Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 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 Despite repeated incidents and recommendations documented in progress notes and assessments, the care plans remained outdated, and staff responsible for care plan revisions did not consistently implement required updates as per facility policy.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.
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What surveyors actually found near you
We read the 6 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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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) |
|---|---|---|---|---|
| Gracemore Nursing And Rehab | 0.6 mi | ★★★★★ | 5 | 0 |
| Senior Care Center - Brunswick | 0.7 mi | ★★★★★ | 0 | 0 |
| Heritage Oaks | 6.6 mi | ★★★★★ | 1 | 0 |
| Marsh's Edge | 7.6 mi | ★★★★★ | 0 | 0 |
| Bayview Nursing Home | 29.6 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.