Inspection Reports for Gracemore Nursing and Rehab
2708 LEE STREET, BRUNSWICK, GA, 31520
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 6, 2025, found no deficiencies, confirming correction of prior issues. Earlier inspections in March 2025 identified multiple deficiencies related to resident dignity, infection control practices, care planning, and emergency preparedness, including incomplete fire safety maintenance and testing. Complaint investigations in March 2025 substantiated some deficiencies, such as failure to report alleged abuse timely and inadequate infection control, while earlier complaints were mostly unsubstantiated. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows improvement with recent follow-up surveys confirming correction of previously cited deficiencies.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
4.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
40 residents
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Deficiencies: 0
Date: May 6, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Gracemore Nursing and Rehab, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 40
Deficiencies: 0
Date: May 6, 2025
Visit Reason
A health revisit survey was conducted from May 5, 2025 through May 6, 2025 at Gracemore Nursing and Rehabilitation to verify correction of deficiencies cited in the prior Recertification and Complaint Investigation survey concluded on March 9, 2025.
Complaint Details
The visit was related to a Complaint Investigation survey concluded on March 9, 2025; deficiencies from that survey were found corrected.
Findings
All deficiencies cited as a result of the Recertification in conjunction with a Complaint Investigation survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 24, 2025
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Mar 9, 2025
Visit Reason
A State Licensure survey was conducted at Gracemore Nursing and Rehabilitation from March 7, 2025, through March 9, 2025, to assess compliance with state health regulations and facility licensure requirements.
Findings
The survey identified multiple deficiencies including failure to maintain resident dignity by not covering urinary catheter drainage bags, inadequate transfer and discharge notifications including bed hold policy information, failure to follow infection control precautions including improper use of PPE, and failure to develop comprehensive care plans for certain residents.
Deficiencies (4)
Failure to ensure urinary catheter drainage bags were covered to protect resident dignity for three residents.
Failure to provide transfer discharge notifications including bed hold policy and room rate information to residents R4 and R20.
Failure to follow standard infection control precautions including improper use of PPE during incontinent care for residents R25, R6, and R1.
Failure to develop care plans for activities of daily living and oxygen therapy for residents R28 and R25.
Report Facts
Dates of hospital transfers: 3
Number of residents with uncovered catheter bags: 3
Number of residents without transfer discharge notifications: 2
Number of residents without care plans: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant AA | CNA | Interviewed regarding catheter care and infection control practices. |
| Licensed Practical Nurse BB | LPN | Interviewed regarding catheter care and infection control practices. |
| Director of Nursing | DON | Interviewed multiple times regarding catheter care, transfer discharge process, infection control, and care plan deficiencies. |
| Clinical Care Coordinator EE | RN | Observed and interviewed regarding failure to use PPE during incontinent care. |
| Certified Nursing Assistant HH | CNA | Observed and interviewed regarding failure to use PPE during incontinent care. |
| Licensed Practical Nurse CC | LPN | Observed and interviewed regarding wound care and infection control practices. |
| Wound Treatment Nurse | Interviewed regarding wound care and infection control requirements for resident R25. | |
| Infection Control Preventionist | ICP | Interviewed regarding PPE availability and infection control practices. |
| Human Resources Manager/Financial Counselor | Interviewed regarding transfer discharge notification process and bed hold policy. | |
| Administrator | Interviewed regarding expectations for transfer/discharge documentation completion. | |
| MDS Coordinator | Interviewed regarding failure to develop ADL care plan for resident R28. |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 8
Date: Mar 9, 2025
Visit Reason
A standard survey was conducted from March 7 to March 9, 2025, including investigation of three complaint intakes (GA00252913, GA00252923, GA00254093). Two complaints were substantiated with deficiencies cited.
Complaint Details
Complaint intake GA00252913 was unsubstantiated. Complaint intakes GA00252923 and GA00254093 were substantiated with deficiencies cited.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to cover urinary catheter drainage bags, failure to report alleged abuse timely, failure to provide transfer/discharge notices including bed hold policies, failure to develop care plans for some residents, improper oxygen administration, failure to follow infection control precautions, and lack of acknowledgment of the Antibiotic Stewardship Program by the pharmacist and medical director.
Deficiencies (8)
Failure to ensure urinary catheter drainage bags were covered for three residents.
