Sears Manor Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Brunswick, Georgia.
- Location
- 3311 Lee Street, Brunswick, Georgia 31521
- CMS Provider Number
- 115520
- Inspections on file
- 18
- Latest survey
- June 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sears Manor Nursing Home during CMS and state inspections, most recent first.
Surveyors found that the facility did not ensure a clean, safe, and homelike environment, with multiple areas in disrepair such as damaged walls, cracked and missing floor tiles, and a hallway exit door with a gap allowing pest entry. Additionally, a resident's room had large indentations in the wall behind the bed that went unreported and unaddressed, with no documentation of required maintenance rounds.
Several residents experienced changes in condition, such as falls, new wounds, or the initiation of a urinary catheter, but their care plans were not updated to include new interventions or reflect these changes. Despite repeated incidents and recommendations documented in progress notes and assessments, the care plans remained outdated, and staff responsible for care plan revisions did not consistently implement required updates as per facility policy.
The facility did not maintain an effective infection surveillance program, as the Infection Preventionist was often unaware of residents with infection symptoms and lacked a structured system for staff to report potential infections or lab tests. Additionally, a CNA failed to follow Enhanced Barrier Precautions during catheter care for a resident, including not wearing a gown, not sanitizing hands properly, and mishandling personal care items, with both the IP and DON confirming these lapses in protocol.
The facility did not properly monitor or evaluate antibiotic use for three residents, resulting in antibiotics being prescribed and administered without appropriate infection screening, diagnostic testing, or adherence to established criteria. The Infection Preventionist did not complete required reviews or communicate with prescribers before antibiotics were started, and documentation of necessary lab results was missing.
A resident with severe cognitive impairment was fed by an RN who stood next to her, contrary to facility policy requiring staff to sit while assisting with meals. This action was acknowledged by staff as a dignity issue and was observed during a survey, with both the Administrator and DON confirming that standing while feeding is not permitted.
Two residents continued to receive psychotropic medications at unchanged doses despite recommendations and facility policy requiring gradual dose reductions (GDR). For one resident, lorazepam was not reduced as ordered by the Medical Director, and for another, olanzapine was not tapered despite no recent behavioral symptoms. In both cases, staff responses to pharmacist GDR requests lacked resident-specific clinical rationale, and documentation did not justify the ongoing medication regimens.
A resident was found with unexplained bruising and reported being in a fight, prompting an incomplete investigation by facility staff. Required documentation, staff interviews, and physician notification were missing, and other residents were not interviewed, resulting in a failure to follow the facility's abuse investigation policy.
A resident with dementia and a history of a left heel pressure ulcer, who was at moderate risk for pressure sores, did not consistently receive physician-ordered heel offloading while in bed. Despite care plan directives and facility policy, multiple observations showed the resident's heels in direct contact with the mattress, and staff interviews revealed a lack of awareness and implementation of the required pressure-relieving device.
A resident with a history of stroke and delusional disorders was found with bruising on her arm and a broken headboard in her bed. Staff observed the headboard on the floor and a metal bracket in the bed but did not promptly report or repair the hazard, resulting in an unsafe environment. The resident was also observed agitated and banging her arm, further highlighting the risk posed by the unrepaired headboard.
A staff member administered insulin to a resident with diabetes and chronic kidney disease without priming the insulin pen as required by facility protocol. The staff member was unaware of the priming procedure, and the Education Coordinator had not yet provided medication administration training to staff.
Surveyors observed that controlled substances, including Lorazepam and Morphine, were stored in a locked box inside a medication room refrigerator, but the box was not permanently affixed as required by facility policy. The DON, RN, and Administrator confirmed they were unaware of the need for permanent attachment, resulting in a deficiency for improper storage of controlled medications.
Surveyors found that bathroom vents in multiple rooms, including those occupied by two residents, were not working, resulting in musty and urine odors. The Maintenance Director confirmed the nonfunctioning vents and noted that maintenance had not been performed recently. No ventilation policy was provided.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple maintenance and environmental concerns observed throughout resident rooms, dining areas, and hallways. Surveyors identified numerous issues, including damaged sheetrock and paint in the main dining room, cracked and missing floor tiles in the 100 Hall, a hallway exit door with a gap at the bottom allowing potential pest entry, and a bathroom door with splintered and unattached veneer. These deficiencies were confirmed by both the Maintenance Director and the Administrator, who acknowledged that such issues should have been reported and addressed. The Maintenance Director also confirmed that while maintenance priorities had been identified, there were no specific dates for completion, and the observed issues had not been scheduled for repair. Additionally, the facility failed to ensure a homelike environment in a resident's room, where three large indentations were found in the wall behind the bed. The resident, who was severely cognitively impaired with a BIMS score of three, was unaware of the damage. The Maintenance Supervisor admitted to not receiving any work orders for the room and, despite being responsible for monthly room rounds, had not identified the damage. There was also no documentation to show that room rounds had been completed, and the Administrator confirmed that the Maintenance Supervisor did not have time to perform these rounds. These failures contributed to an environment that was not adequately maintained or homelike for the residents.
