Sears Manor Nursing Home

Inspectors wroteBased on observations, interviews, and record review, the facility failed to 1. ensure resident rooms, dining rooms, and hallways were clean and in good repair and 2. ensure a homelike environment was maintained by repairing three indentions measuring 16 inches x 3 inches in the wall behind the resident's bed for one resident (Resident (R) 9) out of a total sample of 25 residents. This failure had a potential to create the lack of a homelike environment for 19 out of 52 resident rooms and facility common areas.

Inspectors wrote4. Review of R38's admission Record, located under the Profile tab of the EMR revealed he was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis affecting left non-dominant side, anemia, left hand contracture, and history of stroke. Review of R38's quarterly MDS, with an ARD of 03/12/25 and located under the MDS tab of the EMR, revealed he scored 11 out of 15 on the BIMS, indicating moderately impaired cognition. R38 had impaired range of motion in the upper and lower extremities on one side. He was independent with bed mobility, required touching/supervision with lying to sitting, and required partial/moderate assistance with bed to chair transfers. In the past quarter, R38 had one fall with no injury and one fall with minor injury. [...]

Inspectors wroteBased on interview and policy review, the facility failed to 1. to develop an effective infection surveillance program in order to conduct appropriate prevention or control activities and 2. ensure staff used appropriate personal protective equipment (PPE) for one of five residents (Resident (R) 59) reviewed for enhanced barrier precautions in a sample of 25. These failures had the potential to cause an avoidable spread of infection throughout the facility.

Inspectors wrote3. Review of R48's undated admission Record located in the electronic medical record (EMR) under the Profile tab revealed R48 was admitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection (UTI). Review of R48's Physician's Orders, dated 03/06/25, provided by the facility, revealed Cipro (broad spectrum antibiotic) 250 milligrams (MG) twice a day for seven days. Review of R48's Health Status Note, dated 03/04/25, located in the EMR under the Prog Notes tab, revealed R48 returned to nursing facility at 3:12 AM on stretcher via transport services. Resident is alert and oriented x 1 [times one] with confusion . Resident will start Cefuroxime [broad spectrum antibiotic] 500 mg [milligrams] BID [twice a day] x [for] 10 days for treatment of UTI. [...]

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure residents were treated with dignity for one of 25 sampled residents (Resident (R) 34). This failure had the potential to cause residents to feel intimidated when staff feed them while standing up next to them.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a gradual dose reduction of psychotropic medication was attempted when indicated for two of five residents (Resident (R) 38 and R13) reviewed for unnecessary medications out of a total sample of 25 residents. This failure had the potential to contribute to avoidable side effects of psychotropic medication, including sedation, dizziness, and increased falls.

Inspectors wroteBased on interviews, record review, and review of the facility's policy, the facility failed to complete a thorough investigation of an allegation of an injury of unknown origin/physical abuse for one resident (Resident (R)37) of two residents reviewed for abuse out of 25 sampled residents. The facility's failure to complete a thorough investigation placed residents at risk of being unprotected from abuse.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to consistently implement interventions to offload pressure for one of four residents (Resident (R)29) out of a total sample of 25 residents. This failure increased the risk for the resident to develop pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to fix a resident's headboard one out of four residents reviewed for accidents out of 25 sampled residents (Resident (R) 37). This failure had the potential to cause injury to the residents.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to properly prime an insulin pen prior to administering it to one of twenty-five residents (Resident (R) 2) observed for medication administration. Medication errors have the potential to result in adverse health outcomes.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure controlled medications (drugs that can cause physical and mental dependence and have restrictions on how they can be filled and refilled) were stored securely in a compartment that was permanently affixed inside the refrigerator in one of two medication storage rooms.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the bathrooms had ventilation for two residents (Resident (R) 21 and R60) out of 26 residents included in the Initial Pool. This failure had the potential to limit airflow in resident bathrooms causing odors or discomfort.

Inspectors wroteBased on observation, resident interview, staff interviews, record review, and review of the facility policy titled, Care of Fingernails/Toenails the facility failed to provide nail care for one of 29 residents (R) R#21, who is unable to independently carry out Activities of Daily Living (ADL).

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Maintenance Service. The facility failed to ensure that residents rooms and living environment was in good repair. Specifically, the facility failed to ensure residents room walls were free from scuff marks and holes, bathroom vents were free of dust, and that the baseboards were securely affixed to the wall boarders.

Inspectors wroteBased on observation, record review, resident and staff interviews, and review of the facility policy titled, Care Plans-Comprehensive the facility failed to follow the care plan related to Activities of Daily Living (ADL) related to nail care for one of 29 residents (R) (R#21). This deficient practice had the potential to affect the continuity of care provided to R#21.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policy titled, Care Plans-Comprehensive the facility failed to ensure the care plan for one of three residents (R) R#19 was updated following a change in physician's order for oxygen.

Inspectors wroteBased on observation, record review, staff interview, and review of the facility policy titled, Oxygen Administration, the facility failed to provide the correct dosage of continuous oxygen for one of nine residents (R) (R#19) as ordered by the physician. The deficient practice had the potential to affect the respiratory status of R#19.

Inspectors wroteBased on observations, record review, interviews, and review of the facility's policy titled, Restraints-Physical the facility failed to release a restraint to allow freedom of movement and activity. This deficient practice affected one of one sampled resident reviewed for physical restraints.

Inspectors wroteBased on observations, record review, interviews, and policy review titled Restraints-Physical and Using the Care Plan, and , the facility failed to ensure R#42's care plan was followed for a physical restraint and failed to ensure that Resident (R) #39 had a care plan developed for range of motion (ROM) and. These deficient practices affected two of 34 sampled residents.

Inspectors wroteBased on observation, record review, interviews, and review of the facility's policy, Introduction to Restorative Nursing Programs the facility failed to provide restorative services and a splint device for one of one resident reviewed for restorative services (Resident (R) #39).