Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gracemore Nursing And Rehab during CMS and state inspections, most recent first.
The facility's Antibiotic Stewardship Program lacked acknowledgment from the Pharmacist and Medical Director, potentially affecting all 23 residents. The Infection Control Preventionist (ICP) was unaware of the need for a commitment agreement with the Pharmacist, and no signed document was available. The Administrator, ICP, and Director of Nursing (DON) were also unaware of the requirement for the Pharmacist's involvement in the program.
The facility failed to maintain the dignity of residents with urinary catheters by not covering their drainage bags. Observations showed that the bags for three residents were uncovered, violating their rights to a dignified existence. Interviews with staff, including a CNA, LPN, and the DON, confirmed that catheter care should include covering the drainage bag, but this was not done. The DON was unaware of this requirement, indicating a lack of adherence to proper protocols.
The facility failed to report an alleged abuse incident involving a CNA and a resident with severe cognitive impairment to the State Survey Agency within the required timeframe. The Administrator concluded the incident was a misunderstanding after an investigation, but the facility's policy mandates reporting all allegations, regardless of findings.
The facility failed to provide proper transfer notifications to two residents, including necessary documentation such as the bed hold policy and reasons for transfer. One resident with complex medical conditions was transferred for respiratory distress, and another with quadriplegia was transferred multiple times for sepsis and a UTI, all without receiving the required notices. Staff interviews revealed systemic issues in the notification process.
The facility failed to provide two residents with written transfer documentation, including the bed hold policy, during their hospital transfers. One resident with complex medical conditions was transferred for respiratory distress, while another with quadriplegia was transferred multiple times for sepsis and a urinary tract infection. The necessary documentation was not provided, as confirmed by the DON and other staff members.
The facility failed to develop comprehensive care plans for two residents, potentially affecting care delivery. One resident lacked a care plan for ADLs despite needing assistance, and another had no care plan for oxygen therapy and wound care despite having chronic conditions and physician orders. The MDS Coordinator and DON acknowledged the oversight during the survey.
A resident with chronic respiratory conditions was administered oxygen at an incorrect flow rate of three liters per minute instead of the prescribed two liters per minute. The discrepancy was confirmed by an LPN, who stated that nurses are responsible for daily checks of oxygen flow rates. The DON was unaware of the issue until it was identified during a survey.
The facility failed to ensure proper infection control practices, including the use of PPE and hand hygiene, for three residents. Staff did not consistently use PPE for a resident on Enhanced Barrier Precautions, allowed a catheter bag to rest on the floor, and neglected hand hygiene during wound care. These lapses increased the risk of infection for the residents involved.
Lack of Acknowledgment in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to have its Antibiotic Stewardship Program (ASP) acknowledged by both the Pharmacist and the Medical Director, which had the potential to affect all 23 residents residing in the facility. Upon review of the ASP documents, it was found that there were no acknowledgment forms signed by the Pharmacist or the Medical Director to confirm their accountability. During an interview, the Infection Control Preventionist (ICP) admitted to being unaware of the need for a commitment agreement with the Pharmacist and did not have the signed document engaging the Pharmacist and other ASP officials. The ICP also mentioned that no previous survey team had requested the signed contract agreement of Statement of Leadership, nor had anyone informed her of this requirement. Additionally, during a separate interview, the Administrator, ICP, and Director of Nursing (DON) all revealed their unawareness of the necessity for the Pharmacist to sign a mutual agreement and participate in discussions regarding their responsibilities in the ASP.
Failure to Cover Catheter Drainage Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure the dignity of residents with urinary catheters by not covering their catheter drainage bags. Observations revealed that the drainage bags for three residents were not covered, which is a violation of the residents' rights to a dignified existence. Resident 1, who has moderate cognitive impairment and several medical conditions including a stage 4 pressure ulcer and chronic kidney disease, was observed with an uncovered catheter drainage bag on multiple occasions. Interviews with staff, including a CNA, LPN, and the DON, confirmed that catheter care should include covering the drainage bag with a privacy cover, but this was not done for Resident 1. Similarly, Resident 6, who also has moderate cognitive impairment and is dependent on staff for care, was observed with a catheter bag that was not covered and was resting on the floor at times. Resident 23, with intact cognitive function but dependent on staff, was also observed with an uncovered drainage bag. The DON was unaware of the requirement to cover the drainage bags, indicating a lack of adherence to proper catheter care protocols. These observations and interviews highlight the facility's failure to maintain the dignity and privacy of residents with catheters.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Survey Agency within the required two-hour timeframe. The incident involved a Certified Nursing Assistant (CNA) allegedly bragging about spanking a resident on the hands for playing with feces. The facility's policy mandates immediate reporting of such allegations, but the Administrator did not report the incident to the State, as she concluded from her investigation that the abuse did not occur. The Administrator's investigation involved interviews with the involved parties and a test to observe the resident's behavior, which led her to believe that the incident was a misunderstanding. The resident involved had severe cognitive impairment, as indicated by a Brief Interview Mental Status (BIMS) score of 00 out of 15, and was dependent on care for personal hygiene. The resident's medical record included diagnoses of Alzheimer's Disease, anxiety disorder, and bipolar disorder. Despite the Administrator's findings, the facility's failure to report the allegation to the State Survey Agency constituted a deficiency, as the policy requires reporting regardless of the investigation's outcome.