Failure to Update Care Plans After Changes in Resident Condition and Falls
Penalty
Summary
The facility failed to ensure that comprehensive care plans were updated to reflect the current needs of several residents following changes in their condition or after significant events such as falls or the development of new wounds. For one resident with a history of stroke, hemiplegia, and impaired mobility, the care plan did not include interventions to keep personal items within reach, despite multiple falls occurring when the resident attempted to reach for items. Progress notes documented repeated falls related to this issue, but the care plan was not revised to address the identified contributing factor. Another resident with hemiplegia, dysphagia, and dementia experienced multiple falls from bed. Although the care plan was updated to include the dates of the falls, no new interventions were added after these incidents. The MDS Coordinator confirmed that she was responsible for revising the care plan but was unaware that new interventions were required following each fall, as outlined in facility policy. Observations confirmed that the resident continued to be at risk, with no additional measures implemented to prevent recurrence. Additional deficiencies were noted for residents with pressure ulcers and new wounds. One resident developed a full-thickness non-pressure wound, and recommendations for wound management, such as limiting sitting time and off-loading, were not incorporated into the care plan. Another resident with new pressure areas and the use of protective boots did not have these changes reflected in the care plan. A resident who required a urinary catheter following urinary retention did not have the care plan updated to reflect this significant change in care needs. These omissions occurred despite facility policies requiring care plans to be reviewed and revised as residents' conditions changed.
Deficient Infection Surveillance and PPE Use During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop and implement an effective infection surveillance program and did not ensure staff used appropriate personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP). The Infection Preventionist (IP) reported that her surveillance activities were limited to tracking antibiotic use and facility-acquired infections, but she was often unaware of residents exhibiting signs or symptoms of infection. There was no established system for nursing staff to report potential infections or lab tests, and the IP relied on antibiotic orders in the electronic medical record (EMR) to identify cases. The IP also did not consistently document the criteria used to determine infections or the final determination in her surveillance records. She acknowledged that the surveillance program was inadequate, citing poor communication with newer staff and a lack of a structured reporting system as barriers. A review of the facility's infection surveillance policy indicated that surveillance should include multiple sources of information, such as laboratory records, skin care sheets, infection control rounds, verbal staff reports, and more. However, the IP admitted to not utilizing all available data sources and expressed difficulty using the EMR-generated spreadsheet, which further hindered her ability to maintain comprehensive surveillance. The policy also required detailed documentation for each infection, but this was not consistently performed. Additionally, direct observation revealed that a Certified Nursing Assistant (CNA) failed to follow EBP protocols during urinary catheter care for a resident. The CNA did not don a gown, failed to sanitize hands before donning gloves or when changing gloves, and placed personal care items inappropriately with clean linen. The CNA was unaware that the resident was on EBP, despite signage indicating this. Both the IP and the Director of Nursing (DON) confirmed that the observed practices did not comply with the facility's EBP policy, which mandates gown and glove use during high-contact care activities such as catheter care.
Failure to Monitor and Evaluate Antibiotic Use
Penalty
Summary
The facility failed to monitor and evaluate antibiotic usage for three of six residents reviewed for antibiotic use. For one resident admitted with a urinary tract infection (UTI), the medical record showed the resident was prescribed two different broad-spectrum antibiotics (Cefuroxime and Cipro) without proper infection screening or completion of McGeer's criteria by the Infection Preventionist (IP). The IP did not clarify the antibiotic order with the nurse practitioner or ensure a urine analysis (UA) and culture were ordered, despite hospital lab results indicating a contaminated specimen and the need for a repeat test. The IP confirmed that infection screening was not completed and that she did not communicate with the prescriber regarding the need for appropriate diagnostic testing before starting antibiotics. Additionally, two other residents were started on antibiotics for urinary infections without proper documentation or adherence to established criteria. One resident was started on Keflex and later Cipro despite negative UA and culture results, and another was started on Cipro for a change in condition without available UA and culture results. The IP was unaware of one resident's prophylactic antibiotic use and acknowledged that the antibiotic order did not meet McGeer's criteria. The IP also stated that she does not routinely discuss antibiotic initiation with the medical director or nurse practitioners before diagnostic results are available. These failures were identified through interviews, record reviews, and policy review, and were found to be inconsistent with CDC guidance and the facility's own antibiotic stewardship policies.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
A deficiency occurred when a registered nurse (RN) assisted a resident with severe vascular dementia and significant cognitive impairment by feeding her while standing next to her in the dining room. The facility's policy on meal assistance specifically requires staff to feed residents in a manner that maintains their dignity, including not standing over them while assisting with meals. The resident, who required supervision or touch assistance with eating but had no range of motion limitations, was observed being fed by the RN who remained standing, contrary to both facility policy and the resident's care plan. During interviews, the RN acknowledged standing while feeding the resident and recognized it as a dignity issue, explaining she did so to monitor other residents. Both the Administrator and the Director of Nursing confirmed that staff are expected to sit next to residents while feeding them, as standing is considered undignified and potentially intimidating. The incident was identified through observation, record review, and staff interviews, confirming a failure to uphold the resident's right to dignity during mealtime assistance.