Failure to report an allegation of staff to resident abuse within the required two-hour time frame.
Failure to ensure transfer discharge notifications including bed hold policy were provided to two residents.
Failure to develop care plans for activities of daily living and oxygen therapy for two residents.
Failure to administer oxygen therapy in accordance with physician orders for one resident.
Failure to ensure staff followed enhanced barrier infection control precautions for three residents.
Failure to follow proper hand hygiene and infection control during wound care for one resident.
Failure to have the Antibiotic Stewardship Program acknowledged by the pharmacist and medical director.
Report Facts
Facility census: 40
Residents sampled: 21
Residents reviewed for infection control: 15
Oxygen flow rate: 2
Oxygen flow rate observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) AA | Interviewed regarding catheter care for resident R1 | |
| Licensed Practical Nurse (LPN) BB | Interviewed regarding catheter care for resident R1 | |
| Director of Nursing (DON) | Interviewed regarding catheter care, transfer/discharge process, infection control, and antibiotic stewardship | |
| Certified Nursing Assistant (CNA) FF | Named in abuse allegation involving resident R24 | |
| Certified Nursing Assistant (CNA) GG | Named in abuse allegation involving resident R24 | |
| Human Resources Manager and Financial Counselor | Interviewed regarding transfer/discharge notification process | |
| Licensed Practical Nurse (LPN) CC | Interviewed regarding oxygen administration and infection control | |
| Clinical Care Coordinator-Registered Nurse (RN) EE | Observed and interviewed regarding infection control practices | |
| Wound Treatment Nurse | Interviewed regarding wound care and enhanced barrier precautions | |
| Infection Control Preventionist (ICP) | Interviewed regarding infection control and antibiotic stewardship | |
| Administrator | Interviewed regarding abuse reporting, transfer/discharge process, infection control, and antibiotic stewardship |
Inspection Report
Life Safety
Census: 40
Capacity: 56
Deficiencies: 5
Date: Mar 8, 2025
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness requirements and life safety code standards, including fire safety and related NFPA codes.
Findings
The facility was found not in substantial compliance with emergency preparedness and life safety code requirements. Deficiencies included an outdated emergency preparedness plan, incomplete maintenance and cleaning of the fire suppression system, failure to conduct fire alarm sensitivity testing, lack of annual sprinkler system and backflow preventer inspections, and improperly sealed fire walls.
Deficiencies (5)
Emergency Preparedness plan was not updated since March 2023.
Maintenance and cleaning of the fire suppression system (hood cleaning and inspection) was not completed.
Fire alarm system sensitivity test/fire alarm system test was not conducted.
Annual inspection for sprinkler system and backflow preventer was not conducted.
Fire walls in the Long Hallway by the Nurse Station and Supply room were penetrated and not properly sealed.
Report Facts
Census: 40
Total Capacity: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and inspection |
Inspection Report
Deficiencies: 0
Date: Mar 15, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Gracemore Nursing and Rehab, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 42
Deficiencies: 0
Date: Mar 15, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the January 21, 2024 Recertification Survey.
Findings
All deficiencies cited as a result of the January 21, 2024 Recertification Survey were found to be corrected during this revisit.
Inspection Report
Life Safety
Deficiencies: 0
Date: Mar 5, 2024
Visit Reason
A Life Safety Code revisit survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the revisit survey.
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 21, 2024
Visit Reason
The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements.
Findings
No State Health deficiencies were cited during the survey conducted from January 19, 2024 through January 21, 2024.
Inspection Report
Routine
Census: 43
Deficiencies: 2
Date: Jan 21, 2024
Visit Reason
A standard survey was conducted at Gracemore Nursing and Rehab from January 19, 2024 through January 21, 2024 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with federal regulations, with deficiencies including failure to submit a Level II PASRR application for a resident with bipolar disorder and schizophrenia, and failure to obtain a physician's order for oxygen therapy for another resident.
Deficiencies (2)
Failure to submit an application for a Level II PASRR for one resident with bipolar disorder and schizophrenia.
Failure to obtain a physician's order for oxygen therapy, including frequency and flow rate, for one resident receiving oxygen.
