Gracemore Nursing And Rehab
GRACEMORE NURSING AND REHAB in BRUNSWICK, GA — inspection on March 9, 2025.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the EMR for R6 revealed an order dated 2/6/2025 for an 18 French Catheter for urinary
Observation on 3/7/2025 at 8:26 am and 2:39 pm revealed R6's catheter bag resting on the floor with no barrier and drainage bag not covered. At 4:00 pm the bag was not covered but was off of the floor and hung appropriately by the bedside below the bladder.
Interview on 3/8/2025 at 9:08 am with the DON the Surveyor revealed her observations from 3/7/2025 and showed the DON the pictures of the resident's bag not covered at 8:26 am, 2:39 pm and resting on the floor.
Surveyor advised at 4:00 pm the bag was off the floor but was not covered.
Review of the Quarterly MDS for R23 dated 1/16/2025 in Section C (Cognitive Patterns) revealed a BIMS score of 14, indicating intact cognitive impairment.
Section GG (Functional Status)-dependent, Section H (Bowel and Bladder)-Indwelling Catheter, Section I (Active Diagnosis)- (including but not limited to) retention of urine, unspecified.
Review of the EMR for R23 revealed an order dated 4/10/2024 for catheter care every shift and Prn: 20 FR with 20 mL (milliliters) of water Coude (type of catheter) catheter to BDS; changed monthly by Urology.
Observations on 3/7/2025 at 8:26 am, 2:39 pm, and 4:00 pm revealed R23's drainage bag not covered.
115554 03/09/2025
Gracemore Nursing and Rehab 2708 Lee Street Brunswick, GA 31520
CNA GG, CNA FF, and the alleged abuser) and findings were that the complainant had misunderstood
misunderstood what CNA FF was reporting to her. CNA FF reported that she had communicated to
move her hands.
The Administrator reported that her investigation included performing a test try with CNA FF with R24 in the room in order to determine if R24 would become combative.
The Administrator reported witnessing R24 attempting to hit CNA FF's hand.
She reported that when CNA GG was reprimanded and terminated in January 2025, CNA GG had to be escorted from the building by law enforcement and CNA GG mentioned that she was going to call the State on the facility.
115554 03/09/2025
Gracemore Nursing and Rehab 2708 Lee Street Brunswick, GA 31520
Review of the EMR revealed three progress notes where the resident was transferred to the hospital.
On 11/11/2024, R20 was admitted to the hospital for sepsis, 9/14/2024 for a urinary tract infection, and on 8/25/2024 for sepsis.
Record review revealed no documentation of R20 or their representative receiving a notice of transfer.
Interview on 3/9/2025 at 8:31 am with the DON confirmed R20 nor his representative received in a writing, a reason for transfer on 8/25/2024, 9/14/2024, and 11/11/2024.
115554 03/09/2025
Gracemore Nursing and Rehab 2708 Lee Street Brunswick, GA 31520
Review of the EMR revealed three progress notes where the resident was transferred to the hospital.
On 11/11/2024 R20 was admitted to the hospital for sepsis, 9/14/2024 for a urinary tract infection, and on 8/25/2024 for sepsis.
Interview on 3/09/2025 at 8:31 am with the Director of Nursing (DON) confirmed that R20 nor his representative received the bed hold policy to include the room rates for R20's hospital transfers on 8/25/2024, 9/14/2024, and 11/11/2024.
Interview on 3/09/2025 at 8:43 am with Human Resources Manager/Financial Counselor revealed that the bed hold policy notices for R20 were not given to him or his representative and should have been.
115554 03/09/2025
Gracemore Nursing and Rehab 2708 Lee Street Brunswick, GA 31520
Review of the admission MDS dated [DATE] for R25, Section O (Special Treatment and Program)
Continued review of R25 's medical record revealed no evidence of the creation of a care plan with interventions to address instructions for O2 therapy use and a plan of care for treatment of wound for umbilicus.
Review of MDS Section M (Skin Conditions) assessed surgical wound.
There was no plan of care for enhanced barrier precautions due to R25 having surgical wounds.
Interview on 3/9/2025 at 10:55 am, the DON reported being unaware of R25 's not having a plan of care for O2 therapy use prior to the survey.