Failure to Attempt Gradual Dose Reduction of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) of psychotropic medications were attempted when indicated for two residents. For one resident with diagnoses of major depression and insomnia, the medical record showed continued administration of lorazepam at 0.5mg twice daily, despite multiple recommendations from the Medical Director to reduce the dose to 0.25mg twice daily. The resident's medication administration records confirmed that the dose was never reduced, and interviews with nurse practitioners and the MDS Coordinator revealed a lack of communication and follow-through on the Medical Director's recommendations. The pharmacist also requested a GDR, but the response from the nurse practitioner was limited to a generic statement without resident-specific rationale, and no dose reduction was attempted. Another resident with dementia, major depression, anxiety, and insomnia was prescribed olanzapine for behavioral disturbances. The resident's care plan and medical records indicated no recent behavioral symptoms, yet a dose reduction of the antipsychotic had not been attempted. The pharmacist recommended a GDR, but the nurse practitioner's response was again limited to a generic statement, without documentation of specific behaviors, risk factors, or clinical rationale for maintaining the current dose. Interviews with staff confirmed that the documentation did not include individualized justification for not attempting a GDR. Facility policy required GDR attempts for psychotropic medications unless clinically contraindicated, with documentation of specific clinical rationale if a reduction was not attempted. The records and interviews demonstrated that these requirements were not met for the two residents, as there was a lack of individualized assessment and documentation regarding the continued use and dosing of psychotropic medications. This failure had the potential to contribute to avoidable side effects, including sedation, dizziness, and increased falls.
Failure to Thoroughly Investigate Alleged Abuse and Injury
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of injury of unknown origin and possible physical abuse involving one resident. According to the facility's policy, all accidents or incidents must be investigated and documented, including witness accounts, notification of family and physician, and detailed reporting. In this case, a registered nurse observed bruising on a resident's right hand and forearm, and upon questioning, the resident claimed to have been in a fight with two girls. An investigation was reportedly started immediately. However, the documentation and investigative process were incomplete. The five-day report submitted to the state did not include the names of staff involved, written statements from staff, or evidence that the attending physician was notified. The resident's responsible party was only notified after the investigation was completed. Additionally, the administrator confirmed that there was no incident report on file and that other residents were not interviewed as part of the investigation. These omissions were contrary to the facility's own policy and resulted in a deficient practice.
Failure to Implement Pressure Offloading Interventions for At-Risk Resident
Penalty
Summary
The facility failed to consistently implement physician-ordered interventions to offload pressure from a resident's heels, as required to prevent pressure ulcers. The resident, who had a history of dementia, a resolved left heel pressure ulcer, and was at moderate risk for developing pressure sores, had a care plan and physician order in place to use a heel manager while in bed. Despite these documented interventions, multiple observations over several days showed the resident lying in bed with her heels in direct contact with the mattress and without the use of a heel manager or any pressure-relieving device. Staff interviews confirmed a lack of awareness and implementation of the heel manager intervention, with one CNA unaware of the device and unable to explain why a pillow was not used, and an RN unable to locate the heel manager in the resident's room. The facility's own policies required systematic assessment and individualized care planning for skin integrity, including the use of pressure reduction devices as ordered. Documentation in the electronic medical record reflected the resident's risk and the need for heel offloading, but these interventions were not consistently carried out. The Director of Nursing acknowledged that the heel manager should have been in place as ordered to prevent further skin breakdown, confirming the lapse in following prescribed care and facility policy.
Failure to Repair Broken Headboard Creates Accident Hazard
Penalty
Summary
A deficiency was identified when the facility failed to repair a broken headboard for a resident, which created an accident hazard. The resident, who had a history of stroke, hypertrophic cardiomyopathy, and delusional disorders, was cognitively intact according to her most recent MDS assessment. During an observation and interview, the resident was found in bed with bruising on her right arm. She stated that the headboard had been broken and was later fixed by maintenance. However, prior to the repair, a registered nurse discovered the headboard on the floor and a metal bracket from the headboard in the resident's bed while making rounds. An investigation was initiated due to the bruising, which was considered an injury of unknown origin. A certified nursing assistant reported that the resident was agitated during the night, refused care, and was observed banging her arm on the bedside table. The CNA moved the table to prevent further injury but did not report the broken headboard, despite having seen it on the floor a week earlier. The administrator confirmed that accident hazards should be reported to prevent resident harm and acknowledged that the resident had a piece of the metal headboard in her bed. The failure to promptly report and repair the broken headboard resulted in a hazardous environment for the resident.
Failure to Prime Insulin Pen Prior to Administration
Penalty
Summary
A deficiency occurred when a staff member failed to properly prime an insulin pen prior to administering insulin to a resident diagnosed with type 2 diabetes mellitus and diabetic chronic kidney disease. According to the facility's insulin administration instructions, the pen should be primed by selecting two units and pressing the plunger to ensure a drop of insulin appears at the needle tip before injection. During a medication administration observation, the Infection Preventionist attached a needle to the insulin pen, set the dose, and administered the injection without priming the pen as required by protocol. The Infection Preventionist later confirmed in an interview that she was unaware of the need to prime the pen and did not recall receiving training on this procedure. The Education Coordinator also stated that staff should prime the insulin pen before use, but acknowledged that she had not yet begun training staff on medication administration since starting her position over a month prior. This lapse in following proper medication administration procedures led to the identified deficiency.
