Cambridge Post Acute Care Center

F-F656

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2. Review of the clinical records revealed Resident R98 was admitted to the facility with diagnoses that included but not limited to chronic obstructive pulmonary disease with acute exacerbation (COPD) (reduction of lung function).

Review of Resident R98's physician's order revealed, oxygen at 2 liters per minute (lpm) via nasal cannula to keep O2 saturation greater than 90 percent.

Review of Resident R98's physician's order revealed, change and date all respiratory supplies and tubing weekly. If oxygen concentrator is present, clean filter.

During an observation on 2/8/2025 at 10:10 am revealed the filter on the oxygen concentrator contained a thick gray fuzzy substance.

During an observation on 2/9/2025 at 7:59 am revealed the filter on the oxygen concentrator contained a thick gray fuzzy substance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 115771 Department of Health & Human Services Printed: 09/09/2025 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 02/10/2025

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 0695 3. Review of the clinical records revealed Resident R64 was admitted to the facility with a diagnosis that included but not limited to asthma. Level of Harm - Minimal harm or potential for actual harm Review of Resident R64's physician's order revealed, O2 at 2 liters (l) via nasal cannula prn to keep oxygen saturation above 90 percent. Residents Affected - Few

Review of Resident R64's physician's order revealed, Resident R64 has asthma, please monitor and report to nurse or physician if resident has shortness of breath with activities of daily living care or while lying flat.

During an observation on 2/8/2025 at 9:03 am revealed the filter on the oxygen concentrator contains a thick layer of gray fuzzy substance.

During an observation on 2/9/2025 at 7:57 am revealed the filer on the oxygen concentrator contains a thick layer of gray fuzzy substance.

47946

4. Review of the clinical records for Resident R105 revealed she was admitted to the facility with diagnoses that included but not limited to other asthma and cough variant asthma.

Observation on 2/8/2025 at 8:32 am revealed Resident R105's oxygen concentrator's built-in filter was dirty with a thick dark brown substance.

Observation on 2/9/2025 at 8:03 am revealed Resident R105's oxygen concentrator's built-in filter was dirty with a thick dark brown substance.

Interview on 2/9/2025 at 10:10 am with the Director of Nursing (DON) stated on every Sunday night shift, the nurse assigned to that resident's hall was responsible for the maintenance and cleaning of the oxygen machine filter, ensuring the nebulizer machine was stored properly when not in use and oxygen tubing was stored in a bag when not in use. She stated, it is my expectation for all my unit nursing manager staff to make rounds on Monday morning to make sure all the maintenance and cleaning of the oxygen equipment were properly done on that Sunday night.

Observation and interview on 2/9/2025 at 10:18 am with DON and Licensed Practical Nurse (LPN) CC both confirmed that Resident R6's oxygen concentrator's built-in filter was dirty with a thick dark brown substance and tank setting was on three liters. LPN CC checked Resident R6's physician orders in the facility's electronic records and confirmed that physician order was two liters.

Observation and interview on 2/9/2025 at 10:30 am with LPN DD confirmed the Sunday night shift nurses were responsible for the respiratory maintenance cleaning of equipment weekly which includes the oxygen concentrators' filters. She stated she does her round every Monday morning to ensure staff cleaned all the equipment. She confirmed Resident R98 and Resident R64 oxygen concentrators' spongy-foam filter was dirty with a thick fuzzy gray substance. She also confirmed that Resident R105's oxygen concentrator's built-in filter was dirty with a thick dark brown substance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 115771 Department of Health & Human Services Printed: 09/09/2025 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 02/10/2025

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 46691 potential for actual harm Based on observations, staff interviews, record review, and review of the facility's policy titled Administering Residents Affected - Few Medications, the facility failed to ensure the medication error rate was less than five percent. There were two errors with 26 opportunities for one of five residents R (Resident R35) for a medication error rate of 7.69 percent.

