Gracemore Nursing and Rehab: Catheter Care Failures - GA
Inspectors visited the facility at 8:26 in the morning on March 7, 2025. The bag was on the floor. They came back at 2:39 in the afternoon. Still on the floor, still uncovered. By 4:00 p.m., someone had hung it properly by the bedside, below the level of the bladder where it belongs. But it still had no cover.
The resident, identified in inspection records as R6, had an 18 French catheter placed under a physician's order dated February 6, 2025, for urinary retention. The order called for the catheter to be changed monthly by urology. According to the quarterly assessment, R6 was always incontinent of both bowel and bladder.
A catheter drainage bag on the floor without a barrier is a contamination risk. The bag collects urine directly from the bladder through a tube running inside the body. When that bag touches a floor, and when the drainage port is left uncovered, the pathway for bacteria runs in both directions.
The director of nursing was interviewed the following morning, March 8, at 9:08 a.m. The inspector showed her the photographs taken the day before. The director saw the same images: bag on the floor at 8:26 a.m., bag on the floor at 2:39 p.m., bag off the floor but uncovered at 4:00 p.m. The inspection record does not indicate she disputed any of it.
R6 was not the only resident affected.
A second resident, R23, had a Coude catheter placed under an order dated April 10, 2024, with catheter care required every shift and as needed. R23's quarterly assessment, dated January 16, 2025, showed a BIMS cognitive score of 14, which indicates intact cognition. R23 understood what was happening around them. The assessment also noted R23 was fully dependent on staff for functional care and had an active diagnosis of urinary retention.
Inspectors checked R23's drainage bag at 8:26 a.m. on March 7. It was not covered. They checked again at 2:39 p.m. Not covered. They checked a third time at 4:00 p.m. Still not covered. Three observations across nearly eight hours, and the bag was never covered during any of them.
The order for R23 had been in place for nearly a year by the time inspectors arrived.
Catheter care ordered every shift means staff were present, were performing care, and were documenting it. The question the inspection record leaves open is not whether staff knew the catheters existed. It is whether anyone considered the bag on the floor, or the uncovered drainage port, a problem worth correcting before a federal inspector photographed it and showed the pictures to the director of nursing the next morning.
Gracemore Nursing and Rehab is located at 2708 Lee Street in Brunswick. The inspection was completed March 9, 2025.
R23, cognitively intact, dependent on staff for every aspect of physical care, spent at least that Friday with an uncovered catheter bag and no indication anyone on the floor had stopped to address it. The order requiring catheter care every shift had been sitting in the chart since the previous spring.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 8, 2026 · Our methodology
GRACEMORE NURSING AND REHAB in BRUNSWICK, GA was cited for violations during a health inspection on March 9, 2025.
Inspectors visited the facility at 8:26 in the morning on March 7, 2025.
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.