The DON reported that the missing care plan was brought to her attention by the MDS Coordinator.
She reported that her expectations were that residents' oxygen care plans are created according to appropriate timeline and individualized to communicate O2 therapy use.
Crossed referenced to F-F695
115554 03/09/2025
Gracemore Nursing and Rehab 2708 Lee Street Brunswick, GA 31520
Observation on 3/7/2025 at 9:05 am to 11:36 am and 1:36 pm to 2:36 pm revealed R25 lying in bed receiving O2 by O2 concentrator (machine that delivers O2) via nasal cannula at three liters instead of two liters.
During an observation at the time of interview with Licensed Practical Nurse (LPN) CC on 3/7/2025 at 3:03 pm, LPN CC verified R25 's physician order for O2 at 2 liters per minute (LPM) and verified the O2 flowmeter (device to measure O2) was set on the wrong flow rate of 3 LPM.
She stated the nurses were responsible for checking the O2 flow rates daily to ensure the flow rate was correct.
Interview on 3/9/2025 at 10:55 am, the Director of Nursing (DON) reported being unaware of R25 's O2 being set on the wrong flow rate until it was brought to her attention during the survey by the nursing staff.
She reported that her expectation was to ensure that the flowmeter was set at the rate prescribed by the physician order.
The risk was that too little, or too much O2 would place the resident at risk.
Cross-referenced to F-F656
115554 03/09/2025
Gracemore Nursing and Rehab 2708 Lee Street Brunswick, GA 31520
staff to follow infection control policies as it pertained to sanitizing their hands every time they
Review of R25's electronic medical record (EMR) and Physician Order Form revealed the following diagnoses but not limited to cutaneous abscess of abdominal wall and unspecified open wound abdominal wall (surgical wound of umbilicus).
Review of the Quarterly Minimum Data Set (MDS) dated [DATE] assessed a Brief Interview Mental Status (BIMS) score of 10, which indicates moderate cognitive impairment.
Review of R25's Physician Order Form listed the following active order dated 11/7/2024 that stated Cleanse ABD (abdominal) surgical wound with wound cleanser pat dry pack area with Aquacel Extra (wound dressing) cover with dry 4x4 (four times four) and secure with tape daily prn (as needed) until resolved every day shift for surgical wound ABD AND as needed for ABD surgical wound.
Continued review listed order for Enhanced Barrier Precaution (EBP). No directions specified for order.
Observation at the time of interview on 3/7/2025 at 9:36 am, the Clinical Care Coordinator-Register Nurse (RN) EE was observed entering R25's room to provide incontinent care while the Surveyor was in the room.
She was observed checking the resident for incontinent care with only gloves on, repositioning the resident in bed.
She reported that she was checking the resident to change her incontinence brief.
She was observed touching the resident body and later observed dressing the resident.
When asked if the resident was on EBP, she stated that the resident was no longer considered on EBNP and that staff was not required to dress in PPE due to resident's wound being healed.
115554
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 115554 B.
Wing 03/09/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Gracemore Nursing and Rehab 2708 Lee Street Brunswick, GA 31520
Observation on 3/7/2025 at 9:05 am to 11:36 am and 1:36 pm to 2:36 pm revealed R25 lying in bed receiving O2 by O2 concentrator (machine that delivers O2) via nasal cannula at three liters instead of two liters.
During an observation at the time of interview with Licensed Practical Nurse (LPN) CC on 3/7/2025 at 3:03 pm, LPN CC verified R25 's physician order for O2 at 2 liters per minute (LPM) and verified the O2 flowmeter (device to measure O2) was set on the wrong flow rate of 3 LPM.
She stated the nurses were responsible for checking the O2 flow rates daily to ensure the flow rate was correct.
Interview on 3/9/2025 at 10:55 am, the Director of Nursing (DON) reported being unaware of R25 's O2 being set on the wrong flow rate until it was brought to her attention during the survey by the nursing staff.
She reported that her expectation was to ensure that the flowmeter was set at the rate prescribed by the physician order.
The risk was that too little, or too much O2 would place the resident at risk.
Cross-referenced to
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.