These failures had the potential to place Resident R35 at risk of medical complications and decreased therapeutic effects of medications.

Findings include:

Review of the facility policy titled Administering Medications, revised April 2019, revealed the Policy Heading section stated, Medications are to be administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation section included . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Review of Resident R35's Electronic Medical Record (EMR) under Admission Record revealed diagnoses including, but not limited to, type 2 diabetes and irritable bowel syndrome (IBS).

Review of Resident R35's EMR under Clinical Physician's Orders revealed an order dated 12/21/2024 for Linzess oral capsule 145 micrograms (mcg), two capsules one time a day for IBS. Further review revealed an order dated 12/26/2024 for NovoLog Flex Pen subcutaneous solution pen-injector 100 unit/milliliter (ml) (insulin aspart) [a medication used to treat diabetes] inject per sliding scale. The sliding scale order included administering four units of insulin if the resident's finger-stick blood sugar (FSBS) was 206 to 235.

During medication pass observation on 2/8/2025 at 10:35 am, Licensed Practical Nurse (LPN) AA was observed administering medications to Resident R35. The medications administered included Linzess oral capsule 290 mg two capsules. Further observation revealed she checked Resident R35's FSBS and determined, based on the physician's order for sliding scale insulin, that Resident R35 required four units of insulin. Observation revealed LPN AA to dial the dose of four units on the NovoLog Flex Pen and administer the insulin to Resident R35. She was not observed to prime the insulin pen needle with two units of insulin before dialing the dose on the pen.

In an interview on 2/8/2025 at 10:45 am, LPN AA verified the container of Linzess was labeled as 290 mg per capsule and confirmed she administered Linzess 290 mg two capsules to Resident R35. She verified the physician's order was for Linzess 145 mg capsules, two capsules one time a day. She stated she was unaware the label on the Linzess stated it was 290 mg capsules. She further stated she should have looked at the dosage on the medication bottle before administering the medication and would notify the provider for further instruction. During a continued interview, LPN AA confirmed she did not prime the NovoLog insulin pen needle with two units of insulin before dialing the dosage on the pen to four units and administering it to Resident R35. She stated she was unaware she should prime the needle before dialing the dose on the pen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 115771 Department of Health & Human Services Printed: 09/09/2025 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 02/10/2025

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 0759 In an interview on 2/9/2025 at 10:45 am, the Director of Nursing (DON) stated her expectations were for nurses to follow the five rights of medication administration and ensure medications were administered Level of Harm - Minimal harm or according to physician orders. She stated the nurse should ensure the correct medication and dosage was potential for actual harm administered to the correct resident at the correct time and by the correct route. She further stated that administering an incorrect medication dosage could potentially cause adverse effects for the resident. During Residents Affected - Few further interview, the DON stated she expected nurses to follow the manufacturer's guidelines for the administration of insulin via an insulin pen. She stated insulin pen needles should be primed with two units of insulin before dialing the ordered dosage on the pen to ensure the resident received the ordered insulin dose. She further stated that if the pen was not primed, the resident could receive a decreased insulin dose, potentially resulting in an adverse outcome. She stated the Nurse Practitioner had recently provided education on insulin administration and she planned further education on medication administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 115771 Department of Health & Human Services Printed: 09/09/2025 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 02/10/2025

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 35180 potential for actual harm Based on observation, staff interview, and review of the facility's policy titled Giving a Bed bath, the facility Residents Affected - Some failed to ensure residents' basins, urinals, and bedpans were labeled and covered for 11 of 69 shared rooms (D2, D5, D18, D16, C9, C15, B16, B5, A15, A5, and A11). These failures had the potential to expose patients to infections due to cross-contamination.

Findings include:

A review of the facility policy, Giving a Bed bath, dated April 2022 under the section titled Steps in the Procedure revealed, 23. Clean washbasins, be sure the resident's name is written on the wash basin, place

in a clean plastic bag and store it in the resident's bathroom, closet or nightstand and return any other supplies to designated storage areas.

