Cambridge Post Acute Care Center
CAMBRIDGE POST ACUTE CARE CENTER in SNELLVILLE, GA — inspection on September 25, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
placement is not present, and no results are in the chart.
Review of the medication administration
interview and observation with RB on 9/23/2025 at 1:28 pm revealed that the dressing on his PICC
dressing was changed along with the new PICC line on Friday, 9/19/2025. He also stated that he told the nursing staff on Wednesday evening, 9/17/2025, that the tape was coming off and he was afraid the PICC line was going to come out.
The PICC line came out on Thursday, 9/18/2025 in the morning, and he went without any of his IV medications for two days until the new PICC line was inserted on the afternoon of 9/19/2025.A telephone interview on 9/23/2025 at 2:12 pm with prior resident RA from complaint GA002580721 revealed the nurse told her that the facility was not equipped to handle PICC lines.An interview and observation on 9/24/2025 at 9:56 am revealed RB sitting in bed and stated that the PICC line dressing would not get changed until the tape came off, it had never been changed once a week. RB stated the dressing had not been changed since it was inserted on Friday, 9/19/2025. An interview on 9/24/2025 at 11:25 am with Unit Manager Licensed Practical Nurse (LPN) FF revealed that the Registered Nurses (RN)s did the PICC line dressing changes and if a PICC line became unusable for any reason, they called the doctor to get an order to reinsert. An interview on 9/24/2025 at 11:37 am with RN GG revealed when a PICC lines came out, they called the Doctor for an order for an x-ray before insertion to see what was going on then another order for x-ray after insertion.
She stated that, we just wait until the PICC is inserted to restart the antibiotic. An interview on 9/24/2025 at 11:45 am with the Director of Nursing (DON) revealed her expectation when a PICC line was not usable for whatever reason, 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 and requested service and got an idea of when the PICC line could be re-inserted, this was considered a stat (immediate) procedure and notified the MD of the timeline.
She also expected the dressing on the PICC line to be changed as ordered and per facility policy. An observation of RBs PICC line dressing change at 1:35 pm on 9/24/2025 with RN HH revealed masks were worn by the residents and RN HH. No gowns were used. RB did have an EBP sign on the room door.
The resident was made comfortable and the bed raised, RN HH wiped down the bedside table with alcohol, removed the dressing with clean gloves, then removed gloves and performed hand hygiene and opened the sterile dressing change kit, then donned (put on) sterile gloves. RN HH broke the sterile field by touching RB's arm with her left hand while cleaning with her right hand.
The Stat lock (Stabilization Device) was not changed, the antibacterial disk around the insertion site was not changed and was left in place. RN HH cleaned the site with alcohol and a chlorhexidine (antiseptic) swab, applied skin prep and a transparent dressing.
The date and initials were written on the dressing.An interview on 9/25/2025 at 9:05 am with the Assistant Director of Nursing (ADON) verified that a follow up chest x-ray was not done after the PICC line placement on 9/19/2025 to verify PICC line placement and the line had been being used daily since insertion. An interview on 9/25/2025 at 9:28 am with dispatcher for the PICC line insertion company to get a message to the RN Supervisor for a return call to discuss the chest x-ray. At 9:49 am, the RN Supervisor and owner of the PICC line insertion company returned call and stated that they always requested that the 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.
115771 09/25/2025
Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078
Delivery Expectations-Nurses, the facility failed to keep one of six residents (R) (RB) free from
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] 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] 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] 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.
115771 09/25/2025
Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078
perform a dressing change. A sign for EBP precautions was posted on the door; however, LPN AA and
gauze and covering the wound with a new bordered gauze island dressing.
While still wearing the
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 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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.