Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Seabury during CMS and state inspections, most recent first.
The facility failed to label and date food items and maintain a clean water filter system. Several bins containing loose sugar, rice flour, brown rice, and flour were not labeled with dates or expiration dates. Additionally, a water filter system feeding a steam receptacle was found soiled and streaked with green/white substances. The Executive Chef could not explain these deficiencies.
The facility failed to ensure a licensed staff member conducted weekly skin checks for a resident with cerebral infarction, leading to an oversight of a red area on the resident's thumb. Additionally, the facility did not follow physician orders for another resident with dementia, administering Tramadol without first giving Tylenol as prescribed.
The facility failed to have a signed advanced directive available in either the paper or electronic clinical record for a resident with severe cognitive impairment and significant medical conditions. The Resident Care Plan indicated DNR/DNH status, but the monthly physician's orders did not reflect this, and the required documentation was missing, contrary to facility policy.
The facility failed to notify the provider of significant weight changes in a resident with heart failure, anemia, and atrial fibrillation, despite a physician's order and care plan requiring such notifications. The ADON could not find documentation of provider notification, and a PA reported inconsistent communication of weight changes by staff.
The facility failed to follow a physician's order for daily weights for a resident with heart failure, missing 24 out of 59 opportunities to document the weight. Additionally, the facility did not ensure a treatment order for a resident with a skin lesion was correctly transcribed, resulting in a gap in wound care treatments due to a glitch in the electronic health record system.
A resident with multiple diagnoses, including hemiplegia, did not receive a weekly skin assessment by a licensed staff member as required. An LPN relied on a Nurse Aid to perform the check, leading to a missed identification of a red area on the resident's thumb, which later developed into a blister. This was against the facility's policy that mandates licensed nurses to conduct weekly skin assessments.
The facility failed to obtain a physician's order for oxygen administration for two residents with respiratory issues. One resident with multiple diagnoses was administered oxygen without an order on multiple occasions, while another resident was observed using an oxygen concentrator without a corresponding order. Staff interviews and record reviews confirmed the absence of necessary physician orders, violating the facility's Oxygen Administration policy.
A resident receiving hospice care was admitted to the facility without a physician's order for hospice services. Despite being on hospice prior to admission, the facility failed to obtain a new order, contrary to their policies requiring accurate and timely physician orders.
The facility failed to obtain laboratory services per the physician's order for a resident with multiple diagnoses. The DNS confirmed that the floor nurses are responsible for verifying and completing requisition forms, but the lab work was not completed as directed.
Failure to Label Food Items and Maintain Clean Water Filter System
Penalty
Summary
The facility failed to ensure food items were labeled and dated, and failed to maintain an adequately clean water filter system for the steam receptacles. During a tour of the Dietary Department, it was observed that several 40-gallon plastic bins containing loose sugar, rice flour, brown rice, and flour did not have labels indicating the date they were filled or their expiration dates. The Executive Chef was unable to explain why these items were not properly labeled and dated, despite the facility's policy requiring such labeling for food storage. Additionally, a water filter system feeding a steam receptacle was found to be soiled and streaked with green/white substances, located above a food storage unit and empty food containers. The Executive Chef could not identify the substances on the water filter system. The facility's Food Storage policy directed culinary managers to maintain adequate food and supplies for food service operations and required all items to be appropriately labeled with expiration or opening dates. The Executive Chef mentioned that the evening staff conducted nightly inventory checks to ensure the kitchen was fully stocked and prepared for meal prep the following day. However, the observed deficiencies indicate a failure to adhere to these policies, resulting in improperly labeled food items and an unclean water filter system.
Failure to Conduct Proper Skin Checks and Follow Pain Medication Orders
Penalty
Summary
The facility failed to ensure a weekly skin check was conducted by a licensed staff member for Resident #7, who had a diagnosis of cerebral infarction with paralysis, hypertension, and congestive heart failure. Despite physician orders directing weekly skin assessments on Mondays, the skin check on 3/18/24 was performed by a Nurse Aid (NA) instead of a licensed nurse. This led to a missed identification of a red area on Resident #7's left thumb caused by a splint, which the resident had reported to staff. The facility's policy mandates that licensed or registered nurses conduct these assessments, but this protocol was not followed, resulting in the oversight of the resident's skin condition. For Resident #48, who had diagnoses including dementia, mood disorder, and muscle weakness, the facility failed to follow physician orders regarding pain medications. The physician's orders specified administering Acetaminophen (Tylenol) first for pain and only using Tramadol if Tylenol was ineffective for severe back pain. However, Resident #48 received Tramadol 35 times over approximately four months without first receiving Tylenol and for reasons other than severe back pain. This deviation from the prescribed medication regimen was due to the resident's preference for Tramadol and the nursing staff's failure to adhere to the physician's instructions. Interviews with the nursing staff and the physician assistant revealed that the facility's practices did not align with the prescribed orders and policies. The Wound Care Nurse confirmed that licensed staff should perform weekly skin checks, and the physician assistant indicated that Tramadol should only be given after Tylenol was deemed ineffective. The facility's failure to follow these protocols resulted in deficiencies in the care provided to both residents.
