Gracemore Nursing and Rehab: Oxygen Dosing Error - GA
The resident, identified in inspection records as R25, lives at Gracemore Nursing and Rehab on Lee Street in Brunswick. The inspection, completed March 9, 2025, documented a single deficiency: the facility failed to administer oxygen therapy in accordance with the physician's order.
R25 carries diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and pulmonary disease. A physician order on file directed oxygen at two liters per minute via nasal cannula, as needed for shortness of breath or compromised oxygen saturation. The order also noted the resident may remove the oxygen as desired, a detail that reflects some preserved autonomy. A cognitive assessment from February 2025 placed R25 in the moderate deficit range, with a BIMS score of 10 out of 15.
On March 7, 2025, inspectors observed R25 lying in bed on oxygen from a concentrator, the machine that draws in room air and delivers purified oxygen. The observation ran from 9:05 in the morning through 11:36, then resumed from 1:36 in the afternoon to 2:36. Throughout that window, the flowmeter was set to three liters per minute, not two.
That is 50 percent more oxygen than the doctor ordered.
At 3:03 that afternoon, a Licensed Practical Nurse identified in the report as LPN CC stood with the inspector and looked at the order and the machine. She confirmed the physician order called for two liters. She confirmed the flowmeter read three. She said nurses were responsible for checking oxygen flow rates daily to make sure the setting matched the order.
Nobody had caught it.
Two days later, on the morning of March 9, the Director of Nursing told the inspector she had been unaware that R25's oxygen was running at the wrong rate until nursing staff brought it to her attention during the survey itself. Her expectation, she said, was that the flowmeter would be set at whatever rate the physician prescribed. She acknowledged the risk plainly: too little oxygen, or too much, puts a resident at risk.
That acknowledgment matters. For a resident with chronic respiratory failure and hypoxia, oxygen therapy is not a comfort measure. It is a medical intervention calibrated to maintain safe blood oxygen levels. Too little oxygen in a compromised respiratory patient can accelerate deterioration. Too much, particularly in patients with COPD, carries its own risks, including suppression of the respiratory drive in certain clinical contexts. The physician set the rate at two liters for a reason.
The inspection report rated the deficiency at the lowest level of harm, meaning minimal harm or potential for actual harm rather than documented injury. There is no record in the report of R25 experiencing a medical event tied to the wrong flow rate. But the window of exposure was not brief. Inspectors documented the error across more than four hours of direct observation, and nothing in the record indicates when the setting was last correct before that morning.
The facility's own oxygen administration policy states that the purpose of the procedure is to provide guidelines for safe oxygen administration, and that staff should verify the physician's order and review the resident's care plan. The daily check that LPN CC described as standard nursing responsibility did not catch a flowmeter set one liter too high.
Gracemore Nursing and Rehab has 120 certified beds. The facility is located at 2708 Lee Street in Brunswick.
R25 remained on oxygen therapy at the time of the inspection. The report does not say whether anyone adjusted the flowmeter before or after the LPN confirmed the error to the inspector at 3:03 in the afternoon.
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 9, 2026 · Our methodology
GRACEMORE NURSING AND REHAB in BRUNSWICK, GA was cited for violations during a health inspection on March 9, 2025.
The resident, identified in inspection records as R25, lives at Gracemore Nursing and Rehab on Lee Street in Brunswick.
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.