Gracemore Nursing And Rehab

F-F656

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 115554 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36377 potential for actual harm Based on observations, staff interviews, record review, and review of the facility's policy titled, Enhanced Residents Affected - Few Barrier, the facility failed to ensure staff follow standard infection control precautions for three of 15 residents (R) (Resident R25, Resident R6, and Resident R1) reviewed for infection control. Specifically, the facility failed to ensure staff practiced using Personal Protective Equipment (PPE) and infection control procedures to prevent cross contamination.

The deficient practice had the potential to increase Resident R25, Resident R6, and Resident R1's risk of infections.

Findings include:

Review of the facility policy titled Enhanced Barriers (EBP) stated in the first line under the title: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organism (MDR)) to residents. Under Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gowns are applied prior to performing

the high contact resident care activity. Personal protective equipment (PPE) is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spay. 3. Example of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.).

1. Review of Resident 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 REDACTED] assessed a Brief Interview Mental Status (BIMS) score of 10, which indicates moderate cognitive impairment.

Review of Resident 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 115554 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Observation at the time of interview on 3/7/2025 at 3:01 pm, Certified Nursing Assistant (CNA) HH was observed entering Resident R25's room, providing incontinent care and not donning/doffing (putting on/taking off) Level of Harm - Minimal harm or PPE. She was only observed using gloves. CNA HH reported to Surveyor that she was unaware of any of potential for actual harm the residents in the room being on EBP. She confirmed providing incontinent care to all of the residents, including Resident R24, for the past weeks and not dressing out in PPE. Residents Affected - Few

During an observation and interview on 3/8/2025 at 9:34 am with Licensed Practical Nurse (LPN) CC, LPN CC confirmed that the EBP sign was not on the resident room door yesterday and not placed on the door until this morning. She stated the Wound Nurse or maybe another staff member placed the EBP sign and PPE hangar on the room door. She confirmed that Resident R25 was the resident who was on EBP.

During a later interview on 3/8/2025 at 9:36 am, the Clinical Care Coordinator-Register Nurse (RN) EE confirmed entering Resident R25's room on 3/7/2025 without donning with full PPE (required gown, gloves, and mask) to check if the resident needed incontinent care/provide incontinent care. She confirmed using only gloves while unpinning the resident diaper, turning the resident to check her sacral area, and to reposition her. RN EE reported that although the resident had bandages, she was not aware that resident was on EBP.

Interview on 3/7/2025 at 3:25 pm, the Wound Treatment Nurse verified that Resident R25 had a surgical open wound to the umbilicus that has not been resolved. The resident should be on EBP which required licensed nursing staff and certified nursing assistants to don/doff in PPE during contact care. She stated that the nurse and certified nursing assistant should have seen the bandages on the wound on the resident's abdominal. She further stated that the EBP sign and PPE door hanger were probably removed by error by staff due to Resident R25 having recovered from the Norovirus outbreaks.

Interview on 3/8/2025 at 4:33 pm with the ICP (Infection Control Preventionist) reported being unaware of the PPE storage supply bins (PPE hangar) not being placed on Resident R25's room door. She stated the appropriate PPE should consist of gloves and a gown.

Interview on 3/9/2025 at 8:33 am with Director of Nursing (DON), she revealed being unaware of the CNA and licensed nursing staff not using PPE when providing incontinent care to a resident who was on EBP for wound infections. She reported that her expectation was that PPE supplies were available for staff use.

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2. Review of the Quarterly MDS for Resident R6 dated 1/16/2025, Section C (Cognitive) revealed a BIMS score of 11, indicating moderate cognitive impairment. Section GG (Functional Status)- dependent, Section H (Bowel and Bladder)-always incontinent of bowel and bladder, Section I (Active Diagnosis)- (including but not limited to) retention of urine, unspecified.

Review of the EMR for Resident R6 revealed an order dated 2/6/2025 for an 18 French (foley catheter size) Catheter for urinary retention to be changed monthly by urology.

Observation on 3/7/2025 at 8:26 am and 2:39 pm revealed Resident R6's catheter bag resting on the floor with no barrier.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 115554 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Interview on 3/8/2025 at 8:58 am with CNA AA revealed that catheter care included ensuring the drainage bag was covered and hanging on the bedside below the bladder and should never be resting on the floor. Level of Harm - Minimal harm or potential for actual harm Interview on 3/8/2025 at 9:03 am with LPN BB revealed that catheter care included ensuring the drainage bag was attached to the bed and below the bladder. It should always be covered with a privacy bag. At no Residents Affected - Few times should the drainage bag be resting on the floor due to infection control practices.

Interview on 3/8/2025 at 9:08 am with the DON revealed that catheter care should be done every shift. The drainage bag should be attached to a part of the bed that is nonmoving, covered with a privacy bag. Surveyor revealed her observations from 3/7/2025 and showed the DON the pictures of the resident's bag resting on the floor at 8:26 am, and 2:39 pm. She revealed under no circumstances should the drainage bag ever be resting on the floor due to infection control.