Observation of rooms on halls A, B, C, and D with the Infection Control Preventionist (ICP) on 2/9/2024 from 4:40 pm through 5:05 pm revealed the following:

Room D2, bathroom, shared by two residents, revealed two basins in a clear plastic bag. Neither of the basins was labeled with a resident name.

Room D5, a bathroom shared by two residents, revealed one basin on the floor, which was unbagged and unlabeled with a resident name. Additionally, two bedpans in a clear plastic bag and two basins in a clear plastic bag were observed. None of the items were labeled with a resident's name.

Room D18, a bathroom shared by two residents, revealed two bedpans in a clear plastic bag and one basin

in a clear plastic bag. None of the items were labeled with a resident name.

Room D16 bathroom, shared by two residents, revealed one urinal attached to the toilet assistance bar. The urinal was not labeled with a resident name. Additionally, a clear plastic bag contained one bedpan and one basin. Neither of the items was labeled with a resident name.

Room C9, a bathroom shared by two residents, revealed two bedpans in a clear plastic bag. Neither of the items was labeled with a resident name.

Room C15, a bathroom shared by two residents, revealed one basin on the floor. The basin was not bagged or labeled with the resident's names.

Room B16 bathroom, shared by two residents, revealed three unlabeled and unbagged urinals.

Room B5, a bathroom shared by two residents, revealed two basins and one bedpan. The items were labeled with the resident's names and placed together in one clear plastic bag.

Room A15 bathroom, shared by two residents, revealed one unlabeled and unbagged basin sitting on the floor. One basin and one bedpan were also observed in a clear plastic bag. Neither item was labeled with a resident name.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 115771 Department of Health & Human Services Printed: 09/09/2025 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 02/10/2025

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 Room A5, a bathroom shared by two residents, revealed two basins in a clear plastic bag, which were not labeled with a resident name. Level of Harm - Minimal harm or potential for actual harm Room A11, a bathroom shared by two residents, revealed two basins in a clear plastic bag, which were not labeled with a resident name. Residents Affected - Some

During an interview with the Infection Control Preventionist (ICP) on 2/9/2025 at 4:48 pm, she stated the Certified Nursing Assistants (CNAs) were supposed to check all the resident's rooms to ensure all basins, urinals, and bedpans were off the floor. All items were to be bagged in a clear bag and labeled with the resident name. The ICP confirmed that numerous bathrooms contained unlabeled and unbagged items. She acknowledged several items sitting directly on the floor, unbagged and unlabeled.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 115771

F-F695

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 11 115771 Department of Health & Human Services Printed: 09/09/2025 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 02/10/2025

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 47947 potential for actual harm Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Residents Affected - Few Oxygen Safety, the facility failed to ensure one resident (R) (Resident R6) was administered oxygen therapy in accordance with the physician order and to ensure that the oxygen concentrators' filters remained clean for three residents (Resident R98, Resident R64, and Resident R105) out of 19 residents receiving respiratory treatments. This deficient practice had the potential to put residents at risk for increased respiratory infections, medical complications and potentially life-threatening complications.

Findings include:

Review of the facility's policy titled, Oxygen Safety, dated April 2022 under the section titled Oxygen Administration revealed, 1. Oxygen therapy is administered to the resident only upon the written order of a licensed physician.

1. Review of the clinical records revealed Resident R6 admitted to the facility with diagnoses that included but not limited to asthma, dependence of supplemental oxygen, and malignant neoplasm of unspecified bronchus or lung.

Review of Resident R6's clinical records revealed a physician order for continuous oxygen (O2) at 2 (two) LPM (liters per minute) via nasal cannula with a start date of 10/26/2024.

Observations on 2/8/2025 at 10:58 a.m. and 2/9/2025 at 8:45 a.m. revealed Resident R6 receiving oxygen therapy via nasal cannula at 3 (three) LPM.

Cross reference to