Inspection Reports for Gracemore Nursing and Rehab

The document is a Statement of Deficiencies and Plan of Correction for Gracemore Nursing and Rehab, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide specific details on deficiencies or findings.

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.

All deficiencies cited as a result of the Recertification in conjunction with a Complaint Investigation survey were found to be corrected.

The visit was related to a Complaint Investigation survey concluded on March 9, 2025; deficiencies from that survey were found corrected.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.

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.

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.

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.

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.

Complaint intake GA00252913 was unsubstantiated. Complaint intakes GA00252923 and GA00254093 were substantiated with deficiencies cited.

The inspection was conducted to assess compliance with emergency preparedness requirements and life safety code standards, including fire safety and related NFPA codes.

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.

The document is a statement of deficiencies and plan of correction for Gracemore Nursing and Rehab, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide specific details on deficiencies or findings.

A health revisit survey was conducted to verify correction of deficiencies cited during the January 21, 2024 Recertification Survey.

All deficiencies cited as a result of the January 21, 2024 Recertification Survey were found to be corrected during this revisit.

A Life Safety Code revisit survey was conducted to verify correction of previously cited deficiencies.

All previously cited survey tags have been corrected as noted during the revisit survey.

The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements.

No State Health deficiencies were cited during the survey conducted from January 19, 2024 through January 21, 2024.

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.

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.

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.

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.

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.

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.

The complaint (GA00230338) was investigated and found to be unsubstantiated.

The document is a statement of deficiencies and plan of correction for Gracemore Nursing and Rehab, indicating a regulatory inspection was conducted.

The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.

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.

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.

Licensure survey conducted to determine compliance with State Long Term Care Requirements.

No health deficiencies were cited during the licensure survey conducted from March 15 through March 17, 2022.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.

The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.

An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00218536.

The complaint #GA00218536 was substantiated with no deficiencies cited.

Complaint #GA00218536 was substantiated with no deficiencies cited.

An abbreviated/partial extended survey was conducted to investigate complaint #GA00217268.

The complaint was unsubstantiated and no regulatory violations were cited during the survey.

Complaint #GA00217268 was investigated and found to be unsubstantiated.

An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00211159 on January 19, 2021.

The complaint was unsubstantiated and no regulatory violations were cited during the survey.

Complaint #GA00211159 was investigated and found to be unsubstantiated.

The document is a statement of deficiencies and plan of correction for Gracemore Nursing and Rehab, indicating a regulatory inspection was conducted.

The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.

A revisit survey was conducted on 10/14/2020 for the Complaint survey of 8/10/2020.

The revisit survey found that all previously cited deficiencies had been corrected.

The revisit survey was related to a complaint survey conducted on 8/10/2020.

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.

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.

Complaint Intake numbers GA00206363 and GA00203218 were investigated. GA00206363 was unsubstantiated. GA00203218 was substantiated with a state health deficiency cited related to narcotic reconciliation.

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.

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.

Complaint Intake numbers GA00206363 and GA00203218 were investigated. GA00206363 was unsubstantiated. GA00203218 was substantiated with the deficiency cited regarding narcotic reconciliation.

A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.

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.

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.

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.

A revisit was conducted to verify correction of deficiencies cited during the annual recertification survey conducted from 2019-11-12 to 2019-11-14.

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.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.

The inspection was conducted to assess compliance with nursing care plans and physical plant standards, including oxygen therapy administration and hot water temperature safety.

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.

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.

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.

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.

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.

An unannounced complaint investigation was initiated on January 2, 2019, based on Georgia Complaint Number 00193112.

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.

Complaint investigation initiated under Georgia Complaint Number 00193112; complainant lacked legal authority for the resident.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.

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.

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.

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.

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.

A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.

The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.

A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and related National Fire Protection Association standards.

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.

A standard survey with a complaint (GA00176595) was conducted at Gracemore Health and Rehab from August 4, 2017, through August 6, 2017.

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.

No deficiencies were found related to the complaint.

An unannounced abbreviated survey was conducted to investigate complaints GA00174964 and GA00170379.

The facility was found to be in substantial compliance with 42 CFR, Part 483, Subpart B, Requirements for long term care facilities.

Investigation of complaints GA00174964 and GA00170379; facility found in substantial compliance.