Failure to Document Advanced Directive
Penalty
Summary
The facility failed to have a signed advanced directive available in either the paper or electronic clinical record for Resident #28, who was diagnosed with congestive heart failure and chronic kidney disease. The admission Minimum Data Set assessment identified the resident as severely cognitively impaired and requiring moderate assistance for bed mobility and transfers. The Resident Care Plan indicated that the resident was a Do Not Resuscitate (DNR) and a Do Not Hospitalize (DNH), but the monthly physician's orders for January, February, and March 2024 did not reflect a current or discontinued order for a DNR or DNH. During an interview and clinical record review, the Director of Nursing Services (DNS) and Assistant Director of Nursing Services (ADNS) confirmed that the clinical record lacked a completed and signed advanced directive form and a corresponding physician's order, which was against the facility's policy requiring such documentation upon admission. Neither the DNS nor ADNS could explain the absence of the required documentation in the clinical record. An interview with a registered nurse (RN) revealed that if a resident was found unresponsive, she would check the electronic or paper clinical record for a code status. However, she was unable to find a physician's order or consent for Resident #28. Although there was a banner in the electronic clinical record indicating the resident's DNR/DNH status, the RN could not identify how the information was placed there without the corresponding order or consent. The facility's Advanced Directive policy directed that copies of any advanced directives should be made and placed in the chart upon admission and communicated to the staff, which was not followed in this case.
Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to notify the provider of significant weight changes in Resident #14, who had diagnoses including heart failure, anemia, and atrial fibrillation. The resident's care plan required notifying medical staff of any significant changes in condition, and a physician's order specified that the resident should be weighed each morning with provider notification if the resident gained more than 2-3 pounds in 24 hours or more than 5 pounds in a week. Despite documented weight increases that exceeded these parameters on multiple occasions between 1/21/24 and 3/20/24, there was no evidence that the provider had been notified as required. During an interview, the Assistant Director of Nursing (ADON) could not find documentation of provider notification for the significant weight increases. Additionally, a Physician Assistant (PA) reported that facility staff inconsistently communicated weight changes as instructed by the physician's order and often discovered uncommunicated weight changes while reviewing resident records. The facility's Change of Condition policy directed consultation with the resident's physician when there is a need to alter the resident's treatment, such as an exacerbation of a chronic condition, but this was not followed in the case of Resident #14.
Failure to Follow Physician Orders for Daily Weights and Wound Care
Penalty
Summary
The facility failed to follow the provider's order for daily weights for a resident diagnosed with heart failure, anemia, and atrial fibrillation. The resident was moderately cognitively impaired and required substantial assistance for transfers and wheelchair propulsion. Despite a physician's order to weigh the resident each morning before breakfast and notify the provider of significant weight changes, the facility missed 24 out of 59 opportunities to document the resident's weight. Interviews with the resident's nurse and the Assistant Director of Nursing (ADON) revealed that the nursing assistants were responsible for obtaining the weights, but there was no documentation of refusals or reasons for the missing entries. The facility's Weight Monitoring policy required daily weight monitoring and documentation when clinically indicated, which was not adhered to in this case. Additionally, the facility failed to ensure a treatment order for a resident with a skin lesion was correctly transcribed and that post-surgical wound treatments were performed. The resident, who was cognitively intact, had a physician's order to cleanse and dress a wound on the left dorsal wrist daily. However, there was a gap in wound care treatments from 2/27/24 to 3/6/24 due to a glitch in the electronic health record system, which the facility staff failed to identify. The Director of Nursing Services (DNS) confirmed the gap and indicated that the system failed to bring the orders forward, resulting in missed wound care treatments. The facility's policy required all physician orders to be accurate and timely, which was not met in this instance.
