Gracemore Nursing and Rehab: Care Plan Failures - GA
The resident, identified in inspection records only as R25, had been assessed at admission as requiring oxygen therapy. That assessment, recorded in the facility's own Minimum Data Set, triggered a requirement that staff build out a formal plan of care directing how the oxygen would be managed. No such plan existed.
The same resident had a surgical wound at the umbilicus. Inspectors reviewed the medical record and found no care plan for wound treatment and no plan for enhanced barrier precautions, a standard protective measure for residents with open surgical wounds. The MDS had flagged the wound. The care plans were never written.
The Director of Nursing told inspectors on the morning of March 9 that she had been unaware R25 was missing the oxygen care plan before the survey began. She said the gap was brought to her attention not by her own review of the resident's chart, but by the MDS Coordinator, apparently after inspectors arrived. She told inspectors her expectation was that oxygen care plans be created on an appropriate timeline and individualized to reflect each resident's specific therapy needs.
That expectation had not been met for R25.
Care plans are the mechanism by which a nursing home translates a resident's medical needs into daily instructions for staff. When a resident requires supplemental oxygen, a care plan tells nurses and aides the prescribed flow rate, when the oxygen should be in use, what symptoms to watch for, and when to escalate. Without one, staff are working without a roadmap for a resident whose breathing already required intervention.
The same logic applies to wound care. R25's records showed a physician order for daily dressing changes, covering the surgical wound with a dry 4x4 gauze pad secured with tape, with additional changes as needed. That order existed. What didn't exist was a coordinated care plan built around it, one that would track the wound's progress, communicate precautions across shifts, and ensure staff handling the wound were following consistent protocols.
Surgical wounds carry infection risk. Enhanced barrier precautions exist precisely because of that risk, and they require coordination across the care team. Inspectors noted the absence of any such plan in R25's record.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting few residents. That designation reflects where things stood at the time of inspection, not necessarily where they would have gone. A resident dependent on oxygen therapy and recovering from abdominal surgery, without documented guidance for either condition, is a resident whose care depends entirely on whoever happens to be on shift making the right call without written support.
The Director of Nursing acknowledged the lapse and described what her expectations had been. She did not describe what had prevented those expectations from being met, or how long R25 had been without the missing plans.
The inspection report cross-referenced the finding to a related federal tag, F695, which governs respiratory care. The facility is located at 2708 Lee Street in Brunswick and operates under CMS provider number 115554.
R25's surgical wound was still being dressed daily when inspectors arrived.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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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.
The resident, identified in inspection records only as R25, had been assessed at admission as requiring oxygen therapy.
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.