Report Facts
Census: 43
Psychotropic medication dosage: 5
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN BB | Interim Director of Nursing | Interviewed regarding responsibility for entering physician orders in electronic health record |
| RN AA | Registered Nurse | Confirmed resident R21 did not have an order for oxygen |
Inspection Report
Life Safety
Census: 41
Capacity: 60
Deficiencies: 5
Date: Jan 20, 2024
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including obstructed exits, non-smoke-tight storage rooms, improperly spaced smoke detectors, improperly maintained smoke barriers, and failure to conduct required quarterly fire drills on each shift.
Deficiencies (5)
Exits were obstructed with items stored in corridors, affecting 20 of 52 residents and one smoke compartment.
Rooms used for storage (nursing office and dietary office) were not smoke tight and doors lacked self-closing devices, affecting 25 of 41 residents in 2 of 3 smoke compartments.
Smoke detectors were not properly spaced near the smoke barrier door by the nurses station; no detector within 5 feet, nearest was 38 feet away, potentially placing 20 of 41 residents at risk.
One of two smoke barriers near the Administrator's office had unsealed penetrations and joints, risking 20 of 41 residents.
Fire drills were not conducted once per quarter per shift; disaster drills were conducted instead during some required fire drill times.
Report Facts
Residents affected by obstructed exits: 20
Residents affected by non-smoke-tight storage rooms: 25
Residents affected by improperly spaced smoke detectors: 20
Residents affected by improperly maintained smoke barriers: 20
Census: 41
Total licensed capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during tour and interviews |
Inspection Report
Abbreviated Survey
Census: 44
Deficiencies: 0
Date: May 16, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey investigating a complaint were conducted on May 16, 2023.
Complaint Details
The complaint (GA00230338) was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with relevant COVID-19 emergency preparedness and infection control regulations. The complaint investigated was unsubstantiated and no deficiencies were cited.
Report Facts
Total census: 44
Inspection Report
Deficiencies: 0
Date: May 18, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Gracemore Nursing and Rehab, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Routine
Census: 33
Deficiencies: 2
Date: Mar 17, 2022
Visit Reason
A standard survey was conducted at Grace More Nursing and Rehab from March 15, 2022 through March 17, 2022 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to complete a Significant Change Minimum Data Set (MDS) Assessment for one resident receiving hospice services, and failure to revise the comprehensive care plan related to advance directives for the same resident.
Deficiencies (2)
Failure to complete a Significant Change Minimum Data Set (MDS) Assessment for one resident receiving hospice services.
Failure to revise the comprehensive care plan related to advance directives for one resident.
Report Facts
Resident census: 33
Sample size: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding MDS assessments and care plan updates |
| Corporate MDS Coordinator | Corporate MDS Coordinator | Interviewed regarding oversight of MDS assessments and care plan updates |
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 17, 2022
Visit Reason
Licensure survey conducted to determine compliance with State Long Term Care Requirements.
Findings
No health deficiencies were cited during the licensure survey conducted from March 15 through March 17, 2022.
Inspection Report
Life Safety
Census: 33
Capacity: 60
Deficiencies: 0
Date: Mar 15, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 29, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00218536.
Complaint Details
Complaint #GA00218536 was substantiated with no deficiencies cited.
Findings
The complaint #GA00218536 was substantiated with no deficiencies cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 15, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00217268.
Complaint Details
Complaint #GA00217268 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 19, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00211159 on January 19, 2021.
Complaint Details
Complaint #GA00211159 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Deficiencies: 0
Date: Oct 14, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Gracemore Nursing and Rehab, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 14, 2020
Visit Reason
A revisit survey was conducted on 10/14/2020 for the Complaint survey of 8/10/2020.
Complaint Details
The revisit survey was related to a complaint survey conducted on 8/10/2020.
Findings
The revisit survey found that all previously cited deficiencies had been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 10, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate Complaint Intake numbers GA00206363 and GA00203218 from 8/4/2020 to 8/10/2020. One complaint (GA00203218) was substantiated.
Complaint Details
Complaint Intake numbers GA00206363 and GA00203218 were investigated. GA00206363 was unsubstantiated. GA00203218 was substantiated with a state health deficiency cited related to narcotic reconciliation.
