BRUNSWICK, GA - A federal inspection at Gracemore Nursing and Rehab revealed multiple lapses in infection prevention protocols that placed residents at heightened risk for healthcare-associated infections, including failures to properly use personal protective equipment and maintain sterile wound care procedures.
Staff Bypassed Protective Equipment Requirements
Inspectors documented repeated instances where nursing staff provided direct care to residents with infectious conditions without following enhanced barrier precautions. These protocols are specifically designed to prevent the transmission of multi-drug resistant organisms between vulnerable residents.
One resident with an unresolved surgical wound to the umbilical area required enhanced barrier precautions according to facility policy. Despite active physician orders for daily wound care, staff members were observed providing intimate care activities without wearing required gowns and gloves. On March 7, 2025, a clinical care coordinator entered the resident's room wearing only gloves while checking for incontinence, repositioning the patient, and assisting with dressing.
The coordinator explained to inspectors that she believed the resident no longer required enhanced precautions because the wound had healed. However, the facility's wound treatment nurse confirmed the surgical wound remained open and unresolved, necessitating continued barrier precautions.
Later that same day, a certified nursing assistant provided incontinence care to multiple residents in the room without donning protective equipment. When questioned, the assistant reported being unaware that any residents in the room required enhanced precautions. She confirmed providing this level of care for several weeks without using proper protective equipment.
The required signage and personal protective equipment storage had been removed from outside the resident's door, apparently in error following resolution of a separate norovirus outbreak. The supplies were not restored until the morning of March 8, after inspectors identified the deficiency.
Medical Significance of Barrier Precautions
Enhanced barrier precautions serve as a critical line of defense in preventing the spread of antibiotic-resistant bacteria in congregate care settings. When staff members touch contaminated surfaces or provide direct care without appropriate protection, pathogens can be transferred from one resident to another through contact with clothing, exposed skin, or contaminated hands.
Surgical wounds present particular concern because they create direct pathways for bacteria to enter the body's normally sterile internal tissues. Open wounds lack the protective barrier of intact skin and provide ideal conditions for bacterial colonization. Multi-drug resistant organisms pose especially serious threats because standard antibiotic treatments may prove ineffective if infection develops.
Facility policy required staff to wear gowns and gloves during high-contact care activities including dressing, bathing, transferring, hygiene assistance, linen changes, and incontinence care. These protective measures prevent contamination of staff clothing and skin that could subsequently transfer organisms to other residents during subsequent care activities.
Catheter Management Deficiencies
Inspectors observed improper handling of urinary catheter drainage equipment that violated fundamental infection control principles. One resident with a physician-ordered indwelling catheter for urinary retention had the drainage bag resting directly on the floor during observations conducted at 8:26 AM and 2:39 PM on March 7.
Urinary catheters present inherent infection risks because they bypass the body's natural defenses against bacterial entry into the bladder. The drainage bag must remain below the level of the bladder to prevent backflow of urine, but contact with floor surfaces introduces environmental pathogens directly into the closed drainage system. Floor surfaces in healthcare facilities harbor numerous microorganisms despite regular cleaning protocols.
When questioned about proper catheter care procedures, a certified nursing assistant correctly stated that drainage bags should be covered, hanging below bladder level, and never resting on the floor. A licensed practical nurse similarly confirmed the bag should be attached to the bed below the bladder and always covered with a privacy bag, emphasizing that floor contact violated infection control practices.
The Director of Nursing acknowledged that catheter care should be performed every shift with the drainage bag attached to a non-moving part of the bed and covered appropriately. After reviewing photographic evidence of the bag on the floor at two different times, she confirmed that under no circumstances should drainage equipment contact floor surfaces.
Compromised Wound Care Procedures
During an observed wound care procedure on March 8, a licensed practical nurse demonstrated multiple breaches of sterile technique that created opportunities for bacterial contamination. The resident being treated had an active stage 4 pressure ulcer, chronic kidney disease, and a separate heel wound requiring specialized dressing changes.
The nurse placed a plastic garbage bag on a pillow at the foot of the bed without any barrier between the contaminated bag and the pillow. Throughout the thirty-minute procedure, she repeatedly removed and donned gloves without performing hand hygiene between changes. After removing contaminated dressings, she changed one glove while leaving the other in place, then continued with wound care without sanitizing her hands.
Following completion of the wound care, the nurse removed the garbage bag containing contaminated materials and placed it directly on the resident's nightstand without a barrier. She then took the pillow that had supported the contaminated garbage bag and placed it behind the resident's head without changing the pillowcase.
Proper hand hygiene represents the single most important factor in preventing healthcare-associated infections. Healthcare workers' hands become contaminated through patient contact and touching contaminated surfaces. Even when gloves are used appropriately, hands can become contaminated during glove removal or through microscopic tears in the glove material. Hand sanitization between glove changes prevents the transfer of pathogens picked up during one care activity to subsequent surfaces or patients.
Open wounds require strict aseptic technique because they lack the protective barrier of intact skin. Any bacteria introduced into the wound bed can multiply rapidly in the warm, moist environment and potentially cause serious infections. Patients with chronic kidney disease face elevated infection risks because compromised kidney function affects immune response and the body's ability to fight bacterial invasion.
The nurse acknowledged during follow-up questioning that she had failed to sanitize her hands between donning and doffing gloves throughout the procedure. She also confirmed placing contaminated items on surfaces without barriers and repositioning a soiled pillow behind the resident's head. She reported returning later to change the pillowcase and clean the nightstand.
Additional Issues Identified
The inspection revealed that facility policies for enhanced barrier precautions existed but were not consistently implemented. Staff members demonstrated knowledge of proper infection control procedures when questioned but failed to follow those procedures during actual patient care. The facility's infection control preventionist reported being unaware that required personal protective equipment supplies had been removed from residents' rooms.
Communication breakdowns contributed to the deficiencies, with clinical staff receiving inconsistent information about which residents required enhanced precautions. The removal of door signage and equipment storage following one infection outbreak led to discontinued precautions for residents with ongoing infectious concerns.
The Director of Nursing expressed expectations that staff would follow infection control policies and that appropriate supplies would remain available, but acknowledged being unaware of the specific violations documented during the inspection. The Administrator similarly stated expectations for proper hand hygiene and barrier use to prevent infection transmission.
These documented failures occurred despite the facility having written policies addressing each aspect of infection prevention. The gap between policy requirements and actual practice placed multiple residents at unnecessary risk for acquiring healthcare-associated infections that could result in serious illness, additional medical treatments, prolonged recovery, and potential complications.
Federal regulations require nursing facilities to establish and maintain infection prevention and control programs designed to provide a safe and sanitary environment. The documented deficiencies indicate systemic failures in program implementation, staff education, and ongoing monitoring of infection control practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gracemore Nursing and Rehab from 2025-03-09 including all violations, facility responses, and corrective action plans.
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