Controlled Medications Not Permanently Affixed in Locked Refrigerator Compartment
Penalty
Summary
Surveyors found that the facility failed to store controlled medications in accordance with both facility policy and regulatory requirements. Specifically, controlled substances requiring refrigeration, including Lorazepam and Morphine, were observed stored in a clear plastic locked container inside a medication room refrigerator. This container was not permanently affixed to the refrigerator, contrary to the facility's policy, which requires that such boxes be attached to the inside of the refrigerator to prevent removal. The Director of Nursing (DON) and a Registered Nurse (RN) both confirmed that the locked box was not permanently affixed and were unaware of the requirement for permanent attachment. The DON stated that the double-locked system in place consisted of the medication room door and the lock on the medication box, with keys managed through the Omnicell system. Interviews with the DON, RN, and the Administrator revealed a lack of awareness regarding the specific requirement for permanently affixed storage for refrigerated controlled substances. The facility's policy, dated 05/01/20, clearly outlines that controlled substances needing refrigeration must be stored within a locked box that is attached to the inside of the refrigerator. Despite this, the observed practice did not meet this standard, resulting in a deficiency related to the secure storage of controlled medications.
Failure to Maintain Functional Bathroom Ventilation
Penalty
Summary
The facility failed to ensure that bathrooms had adequate ventilation for two residents out of 26 included in the Initial Pool. Observations during the survey revealed that the bathroom vents in several rooms on the left side of the 200-hallway, including those occupied by two residents, were not functioning. Specifically, the vent fans in these bathrooms did not operate and were unable to pull up a piece of tissue paper, and the bathrooms had noticeable musty or heavy urine odors. The Maintenance Director confirmed during an environmental tour that the vents in these rooms were not working and stated that most of the vents on that side of the hallway were likely nonfunctional. The Maintenance Director also indicated that he had not recently checked or worked on the vents in this area. No facility policy on ventilation was provided when requested.
Latest citations in Georgia
Surveyors found that clean linens and personal clothing were stored and staged in close proximity to the dirty laundry area, with an open door between the clean and soiled sides and all washer and dryer doors open. Clean resident clothes, unlabeled garments, and bagged items were placed next to dryers and directly in front of the dirty linen room, and dirty barrels had to be pushed past racks of clean clothing to reach the washers, contrary to facility policies requiring separation of clean and soiled linens. Environmental staff believed keeping doors open and covering dirty barrels reduced infection spread, while the Environmental Services Director, IP nurse, and Administrator acknowledged that the dirty room door should be closed, linens should not be on dirty barrels, and clean resident clothing should not be stored in that location.
A resident with a suprapubic catheter, colostomy, sacral wound, and dependence on staff for bathing and hygiene was care planned for Enhanced Barrier Precautions (EBP), including use of PPE during high-contact care. During observed catheter care and a bed bath, a CNA wore only gloves and did not don a gown, despite EBP signage and a star posted on the door and PPE supplies available outside the room. In interviews, the CNA admitted forgetting to wear a gown and not recognizing additional required actions, while the IP nurse and DON confirmed that staff had been educated that gowns and gloves are required for high-contact care involving indwelling devices and wounds under the facility’s EBP policy.
A resident with multiple neurologic and psychiatric diagnoses, intact cognition, and unilateral functional limitations was found with an open box of lubricant eye drops stored at the bedside without any documented assessment for self-administration or prescriber’s order for self-administration or bedside storage, contrary to facility policy. Observations on multiple days confirmed the eye drops remained at the bedside, while staff interviews showed that CNAs and the IP recognized that residents were generally not to self-administer medications and that bedside medications required assessment and orders. The Administrator confirmed that the resident should not have had eye drops in the room and that residents with bedside medications are typically assessed for self-administration, and staff acknowledged that unsecured eye drops at the bedside could be accessed or ingested by other residents and cause harm.
The facility failed to maintain a safe, clean environment when multiple ceiling tiles throughout the building, including above a resident’s bed, near the nurses’ station, in a glass day room above a resident’s chair, and in a main hall, were observed with brown circular stains, bulging, and a white moldy substance. The Maintenance Director confirmed the stained and bulging tiles, acknowledged the risk that tiles above a resident’s bed could fall, and attributed the condition to rain-related roof leaks. The Administrator also confirmed that roof leaks and recent rainfall caused the brownish stains despite her reported daily rounds.
A resident with severe cognitive impairment, on hospice and fully dependent for ADLs, was sexually abused when another cognitively impaired male resident with a long-standing history of sexually inappropriate behavior toward female residents entered her room and placed his hand inside her pants. The abusing resident had multiple dementia and psychiatric diagnoses, was care planned for sexually inappropriate behaviors with prior documented incidents, and was on psychotropic medication for OCD-related sexual obsession. Despite these known risks and existing care plan interventions, he was able to access the female resident’s room and make inappropriate physical contact, and the facility’s investigation substantiated the abuse.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for two residents. One resident was receiving an antipsychotic (Haloperidol) for schizophrenia with associated behavior and side-effect monitoring orders, but there was no corresponding care plan addressing antipsychotic use or its indication. Another resident had an indwelling Foley catheter for neurogenic bladder related to prostate cancer, with goals to prevent catheter-related trauma; however, the care plan omitted key interventions such as balloon volume parameters and use of a leg strap or securement device, despite physician orders requiring a leg strap and observations showing the catheter positioned under the leg without securement. An MDS coordinator and the administrator acknowledged that required interventions and standard catheter care components were missing from the care plans.
