Gracemore Nursing And Rehab
GRACEMORE NURSING AND REHAB in BRUNSWICK, GA — inspection on March 9, 2025.
Found 2 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 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