Findings
The facility failed to maintain accurate reconciliation of narcotics for one of three residents reviewed for medications, specifically a discrepancy in oxycodone HCL 5 mg tablets accounting for resident #1. The facility could not account for seven oxycodone tablets prescribed to the resident.
Deficiencies (1)
Failure to maintain accurate reconciliation of narcotics for resident #1, with a discrepancy of seven oxycodone HCL 5 mg tablets unaccounted for.
Report Facts
Medication tablets prescribed: 137
Medication tablets administered: 24
Medication tablets administered: 23
Medication tablets destroyed: 106
Medication tablets unaccounted for: 7
Complaint investigation period: 6
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 10, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate Complaint Intake numbers GA00206363 and GA00203218. One complaint (GA00203218) was substantiated while the other was unsubstantiated.
Complaint Details
Complaint Intake numbers GA00206363 and GA00203218 were investigated. GA00206363 was unsubstantiated. GA00203218 was substantiated with the deficiency cited regarding narcotic reconciliation.
Findings
The facility failed to maintain accurate reconciliation of narcotics for one of three residents reviewed for medications. Specifically, there was a discrepancy in the accounting of oxycodone HCL 5 mg tablets prescribed to Resident #1, with seven tablets unaccounted for despite documentation of administration and destruction.
Deficiencies (1)
Failure to maintain accurate reconciliation of narcotics for Resident #1, with seven oxycodone HCL 5 mg tablets unaccounted for.
Report Facts
Medication tablets prescribed: 137
Medication tablets administered: 24
Medication tablets administered: 23
Medication tablets destroyed: 106
Medication tablets unaccounted: 7
Dates of medication receipt: 3
Inspection Report
Routine
Census: 29
Deficiencies: 0
Date: Jul 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 29
Inspection Report
Routine
Census: 42
Deficiencies: 0
Date: May 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with COVID-19 related regulations and preparedness.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 42
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 21, 2020
Visit Reason
A revisit was conducted to verify correction of deficiencies cited during the annual recertification survey conducted from 2019-11-12 to 2019-11-14.
Findings
All deficiencies cited in the prior annual recertification survey were found to be corrected. The facility was in substantial compliance as of 2019-12-30.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 2, 2020
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Routine
Deficiencies: 2
Date: Nov 14, 2019
Visit Reason
The inspection was conducted to assess compliance with nursing care plans and physical plant standards, including oxygen therapy administration and hot water temperature safety.
Findings
The facility failed to follow the care plan for continuous oxygen therapy for one resident and did not maintain hot water temperatures below 110 degrees Fahrenheit in multiple sinks and shower rooms, posing a risk of scalding.
Deficiencies (2)
Failure to follow the care plan related to administering oxygen therapy continuously for one resident (R#39).
Hot water temperatures exceeded 110 degrees Fahrenheit in 14 out of 38 sinks across seven resident rooms and two shower rooms.
Report Facts
Number of sinks with hot water temperature above 110 degrees Fahrenheit: 14
Number of resident rooms with hot water temperature above 110 degrees Fahrenheit: 7
Number of shower rooms with hot water temperature above 110 degrees Fahrenheit: 2
Oxygen ordered for resident R#39: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding expectations for nursing staff to verify oxygen use when documenting oxygen saturation. | |
| Maintenance Supervisor | Interviewed about hot water temperature monitoring and maintenance. | |
| Administrator | Interviewed about instructions given to staff and residents regarding hot water use. |
Inspection Report
Routine
Census: 45
Deficiencies: 5
Date: Nov 14, 2019
Visit Reason
A standard survey was conducted at GraceMore Nursing and Rehabilitation from November 12, 2019 through November 14, 2019 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with several regulatory requirements including failure to administer oxygen therapy as ordered for one resident, improper preparation and serving of pureed diets for seven residents, inadequate food storage and labeling practices, unclean ice machine, and a loose handrail in a resident bathroom.
Deficiencies (5)
Failed to follow the care plan related to administering oxygen therapy continuously for one resident (R#39).
Failed to ensure respiratory care including oxygen administration as ordered for one resident (R#39).
Failed to follow pureed breaded pork chop recipe and proper scoop amount during lunch service for seven residents on pureed diet.
Failed to properly label and date perishable food items and discard expired food items in kitchen storage areas; failed to maintain cleanliness of ice machine and kitchen floor.