A resident with a history of resistiveness to care and noncompliance with the non‑smoking policy had a comprehensive care plan that was not updated to reflect multiple interventions implemented in response to repeated smoking and vaping violations. Although the care plan noted the need for supervision while smoking and review of the smoking policy, it did not include measures such as daily room searches for smoking materials, added smoke detection in the room, relocation closer to the nurses’ station, q2h visual rounds for smoke, post‑outing nursing checks, initiation of a PAR process for vaping, or issuance of a discharge notice. Facility forms showed inconsistent documentation of daily room searches and incomplete IDT documentation on the PAR tracking, despite multiple documented episodes of policy violations and removal of vaping devices.
A cognitively intact but physically impaired resident with a history of noncompliance with the facility’s non‑smoking policy repeatedly smoked and vaped in his room while keeping multiple vape devices and other items at bedside. The facility’s Smoking Policy required that non‑compliant smokers have daily documented searches and be prohibited from keeping smoking materials in their rooms, yet monitoring forms showed many days without documented searches, Patient at Risk tracking was incomplete, and staff acknowledged that daily room checks and frequent rounds were not consistently performed. Multiple staff, including a CNA, social worker, Infection Preventionist, MDS coordinator, Activities Director, and the Administrator, reported ongoing violations and repeated discovery of vape devices in the resident’s room, including during surveyor observations, demonstrating that the environment was not maintained free from accident hazards and that required supervision and monitoring were not reliably implemented.
Surveyors found that a treatment cart containing topical medications was left unlocked and unattended in a hall across from a resident’s room after wound care was completed by an LPN. The facility’s policy requires that medication carts and supplies be locked or attended and accessible only to licensed or otherwise authorized staff. During interviews, the LPN confirmed the cart had been left unlocked and unattended, the IP LPN confirmed the LPN’s report that the cart was left unlocked, and the Administrator stated that all medications, including topical medications, were expected to be locked when not in sight of authorized staff.
The facility failed to implement its infection prevention and control program by not operationalizing a documented Legionella water management plan despite having a written policy, and by not fully implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices and other risks. A resident with an indwelling urinary catheter had no EBP care plan or orders, no EBP signage, and staff providing catheter care wore only gloves without gowns, while multiple staff members reported not knowing what EBP was or misidentified who should be on EBP. Another resident receiving tube feeding had care initiated by an LPN who wore gloves but no gown and repeatedly touched her hair with the same gloved hands before handling the feeding tube and equipment, later acknowledging she should have changed gloves and was unaware of EBP requirements, even though other clinical staff stated gowns and gloves should be used for feeding tube care. A resident on isolation for C. diff had a door sign indicating isolation but no instructions for visitors on required PPE or to seek staff guidance, and the IP confirmed there was no system to direct visitors about precautions, contributing to the overall infection control deficiency.
Failure to Maintain Separation of Clean and Soiled Laundry
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to separation of clean and soiled linens. Facility policies titled “Infection Prevention and Control Program” and “Handling Soiled Linens” required that clean linen always be separated from soiled linen. During an observation of the laundry area, all washer and dryer doors were open in the clean linen area. Clean linens, including sheets, towels, blankets, and washcloths, were folded on a table to the left of the washer and dryer room. On the right side of the room, next to the dryers and directly in front of the open door to the dirty laundry room, there were residents’ clean clothes on a rack, piles of folded clean clothes to be hung, a rack of unlabeled clothes, and a bag of unlabeled clothes. Dirty laundry barrels had to be pushed past the clean clothing on the racks to reach the washers, placing soiled items in close proximity to clean items despite policy requirements for separation. Environmental staff working in the laundry stated they believed they were reducing the spread of infection by keeping all doors open, covering dirty barrels, and circulating air, and they explained that the uncovered rack and bagged clothes near the dirty area were no-name clothes sometimes distributed to residents in need. They also stated that the rack of clean personal resident clothing parked in front of the open dirty linen room door was awaiting distribution by a staff member who worked only at night. The Environmental Services Director reported that the door to the dirty side of the laundry should always be closed and that no linen should be on top of dirty barrels. The Infection Preventionist nurse, when shown pictures and concerns about cross-contamination, confirmed there was a problem in the laundry but stated she had not been aware of it previously. The Administrator stated that residents’ clothes should not be stored where they were observed and should be handed out immediately once clean, and that she expected the laundry to be organized to prevent cross-contamination between dirty and clean clothes.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Enhanced Barrier Precautions (EBP) policy for the use of personal protective equipment (PPE) during high-contact care. The facility’s EBP policy, updated February 2025, requires gowns and gloves for residents with wounds and/or indwelling medical devices, including urinary catheters and ostomies, when staff perform high-contact activities such as bathing, dressing, toileting, hygiene, and catheter care. The policy also directs that gowns and gloves be made available near or outside the resident’s room and that EBP be implemented for residents with indwelling devices or wounds, even if they are not known to be infected or colonized with a multidrug-resistant organism. The resident involved had a suprapubic catheter, colostomy, sacral wound, and neurogenic bladder and bowel, and was care planned for EBP implementation during catheter and skin care. The resident was cognitively intact but dependent on staff for bathing, dressing, toileting, hygiene, bed mobility, and transfers, and used an indwelling catheter and ostomy. During an observation, a CNA provided suprapubic catheter care and a bed bath to this resident while only wearing gloves, despite EBP signage and a star posted on the door and PPE supplies available outside the room. The CNA did not don a gown and was unable to identify any additional actions needed before care until prompted about the EBP signage, at which point he acknowledged he should have worn a gown but forgot. In a subsequent interview, the IP nurse and DON confirmed that staff had been educated that gowns are required during high-contact care for residents with catheters, colostomies, and other devices, and that the posted signage and star were intended to alert staff to the need for enhanced PPE use.
