Cambridge Post Acute Care Center
Inspection Findings
F-Tag F0684
F 0684
facility call the provider and obtain an order for a chest x-ray, as the PICC line nurse could not write orders or call for a chest x-ray because they did not work for the facility.
Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/25/2025
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-Tag F0760
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, resident and staff interviews, and review of the facility's policy titled, Medication Delivery Expectations-Nurses, the facility failed to keep one of six residents (R) (RB) free from significant medication error.Findings include:Review of the facility's policy titled Medication Delivery Expectations-Nurses last revised June 2025 documented under Protocol: .8. Notify the physician if medication will be given late or obtain an alternative order or different start time, if appropriate.Review of the electronic medical record (EMR) revealed RB was admitted with diagnoses of but not limited to intraspinal abscess and granuloma, infection following a procedure, candidiasis, chronic obstructive pulmonary disease (COPD), asthma, depression, and muscle weakness.Review of RB's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficits.Review of the care plans for RB revealed the care plan was updated 8/16/2025: readmission on [DATE REDACTED] with s/p (status post) transfusion status. 8/16/2025 readmission with DX (diagnosis) of extraspinal abscess and granuloma, infection following procedure. Focus: Resident is receiving antibiotic/fluids intravenously via PICC related to sepsis (life-threatening reaction to an infection). readmission on [DATE REDACTED] with IV antibiotic therapy via PICC (peripherally inserted central catheter) line for infection with status post spinal abscess of C2-C4 (cervical vertebrae) with s/p (status post) surgical procedure. 8/16/2025 readmission IV antibiotic therapy continue. Outcome: Resident will have a resolution
in infection through next review date. Interventions: Administer Intravenous fluids as ordered per MD (medical doctor). Change IV site per facility protocol. Dressing changes to IV site per facility protocol.
Monitor IV site for s/s (signs/symptoms) of infection. Monitor/observe for adverse reaction to medication and report abnormal findings to MD/RP (responsible party)/Resident. PICC line maintenance care as ordered.Review of the Physician's orders for RB revealed an order for Micafungin Sodium-NaCl sodium chloride) intravenous Solution 100-0.9 mg (milligram)/100 ml (milliliter)-% (percentage) use intravenously every 24 hours for antibiotic therapy until 10/05/2025 23:59. Cefazolin Sodium injection solution reconstituted 2 GM (grams) Use 1 dose intravenously every eight hours for abscess to cervical spine until 10/6/2025.Review of the Medication Administration Record (MAR) for September 2025 for RB revealed Cefazolin doses were missed on 9/18/2025 at 1400 (2:00 pm), and 2200 (10:00 pm), 9/19/2025 at 0600 (6:00 am), and 1400 (2:00 pm), and on 9/22/2025 the dose at 1400 was missed. Number eight (8) was inserted in the MAR for these dates meaning the medication was not given. Micafungin Sodium-NaCl Intravenous solution 100-0.9 mg/100 ml dose was missed on 9/18/2025 and 9/19/2025. An interview with Registered Nurse (RN) GG on 9/24/2025 at 11:37 am revealed when a PICC line came out, we just wait until the PICC is inserted to restart the antibiotic. An interview on 9/24/2025 at 11:45 with the Director of Nursing (DON) revealed her expectation when a PICC line was not usable for whatever reason was the nurse was to call the Doctor and request an alternative route for the medication, if there was no alternative,
we got an order to reinsert.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/25/2025
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-Tag F0880
F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Observation of a dressing change for Resident R15 on 9/24/2025 at 11:42 am, LPN AA entered Resident R15's room to perform a dressing change. A sign for EBP precautions was posted on the door; however, LPN AA and Wound Tech II did not wear gowns prior to or during the procedure. When treating the right hip wound, LPN AA removed the soiled packing but did not change her gloves before applying Dakin's solution to gauze and covering the wound with a new bordered gauze island dressing. While still wearing the same contaminated gloves, she reached into her pocket to retrieve a marker to date the dressing and then returned the marker to her pocket without cleaning it. The same practice was observed during the sacral dressing change, when
she again retrieved the marker from her pocket while wearing contaminated gloves and then returned it to her pocket. When changing the dressing on the left hip, LPN AA changed gloves after removing the soiled dressing from the right hip; however, hand hygiene was not performed after glove removal.
In an interview following the observation, the surveyor asked LPN AA why she wore a gown for one resident prior to a dressing change but did not wear one for Resident R15. LPN AA stated she forgot to do it and acknowledged she ignored the EBP signage on the door, explaining that there were no PPE supply boxes or a cart at the doorway to remind her. Wound tech II also confirmed that gowns should have been worn when providing high-contact care to the resident, but acknowledged they failed to do so.
In an interview with the Infection Preventionist (IP)/Staff Development Nurse on 9/24/2025 at 12:33 pm, she stated that staff were frequently educated on EBP and the use of gowns during high-contact care to residents with wounds or catheters, both to protect residents and to reduce the risk of infection.
In an interview with the Director of Nursing (DON) on 9/24/2025 at 12:35 pm, she stated her expectations were that staff consistently followed infection control practices, including frequent hand hygiene, sanitizing hands when changing gloves since glove changes do not substitute for hand hygiene, and adhering to EBP precautions for residents with wounds, central lines, or catheters.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
CAMBRIDGE POST ACUTE CARE CENTER in SNELLVILLE, GA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SNELLVILLE, GA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CAMBRIDGE POST ACUTE CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.