Failure to Conduct Weekly Skin Assessments by Licensed Staff
Penalty
Summary
The facility failed to ensure that a weekly skin assessment was completed by a licensed staff member for Resident #7, who had a diagnosis of hypertension, congestive heart failure, and hemiplegia/hemiparesis following a cerebral infarction. Physician orders directed that weekly skin checks be completed on Mondays during the day shift. However, on 3/18/24, LPN #1, who was responsible for the skin check, was too busy administering medications and relied on a Nurse Aid (NA) to conduct the skin observation. The NA reported no skin impairment, and LPN #1 documented that Resident #7's skin was intact without personally verifying it. This led to a failure in identifying a red area on Resident #7's left thumb, which was later observed to have developed into a blister due to shearing against a splint. The facility policy mandates that licensed nurses conduct weekly skin assessments, which was not adhered to in this case. Resident #7, who was cognitively intact and dependent on staff for various activities, had previously informed staff about the red area on the left thumb, which had become red within the last week. Despite this, the area was not properly assessed or documented by licensed staff. The Physician Assistant (PA) later noted a small closed blister on the left thumb, likely caused by the splint, and recommended discontinuing the use of all splints until the area healed. The Wound Nurse confirmed that the facility policy requires licensed nurses to perform weekly skin checks, and it was not acceptable for a NA to perform this task. This oversight in following the facility's policy led to the deficiency in providing appropriate pressure ulcer care for Resident #7.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for oxygen administration for two residents with respiratory issues. Resident #10, diagnosed with malignant neoplasm of the frontal lobe, atrial fibrillation, and congestive heart failure, was found to have low oxygen saturation levels and was administered oxygen without a physician's order on multiple occasions. Despite the resident's care plan indicating the need for oxygen monitoring, the nursing staff did not secure the necessary orders, as confirmed by interviews with the LPN and ADNS. The deficiency was identified through nursing notes and a Physician Assistant's progress note, which highlighted the resident's ongoing need for oxygen due to respiratory illness and antibiotic therapy for bronchitis/possible pneumonia. Similarly, Resident #215, diagnosed with heart failure, atrial fibrillation, and dementia, was observed using an oxygen concentrator without a corresponding physician's order. The resident's admission assessment did not indicate the use of oxygen therapy, and subsequent observations revealed the presence of an oxygen concentrator and nasal cannula in use. Interviews with LPNs revealed a lack of awareness regarding the oxygen administration and the absence of a physician's order. The deficiency was further confirmed by the review of physician and nursing progress notes, which failed to document any orders for oxygen use. The facility's Oxygen Administration policy, which mandates obtaining a physician's order for oxygen administration except in emergencies, was not adhered to in these cases. The failure to secure physician orders for oxygen administration was identified through observations, clinical record reviews, and staff interviews, highlighting a significant lapse in following established protocols for respiratory care.
Lack of Physician's Order for Hospice Services
Penalty
Summary
The facility administered hospice services to Resident #28 without obtaining a physician's order. Resident #28, who was admitted with diagnoses including congestive heart failure and chronic kidney disease, was identified as severely cognitively impaired and required moderate assistance for bed mobility and transfers. The resident's care plan indicated hospice care, with interventions such as pain assessments and administration of comfort medications. However, a review of the monthly physician's orders for January, February, and March 2024 did not show any active or discontinued orders for hospice services. The Director of Nursing Services (DNS) confirmed that Resident #28 had transferred from independent living to long-term care in January and had been receiving hospice services prior to admission. Despite this, no new hospice order was obtained upon the resident's admission to the facility. The facility's policies on Coordination of Hospice Services and Physician Orders require that a physician's order be in place at the time of admission and that all orders be accurate and timely, which was not adhered to in this case.
Failure to Obtain Timely Laboratory Services
Penalty
Summary
The facility failed to obtain laboratory services per the physician's order for a resident diagnosed with bipolar disorder, hypertension, dementia, and hypothyroidism. The physician orders dated 1/18/24 directed the staff to obtain a complete blood count, basic metabolic panel, thyroid stimulating hormone, and vitamin D12 levels. However, a review of the clinical record revealed that the laboratory results were not available as ordered. An interview with the Director of Nursing Services (DNS) confirmed that the floor nurses are responsible for verifying laboratory orders and completing requisition forms, but the DNS could not explain why the laboratory work was not completed as directed. The facility policy states that the facility is responsible for the timeliness of laboratory services.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bloomfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Touchpoints At Bloomfield | 0.8 mi | ★★★★★ | 19 | 0 |
| Bloomfield Center For Nursing & Rehabilitation | 0.8 mi | ★★★★★ | 2 | 0 |
| Complete Care At Kimberly Hall-south | 2.1 mi | ★★★★★ | 0 | 0 |
| Complete Care At Kimberly Hall North | 2.1 mi | ★★★★★ | 7 | 0 |
| Caleb Hitchcock Health Center | 2.5 mi | ★★★★★ | 11 | 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.