Gracemore Nursing: Infection Control Failures - GA
The March inspection at Gracemore Nursing and Rehab found staff routinely ignored infection control procedures for three residents, including one with an unhealed surgical wound to the umbilicus and another whose catheter bag rested directly on the floor.
Clinical Care Coordinator RN EE entered the room of a resident with an abdominal surgical wound on March 7, touching the resident's body and changing their incontinence brief while wearing only gloves. When questioned, she claimed the resident was no longer on enhanced barrier precautions because "the wound was healed."
But the resident still had active physician orders for daily wound cleaning and dressing changes. The facility's wound treatment nurse confirmed the surgical wound "has not been resolved" and that staff should have recognized the bandages covering the abdominal area.
The enhanced barrier precautions sign and protective equipment hanger had been removed from the door, apparently by mistake after the resident recovered from a norovirus outbreak. CNA HH told inspectors she was "unaware of any of the residents in the room being on EBP" and had been providing care without protective equipment for weeks.
Licensed Practical Nurse CC confirmed the warning sign wasn't placed back on the door until the morning of March 8, after inspectors arrived.
Another resident's catheter drainage bag was observed resting directly on the floor twice on March 7 — at 8:26 am and again at 2:39 pm. The resident had urinary retention and required an 18 French catheter changed monthly.
CNA AA explained proper catheter care required keeping the drainage bag "covered and hanging on the bedside below the bladder and should never be resting on the floor." LPN BB confirmed the bag should "always be covered with a privacy bag" and never touch the floor "due to infection control practices."
When Director of Nursing showed the floor photos, she said "under no circumstances should the drainage bag ever be resting on the floor due to infection control."
The most egregious violation occurred during wound care for a resident with a stage 4 pressure ulcer and colon cancer. LPN CC placed a garbage bag on a pillow at the foot of the bed to collect contaminated supplies, with no protective barrier underneath.
During the 30-minute procedure, she repeatedly removed and put on gloves without sanitizing her hands between changes. She discarded contaminated dressing materials into the makeshift trash collection, then moved the garbage bag to the resident's nightstand without any barrier protection.
After completing wound care, she took the pillow that had been under the contaminated trash bag and placed it directly behind the resident's head without changing the pillowcase.
When asked about hand hygiene protocols, LPN CC "admitted she forgot to sanitize her hands in-between donning and doffing her gloves every time." She also confirmed placing the contaminated trash bag on the nightstand and the soiled pillow behind the resident's head.
The facility's Enhanced Barrier Precautions policy specifically requires gowns and gloves during "high contact resident care activities" including dressing, bathing, transferring, hygiene care, changing linens, changing briefs, and device care. The policy states personal protective equipment "is changed before caring for another resident."
Director of Nursing told inspectors she was "unaware of the CNA and licensed nursing staff not using PPE when providing incontinent care to a resident who was on EBP for wound infections." The Infection Control Preventionist said she was unaware the PPE supplies weren't available on the resident's door.
Administrator confirmed her expectation that staff "follow infection control policies as it pertained to sanitizing their hands every time they donned and doffed their gloves and that they should use a barrier to prevent infection."
LPN CC later reported she changed the contaminated pillowcase and wiped down the nightstand at 10:50 am, after inspectors documented the violations.
The facility cares for residents with moderate cognitive impairment who depend on staff for most daily activities. Two of the affected residents were always incontinent of both bowel and bladder, requiring frequent intimate care that increases infection transmission risks.
All three residents had conditions that made them particularly vulnerable to infections — surgical wounds, pressure ulcers, chronic kidney disease, and cancer. The facility's own policies recognized these risks by requiring enhanced protective measures that staff repeatedly failed to follow.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 17, 2026 · Our methodology
GRACEMORE NURSING AND REHAB in BRUNSWICK, GA was cited for violations during a health inspection on March 9, 2025.
CNA HH told inspectors she was "unaware of any of the residents in the room being on EBP" and had been providing care without protective equipment for weeks.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.