Failure to Assess and Obtain Orders for Self-Administration and Bedside Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for self-administration of medications and bedside medication storage for one resident. The facility’s policies require that residents who wish to self-administer medications must be assessed by the interdisciplinary team for cognitive, physical, and visual ability, and that a prescriber’s order for self-administration and bedside storage must be present in the medical record and reflected on the MAR and medication label. For the resident in question, who had diagnoses including cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, hemiplegia and hemiparesis, speech and language deficits, and cerebral atherosclerosis, the EHR showed no assessment for self-administration and no physician order for self-administration or bedside storage, despite active ophthalmic medication orders. The resident’s MDS documented intact cognition with a BIMS score of 15, use of corrective lenses, and functional limitations in range of motion on one side of both upper and lower extremities. Surveyor observations on two consecutive days found an open box of lubricant eye drops on the resident’s bedside table. Staff interviews revealed inconsistent understanding and enforcement of the facility’s policies. A CNA stated that residents did not self-administer medications and that only nurses administered them, but also reported that when she previously reported the eye drops, she was told the resident could have them because he was independent. The Infection Preventionist acknowledged the resident had an order for eye drops and believed he obtained them from the VA, and stated he should not have the lubricant eye drops because they were a hazard for other people. The Administrator confirmed that typically a resident with medications at the bedside should be assessed for self-administration and stated the resident should not have eye drops in his room. The report notes that unsecured medications at the bedside had the potential to cause adverse reactions if accessed or ingested by other residents.
Failure to Maintain Safe and Clean Ceiling Surfaces Throughout Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment as required by its Maintenance Service policy, which assigns the Maintenance Department responsibility for keeping the building in good repair and free from hazards. Surveyors observed multiple stained and damaged ceiling tiles in several areas of the facility, including near the nurses' station, in a resident bedroom (room [ROOM NUMBER]A), in the glass day room, and in the middle of the east hall. On several occasions, ceiling tiles near the nurses' station were noted to have tannish-brown circular stains of varying sizes, and at one point a white, moldy substance was observed on a ceiling tile in that same area. In room [ROOM NUMBER]A, surveyors observed brown rings roughly 16 inches in diameter on ceiling tiles located directly above a resident’s bed, with the Maintenance Director later confirming that these tiles were stained, bulging, and at risk of falling on the resident. Additional observations in the glass day room identified two stained ceiling tiles above a resident’s chair, each with brown circular stains approximately three inches in diameter. In the east hall, a ceiling tile with a brown circular stain approximately 10 inches in diameter was also documented. The Maintenance Director and the Administrator both acknowledged that the stains and damage were related to roof leaks associated with recent rainfall, and the Administrator confirmed awareness of roof leaks that had previously been repaired and that the brownish stains were due to recent rain.
Failure to Prevent Sexual Abuse of a Cognitively Impaired Resident by Another Resident
Penalty
Summary
The facility failed to protect a dependent, cognitively impaired resident (R113) from sexual abuse by another resident (R12). R113 had severe cognitive impairment with a BIMS score of 5, was on hospice care, and was fully dependent for toileting, bathing, dressing, footwear, and personal hygiene. On the day of the incident, a CNA observed R12 in R113’s room with his right hand inside R113’s pants while she was seated in a geriatric chair. Staff witness statements and nursing progress notes documented that R12 was found in R113’s room with his hand in her pants, and the facility’s investigation substantiated that R12 touched R113 inappropriately. R12 also had severe cognitive impairment with a BIMS score of 4 and multiple psychiatric and dementia-related diagnoses, including vascular dementia with mood disturbance, Alzheimer’s disease, major depressive disorder, obsessive-compulsive personality disorder, unspecified psychosis, and unspecified mood affective disorder. He required extensive physical assistance, used a manual wheelchair, and was fully dependent for toileting, bathing, lower body dressing, and footwear. R12’s care plan, in place since 2017, identified him as having sexually verbally and physically inappropriate behavior, including documented prior incidents in which he inappropriately touched or attempted to touch female residents. His care plan included interventions such as discussing his behavior when reasonable, explaining that it was inappropriate, intervening to protect others, diverting his attention, and removing him from situations as needed, as well as monitoring and recording occurrences of target behaviors such as sexual aggression toward others. Despite this known history of sexually inappropriate behavior toward female residents and the presence of care plan interventions, R12 was able to enter R113’s room and place his hand inside her pants. The Administrator confirmed that the CNA reported finding R12 in R113’s room with his hand in her pants while R113 was in her wheelchair, and that the facility’s investigation substantiated the abuse allegation. The facility’s abuse policy stated that it would not condone resident abuse by anyone, including other residents, and defined sexual abuse to include sexual harassment, sexual coercion, or sexual assault. The occurrence of this incident demonstrated that the facility did not effectively prevent sexual abuse of R113 by another resident, despite R12’s documented behavioral history and existing care plan.
