Cycle 1
Health 2025-03-09 · Fire 2025-03-09
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Brunswick, GA
Gracemore Nursing And Rehab
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2708 Lee Street, Brunswick, GA
(912) 265-6771
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
42
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Crossroads Medical Management
Operator or chain grouping
Approved since
1993-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.72
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.69
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.33
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.63
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
3.51
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,818
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.82% · Performance 23.24% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 9.16% · Performance 9.83% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.96
Baseline 59.57% · Performance 47.50% · Measure score 3.96 · Achievement 3.96 · Improvement 2.98
Adjusted total nurse staffing
2.10
Baseline 4.08 hours · Performance 3.67 hours · Measure score 2.10 · Achievement 2.10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.11% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 13.11% · Lower 95% interval 6.86% |
| Discharge to community | 33.15% |
50.57%
17.4 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 22.64% · Lower 95% interval 22.69% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 18% |
95.27%
77.3 pts worse
|
Numerator 9 · Denominator 50 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 50 |
| Discharge self-care score | 44.12% |
53.69%
9.6 pts worse
|
Numerator 15 · Denominator 34 |
| Discharge mobility score | 35.29% |
50.94%
15.6 pts worse
|
Numerator 12 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 2 · Denominator 50 · Adjusted rate 4.22% |
| Healthcare-associated infections requiring hospitalization | 9.82% |
7.12%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 18.52% · Lower 95% interval 5.5% |
| Staff COVID-19 vaccination coverage | 11.29% |
8.2%
3.1 pts better
|
Numerator 7 · Denominator 62 |
| Staff flu vaccination coverage | 45.33% |
42%
3.3 pts better
|
Numerator 34 · Denominator 75 |
| Discharge function score | 52.94% |
56.45%
3.5 pts worse
|
Numerator 18 · Denominator 34 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
9.6%
8.2 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 3.3% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
5.9%
0.3 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 2.6% · Q3 5.9% · Q4 2.9% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.4% |
20.7%
9.3 pts better
|
19.6%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 12.8% · Q3 8.6% · Q4 13.9% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.1% |
21.4%
5.3 pts better
|
16.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 17.2% · Q3 15.4% · Q4 20.7% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.6% |
17.9%
10.3 pts better
|
16.3%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.6% |
16.2%
6.6 pts better
|
14.9%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 8.6% · Q3 3.2% · Q4 17.6% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.1% |
1.1%
3 pts worse
|
1.0%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 7.0% · Q3 0.0% · Q4 0.0% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.5%
1.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.7% |
16.1%
9.4 pts better
|
19.8%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 3.0% · Q3 11.8% · Q4 2.9% · 4Q avg 6.7% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
6.2%
2 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.6% · Q3 2.4% · Q4 4.8% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
80.4%
19.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.7% |
12.2%
7.5 pts better
|
12.0%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.7% · Observed 4.5% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
2.2%
1 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.2%
21.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.0% |
24.2%
1.2 pts better
|
23.9%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 25.0% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-21 · Fire 2024-01-21
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-03-17 · Fire 2022-03-17
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-09
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-23
E · Potential for more than minimal harm
2024-01-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-04
E · Potential for more than minimal harm
2024-01-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-01-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-01-21
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-01-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-04
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-09
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-09
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-23
D · Potential for more than minimal harm
2024-01-21
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-01-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-04
D · Potential for more than minimal harm
2022-03-17
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2022-05-01
D · Potential for more than minimal harm
2022-03-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-05-01
Penalties and ownership
What sits behind the stars
Ownership
Davis Iii, William C
5% Or Greater Direct Ownership Interest · Individual
Davis, William
5% Or Greater Direct Ownership Interest · Individual
Davis, William
Corporate Director · Individual
Gracemore LLC
5% Or Greater Direct Ownership Interest · Organization
Popwell, Pam
Operational/Managerial Control · Individual
Smith, Holly
Operational/Managerial Control · Individual
Soundappan, Appavuchetty
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Sears Manor Nursing Home
Brunswick, GA
2-star overall rating with 2-star inspections with $14,892 in total fines with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Senior Care Center - Brunswick
Brunswick, GA
1-star overall rating with 1-star inspections with $16,801 in total fines with 15 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Heritage Oaks
Saint Simons Island, GA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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