Failed to ensure one of eight handrails on the 100 long hall was firmly and securely attached to the wall.
Report Facts
Resident census: 45
Residents on pureed diet: 7
Handrails inspected: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JJ | Cook | Interviewed regarding preparation of pureed pork chops |
| Dietary Manager | Dietary Manager | Interviewed regarding menu planning and food preparation |
| Registered Dietician | Registered Dietician | Interviewed regarding expectations for pureed diet preparation and serving |
| Maintenance Director | Maintenance Director | Interviewed regarding cleaning of ice machine and handrail maintenance |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding cleaning responsibilities for ice machine |
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen therapy administration and nursing expectations |
| Administrator | Administrator | Interviewed regarding facility maintenance and ice machine cleanliness |
Inspection Report
Life Safety
Census: 43
Capacity: 60
Deficiencies: 2
Date: Nov 13, 2019
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Plan and to perform a Life Safety Code Survey related to fire safety compliance.
Findings
The facility's Emergency Preparedness Plan was found not in substantial compliance with Appendix Z requirements, specifically failing to identify the role of the facility under a waiver declared by the Secretary. Additionally, the fire alarm system was not properly inspected and maintained, as the sensitivity test for smoke detectors had not been completed, placing residents at risk.
Deficiencies (2)
Emergency Preparedness Plan did not identify the role of the facility under a waiver declared by the Secretary in accordance with section 1135 of the Act.
Fire alarm system was not inspected, tested, and properly maintained; sensitivity test for smoke detectors was not completed.
Report Facts
Census: 43
Total Capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A and Staff M confirmed findings related to Emergency Preparedness Plan and fire alarm system deficiencies |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Date: Jan 2, 2019
Visit Reason
An unannounced complaint investigation was initiated on January 2, 2019, based on Georgia Complaint Number 00193112.
Complaint Details
Complaint investigation initiated under Georgia Complaint Number 00193112; complainant lacked legal authority for the resident.
Findings
The complainant was not the responsible party nor had legal authority for the resident at the time of admission. Two attempts were made to contact the Ombudsman and messages were left.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 10, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Routine
Census: 47
Deficiencies: 0
Date: Jul 19, 2018
Visit Reason
A standard survey was conducted at GraceMore Nursing and Rehabilitation from July 16, 2018 through July 19, 2018 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with the Health portion of the Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B.
Inspection Report
Life Safety
Census: 47
Capacity: 60
Deficiencies: 2
Date: Jul 17, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to properly test emergency lighting at required intervals and failure to conduct and document fire drills as required, placing all 47 residents at risk in the event of a fire.
Deficiencies (2)
Failure to ensure emergency lights were tested at proper intervals and documentation of such tests was incomplete, with missing monthly tests for January and February 2018.
Failure to conduct and properly document fire drills during 1st, 2nd, and 3rd shifts of the 4th quarter of 2017.
Report Facts
Census: 47
Total Capacity: 60
Missing monthly emergency light tests: 2
Missing fire drills: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings related to emergency lighting and fire drills |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 10, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.
Inspection Report
Life Safety
Census: 42
Capacity: 60
Deficiencies: 2
Date: Aug 9, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and related National Fire Protection Association standards.
Findings
The facility was found not in substantial compliance due to failure to perform sensitivity testing on the fire alarm system within the last 5 years and failure to properly maintain rated smoke barrier walls, including unsealed or improperly sealed penetrations.
Deficiencies (2)
Failure to perform sensitivity testing for the fire alarm system in the last 5 years.
Failure to properly maintain rated smoke barrier walls with several unsealed or improperly sealed penetrations.
Report Facts
Census: 42
Total Capacity: 60
Years since last sensitivity testing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Date: Aug 6, 2017
Visit Reason
A standard survey with a complaint (GA00176595) was conducted at Gracemore Health and Rehab from August 4, 2017, through August 6, 2017.
Complaint Details
No deficiencies were found related to the complaint.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B. No deficiencies were found related to the complaint.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 16, 2017
Visit Reason
An unannounced abbreviated survey was conducted to investigate complaints GA00174964 and GA00170379.
Complaint Details
Investigation of complaints GA00174964 and GA00170379; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with 42 CFR, Part 483, Subpart B, Requirements for long term care facilities.
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