Failure to Develop and Implement Complete Care Plans for Antipsychotic Use and Foley Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for identified resident needs, as required by its Comprehensive Care Plan policy. The policy states that care plans must address all needs identified in the comprehensive assessment, including medical, nursing, mental, and psychosocial needs, and must be developed within seven days after completion of the comprehensive MDS assessment. It also requires that all triggered Care Area Assessments (CAAs) and other factors identified by the IDT or resident preferences be incorporated into the plan of care. For one resident, R44, the clinical record showed physician orders for Haloperidol 10 mg by mouth twice daily for schizophrenia, along with orders for behavior monitoring and psychiatric medication side effect monitoring. Despite these orders, the resident’s care plan dated 03/11/2026 did not include any care plan addressing antipsychotic medication use or its indication. The MDS Coordinator stated that all residents receiving antipsychotic treatment should have a comprehensive care plan in place beginning with the date the medication was originally ordered, and upon review of the record confirmed that such a care plan was not present for this resident at the time of the survey. For another resident, R3, the care plan dated 03/13/2026 identified a problem of an indwelling catheter secondary to neurogenic bladder related to prostate cancer, with goals including remaining free from catheter-related trauma. The listed interventions included positioning the catheter bag and tubing below bladder level, monitoring and documenting intake and output per policy, and monitoring for pain, discomfort, and signs and symptoms of UTI. However, the care plan did not address the amount of water in the catheter balloon, use of a leg strap or securement device, or other securement measures. Physician orders specified checking a leg strap every shift and documented that the resident was admitted with an 18F catheter attached to a bedside drainage bag, but observations showed the Foley catheter positioned under the resident’s leg without a leg strap or securement device on two occasions, and a CNA reported being unaware that a leg strap was required. The MDS Coordinator confirmed that these ordered interventions were missing from the care plan.
Failure to Revise Care Plan for Ongoing Smoking Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan to reflect current interventions implemented in response to ongoing noncompliance with the facility’s non‑smoking policy. The facility’s policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and that it include measurable objectives, timeframes, and alternative interventions as needed, with qualified staff notified when changes are made. The resident’s care plan included a focus on resistiveness to care and noncompliance with smoking, noting that the resident continued to go outside beyond facility property to smoke, and an intervention to review the smoking policy with the resident. Another care plan focus identified the resident as a smoker requiring supervision while smoking, with interventions stating the resident required supervision while smoking and that the charge nurse should be notified if a smoking policy violation was suspected. Despite repeated and ongoing noncompliance with the non‑smoking policy, the care plan was not revised to include additional interventions that were actually implemented. These unreflected interventions included daily room searches for smoking paraphernalia, placement of a smoke detector in the resident’s room, relocation of the resident’s room closer to the nursing station, every‑two‑hour visual rounds to check for smoke, nursing checks upon return from outings, initiation of a Patient at Risk (PAR) process for vaping noncompliance, and issuance of a 30‑day discharge notice for repeated violations of the non‑smoking policy. Documentation on the Smoking Materials Monitoring Form showed initials on selected days only, indicating daily room searches were not consistently completed and documented for the entire month. The PAR Smoking Tracking form documented multiple observations of vaping in the room, repeated room checks, removal of vapor devices, and the resident’s refusal to comply with facility policies, with later weeks lacking IDT signatures and documentation, while the PAR Grid showed multiple prior entries for violating the non‑smoking policy.
Failure to Control Smoking and Vaping Hazards for a Noncompliant Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision for a resident with a known history of noncompliance with the facility’s non‑smoking policy. The facility’s Smoking Policy requires that residents not be allowed to keep cigarettes, cigars, pipes, matches, or lighters in their possession or rooms, and that non‑compliant smokers receive daily searches with documentation, while compliant smokers receive weekly searches. The policy also requires incident reports and review in a “Patients at Risk” process whenever smoking materials are found. Despite these written procedures, the resident’s Smoking Materials Monitoring Form for April showed multiple days without documented searches, indicating that required daily room searches were not consistently completed or recorded. The resident at issue was cognitively intact, with a BIMS score of 15, and had significant physical impairments including hemiplegia and hemiparesis on the left side, use of a manual wheelchair, and other neurologic and psychiatric diagnoses such as cerebral aneurysm, cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, and speech and language deficits. The care plan identified the resident as resistive to care and noncompliant with smoking, noting that he continued to go outside beyond facility property to smoke, and also identified him as a smoker requiring supervision while smoking. Progress notes and Patient at Risk documentation showed a pattern of repeated violations of the non‑smoking policy, including multiple instances of vaping and smoking in his room, with staff repeatedly finding vape devices and other smoking paraphernalia in his possession and in his room. Throughout the period reviewed, staff observations and interviews confirmed ongoing noncompliance with the smoking policy and inconsistent implementation of the facility’s own interventions. Staff documented several occasions when the resident was observed vaping or smoking in his room, including in the presence of a state surveyor, and room searches revealed multiple vape devices hidden under the sheets. Staff interviews indicated that daily room checks were not always performed due to competing demands, that logs of every‑two‑hour rounds were not maintained, and that there was confusion or inconsistency regarding whether the resident could keep items such as air freshener at bedside. The social worker, Infection Preventionist, MDS coordinator, Activities Director, CNA, and Administrator all acknowledged that the resident’s room had to be searched for cigarettes and vaping paraphernalia and that prohibited items were repeatedly found, while documentation showed gaps in the required daily searches and incomplete follow‑through on the Patient at Risk tracking process. These actions and inactions resulted in the environment not being kept free from accident hazards as required by the facility’s policy and regulatory standards. The deficiency is further supported by the facility’s own records showing repeated entries on the Patient at Risk grid for violations of the non‑smoking policy over an extended period, as well as narrative notes describing the resident’s statements that he would continue to vape in his room and would simply obtain new devices if they were confiscated. Despite the known pattern of behavior and the facility’s policy requiring close supervision, daily searches, and thorough documentation for non‑compliant smokers, the monitoring forms and staff interviews demonstrate that these measures were not consistently carried out. The presence of multiple vape devices and cans of air freshener at the bedside during surveyor observations, along with staff acknowledgment that room checks were missed and that logs of frequent rounds were not kept, illustrate the facility’s failure to effectively implement its own safety procedures to prevent accident hazards related to smoking and vaping in the resident’s room.