3. Review of the Quarterly MDS dated [DATE REDACTED] for Resident R1 revealed in Section C (Cognitive Patterns) a BIMS score of 9, indicating moderate cognitive impairment, Section G (Functional Status) - substantial assistance and dependent for most tasks, Section H (Bowel and Bladder) - always incontinent of bladder and bowels, Section I (Active Diagnosis) (including but not limited to) - malignant neoplasm of colon, unspecified and pressure ulcer of left buttock, stage 4, and chronic kidney disease stage 3 unspecified.

Review of a physician's order for Resident R1 dated 2/19/2025 revealed cleanse left heel wound with wound cleanser, pat dry with gauze, apply skin prep around wound, apply mesalt (wound dressing) to wound bed, and cover with 2x2 sterile border gauze 3 times a week and as needed.

An observation of wound care on 3/8/2025 from 9:35 am to 10:05 am with LPN CC revealed LPN CC reading

the physician order out loud before entering the resident's room. She then showed nurse surveyor and this surveyor the supplies she was going to use. She sanitized her hands and put gloves on. She removed the resident's boots and socks. She placed a garbage bag on a pillow at the end of the resident's bed to discard supplies she was using for wound care without a barrier. She then removed her gloves and placed them in

the garbage bag at the end of the resident's bed and did not sanitize her hands. Next, she donned a protective gown, mask, and gloves. She prepped the area on the left heal by removing the covering, placing

it in the palm of her gloved hand and removed the glove and discarded it into trash at the end of resident's bed. She donned a new glove without sanitizing her hand and continued with wound care. Once finished with wound care, she removed gloves and discarded them into the trash bag at the end of the resident's bed. She did not sanitize her hands. She donned new gloves. She then applied A and D ointment to the resident's legs. She removed the gloves and placed them in the trash bag at the end of the bed and did not sanitize her hands. She then took the trash bag and placed it on the resident's nightstand without a barrier. She then took

the pillow that was at the foot of the bed and placed it behind the resident's head without changing the pillowcase. She then donned gloves and put a clean pair of socks back onto the resident and placed boots back on resident. Surveyor asked what the protocol was for donning/doffing gloves. She admitted she forgot to sanitize her hands in-between donning and doffing her gloves every time she donned and doffed gloves. When asked about the pillow and trash bag she confirmed she placed dirty/used supplies into the trash bag that was resting on a pillow at the foot of the resident's bed without a barrier and removed the trash bag and placed it on the resident's nightstand without a barrier. She also verified she placed a dirty pillow behind the resident's head. Later, at 10:50 am, LPN CC reported she changed the pillow covering and wiped down the resident's nightstand.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 115554 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Interview on 3/9/2025 at 8:32 am with the Director of Nursing (DON) revealed that hand hygiene should be performed before, during, and after wound care. She revealed hands should be sanitized every time gloves Level of Harm - Minimal harm or are donned. DON revealed nurses use trash bags by the bedside to discard supplies. A barrier should be potential for actual harm used due to infection control practices.

Residents Affected - Few Interview on 3/9/2025 at 10:21 am with the Administrator revealed her expectations were for her staff to follow infection control policies as it pertained to sanitizing their hands every time they donned and doffed their gloves and that they should use a barrier to prevent infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 115554

F-F695

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 115554 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 36377 potential for actual harm Based on observations, staff interviews, record review, and review of the facility policy titled, Oxygen Residents Affected - Few Administration, the facility failed to ensure that one of four sampled residents (R) (Resident R25) was administered oxygen (O2) therapy in accordance with the physician orders. This failure had the potential to place Resident R25 at risk for medical complications, unmet needs, and a diminished quality of life.

Findings include:

A review of the facility policy titled Oxygen Administration stated under Policy Statement: The purpose of this procedure is to provide guidelines for safe oxygen administration. Under Policy Interpretation and Implementation: 1. Verify that there is a physician 's order for this procedure. Review the physician 's orders or facility protocol for oxygen administration. 2. Review the resident 's care plan to assess any special needs of the resident.

A review of Resident R25's electronic medical record (EMR) revealed the following diagnoses but not limited to chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and hypokalemia pectoris pulmonary disease.

A review of the Quarterly Minimum Data Set (MDS) for Resident R25 dated 2/6/2025 revealed a Brief Minimum Data Set (BIMS) score of 10 out of 15, which indicates moderate cognitive deficit. A review of Section O (Special Treatments and Programs) documented that Resident R25 received oxygen therapy while a resident.

A review of Resident R25's Physician Orders Form listed an order dated 10/28/2025 for oxygen at two liters per minute via nasal cannulas as needed for SOB (Shortness of Breath) or compromised O2 (oxygen saturation), may remove as desired.

Observation on 3/7/2025 at 9:05 am to 11:36 am and 1:36 pm to 2:36 pm revealed Resident 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 Resident 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 Resident 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