cat hair and the urine odor. During further interview, she revealed she would have the resident feed the cats at a less used entrance, and would ask for staff to pressure wash or find some other way to reduce the cat hair and urine odor from the outdoor sitting area.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115771 B. Wing 07/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Observation and interview on7/3/2024 at 2:30 pm, with Resident R14 stated, I would love to go outside, but now it's too hot and the stench is horrible. There are cats all over there and people just throw their trash down Level of Harm - Minimal harm or anywhere. potential for actual harm

Observation on 7/3/2024 at 3:30 pm, in room C14, revealed on the outer wall of the bathroom, an area of Residents Affected - Many wallpaper peeling away from the wall, with dark detaching edging on the bottom of the wallpaper. There are large brown, water spots in various places on the ceiling tiles in the resident's room.

Observation on 7/5/2024 at 7:30 am, upon arrival at facility, there was garbage and debris including tissues, paper, disposable cups, and a disposable face mask in the parking lot, on the sidewalk, and inside the covered porch at the front entrance of the facility, despite there being a trash bin near the front door. These

observations were in common areas that are frequented by the residents, staff and visitors.

Interview on 7/5/2024 at 8:30 am with the Administrator, confirmed the environmental concerns identified

during the survey. The Administrator stated the new Maintenance employee usually picks up all the outdoor trash in the morning.

Observation and interview at 8:40 am, with the Environmental Director (ED) of the front outside areas of the facility were confirmed, and he stated the area and trash is unsightly to the facility and stated that's why a staff member comes around in the early morning hours to remove the trash. During further interview, the ED stated that the most frequented time of day by visitors is early in the morning, and after people get off work in

the afternoons. He agreed that the trash needed to be cleaned from the exterior.

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