Unlocked and Unattended Treatment Cart with Topical Medications
Penalty
Summary
Surveyors identified a deficiency related to medication storage when a treatment cart containing topical medications was left unlocked and unattended in a hall. The facility’s policy titled “Medication Storage in the Facility,” effective 10/01/2025, states that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that medication rooms, carts, and supplies are to be locked or attended by authorized personnel. During an observation on 04/29/2026 at 9:35 AM, after wound care was provided to resident R3 by the wound care LPN, the treatment cart was observed left in the [NAME] hall across from R3’s room, unlocked and unattended for 30 minutes. In an interview, the wound care LPN confirmed that the treatment cart had been left unlocked and unattended. The Infection Preventionist LPN later confirmed that the wound care nurse told her the cart was left unlocked, and the Administrator stated that her expectation was that all medications, including topical medications, be locked when not in sight of a licensed nurse or authorized person. This deficient practice occurred in a facility with a census of 94 residents and involved the failure to follow the facility’s own policy requiring that medication carts be locked or attended by authorized personnel, resulting in unsecured access to topical medications on the treatment cart.
Failure to Implement Legionella Water Management and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to provide and implement an infection prevention and control program, including a documented water management plan for Legionella and other waterborne pathogens, and a fully implemented Enhanced Barrier Precautions (EBP) program. The Administrator stated there was no Legionella water program in place, and the Maintenance Supervisor reported he was unaware of the requirement for such a program. This was despite the existence of a written Legionella Water Management Program policy, revised in September 2022, which described the need for an interdisciplinary water management team, detailed water system diagrams, identification of risk areas and situations for Legionella growth, control measures, monitoring systems, and annual review. Interviews confirmed that the expectation was that the facility would be conducting this water program, but it was not being done. The facility also failed to implement EBP for residents with indwelling medical devices and other risk factors, as required by its own policy. One resident with Alzheimer’s disease, urinary obstruction, and emphysema had an indwelling urinary catheter documented in the care plan and physician orders, but the care plan did not address EBP related to the catheter, and there was no order for EBP in the record. During catheter-related care, a CNA wore gloves but did not wear a gown, and there was no EBP signage or PPE setup at the room. Multiple staff members, including CNAs and a housekeeper who regularly worked on the resident’s hallway, reported they did not know what EBP was or incorrectly associated EBP only with residents on Transmission-Based Precautions. The DON acknowledged that an attempt to roll out EBP months earlier had not been completed, and that expected signage and PPE caddies for EBP were not fully in place. Additional infection control lapses were observed during tube feeding care and contact isolation. A resident receiving continuous tube feeding had a care plan and physician’s order for enteral nutrition, and an LPN initiated the feeding while wearing gloves but no gown. During the procedure, the LPN repeatedly touched her hair with the same gloved hands and then handled the feeding tube, pump, and syringe used to inject air and check residuals, only removing gloves and using hand sanitizer at the end. The LPN later acknowledged she should have changed gloves after touching her hair and stated she did not know what EBP was or that a gown was required for feeding tube care, while another LPN and the IP stated that EBP with gown and gloves should be used for feeding tube care and that staff should not touch their hair during care without changing gloves and performing hand hygiene. For a resident with a positive urine culture and a subsequent positive C. difficile culture who was on isolation, the door sign indicated isolation but did not provide instructions for visitors on required precautions or direct them to staff for guidance. The IP confirmed there was no system to direct visitors about PPE use for residents on contact isolation and acknowledged that visitors would not know to wear PPE if it was simply present in or on the door of the room. Overall, the survey findings show that the facility did not operationalize its written Legionella water management policy and did not consistently apply its EBP policy for residents with indwelling devices or wounds. Staff interviews and observations demonstrated a lack of knowledge and implementation of EBP, incomplete use of PPE during high-contact care activities such as catheter care and tube feeding, and unclear isolation signage that did not instruct visitors on appropriate precautions. These combined inactions and omissions in policy implementation, staff education, and practice led to the cited infection prevention and control deficiency.
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