Failure to Provide Transfer Notifications
Penalty
Summary
The facility failed to provide timely and appropriate transfer and discharge notifications to two residents, R4 and R20, as required by their policy. Specifically, the facility did not ensure that these residents received written documentation that included the bed hold policy and the reasons for their transfers. R4, who had multiple complex medical conditions including end-stage renal disease and chronic obstructive pulmonary disease, was transferred to the emergency department for respiratory distress without receiving the necessary transfer documentation. Similarly, R20, who had a history of quadriplegia and spinal cord injuries, was transferred to the hospital on three separate occasions for sepsis and a urinary tract infection without receiving the required notices. Interviews with facility staff, including the Director of Nursing, Human Resources Manager, Financial Counselor, and the Administrator, revealed systemic issues in the process of providing transfer notifications. The staff confirmed that the bed hold policy and transfer documentation were not completed or sent with the residents as required. The facility's policy stipulated that the charge nurse or the Business Office Manager should ensure these documents accompany the resident during transfers, but this was not adhered to in the cases of R4 and R20. The Administrator acknowledged that the expected procedure was not followed, and the necessary documents were missing from the residents' records.
Failure to Provide Bed Hold Policy During Resident Transfers
Penalty
Summary
The facility failed to provide written transfer documentation, including the bed hold policy and information on the cost of reserving the bed, to two residents, R4 and R20, during their transfers to the hospital. R4, who had multiple complex medical conditions including end-stage renal disease and chronic obstructive pulmonary disease, was transferred to the emergency department for respiratory distress. The Director of Nursing confirmed that the necessary documentation was not provided at the time of R4's transfer, and the Business Office Manager was supposed to send it the next day if the charge nurse did not do so initially. Similarly, R20, who had a history of quadriplegia and spinal cord injuries, was transferred to the hospital on three occasions for sepsis and a urinary tract infection. The Human Resources Manager and Financial Counselor confirmed that the bed hold policy notices were not given to R20 or his representative during these transfers. The Administrator acknowledged that the transfer/discharge documents were not completed and could not be located in the residents' records, indicating a lapse in the facility's process for handling such documentation.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, R28 and R25, which could potentially affect the delivery of proper care and services. For R28, the facility did not create a care plan for activities of daily living (ADL) until the last day of the recertification survey, despite the resident having moderate cognitive impairment and requiring assistance with eating, oral hygiene, toileting, and bathing. The MDS Coordinator acknowledged the absence of an ADL care plan and created one only after the survey began. The Director of Nursing (DON) confirmed that the care plan should have been developed within 14 days of admission. For R25, the facility did not create a care plan addressing oxygen therapy use and wound care for a surgical wound on the umbilicus. The resident had diagnoses including chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, and there were physician orders for oxygen therapy and wound care. Despite these needs, there was no evidence of a care plan for these interventions. The DON was unaware of the missing care plan until informed by the MDS Coordinator and stated that care plans should be created in a timely manner and individualized to communicate specific care needs.
Oxygen Therapy Administered at Incorrect Flow Rate
Penalty
Summary
The facility failed to administer oxygen therapy to a resident in accordance with the physician's orders. The resident, who had diagnoses including chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, was observed receiving oxygen at a flow rate of three liters per minute instead of the prescribed two liters per minute. This discrepancy was noted during observations conducted over several hours on a specific day. The Licensed Practical Nurse (LPN) confirmed the incorrect oxygen flow rate and acknowledged that it was the nurses' responsibility to check the flow rates daily. The Director of Nursing (DON) was unaware of the issue until it was highlighted during the survey. The facility's policy on oxygen administration requires verification of physician orders and adherence to prescribed flow rates, which was not followed in this instance.
Infection Control Deficiencies in PPE and Hygiene Practices
Penalty
Summary
The facility failed to ensure staff followed standard infection control precautions for three residents, leading to potential increased risk of infections. For one resident with a surgical wound, staff did not consistently use Personal Protective Equipment (PPE) as required under Enhanced Barrier Precautions (EBP). The Clinical Care Coordinator and a Certified Nursing Assistant (CNA) were observed providing care without donning full PPE, despite the resident having an unresolved surgical wound. The Wound Treatment Nurse confirmed the resident should have been on EBP, and the Infection Control Preventionist and Director of Nursing were unaware of the lapses in PPE usage. Another resident with a urinary catheter was observed with the catheter bag resting on the floor, which is against infection control practices. The catheter bag should have been attached to the bed and covered with a privacy bag to prevent contamination. Interviews with staff, including a CNA and Licensed Practical Nurse (LPN), confirmed the correct procedure for catheter care, which was not followed in this instance. The Director of Nursing acknowledged that the drainage bag should never rest on the floor. For a third resident with a pressure ulcer, an LPN failed to perform proper hand hygiene during wound care. The LPN did not sanitize her hands between glove changes and placed a trash bag with used supplies on the resident's nightstand without a barrier. Additionally, a pillow used to support the resident's head was not changed after being used to support the trash bag. The Director of Nursing confirmed that hand hygiene should be performed before, during, and after wound care, and barriers should be used to prevent infection.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brunswick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sears Manor Nursing Home | 0.6 mi | ★★★★★ | 0 | 0 |
| Senior Care Center - Brunswick | 0.7 mi | ★★★★★ | 0 | 0 |
| Heritage Oaks | 6.4 mi | ★★★★★ | 1 | 0 |
| Marsh's Edge | 7.7 mi | ★★★★★ | 0 | 0 |
| Bayview Nursing Home | 29.8 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.