Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Seacrest Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Kitchen sanitation, cooling, and storage failures: Staff did not document cooling for cooked TCS foods, and a pan of beef tips was found at 43.7 F after cooking with no evidence it had been divided for faster cooling. The dish machine sanitizing solution was not consistently tested with strips, wet pans were stored in the clean pot/pan area, a wall-mounted fan was visibly dirty, and items in a resident freezer were unlabeled despite policy requiring resident identification.
Dish machine drain lines were observed below the flood rim of the floor drain during a kitchen tour, and the DM stated maintenance would be contacted. The NHA later stated the drain line position would be addressed and properly air gapped. The 2013 FDA Food Code was cited regarding direct connections between sewage systems and drains from equipment used for food, portable equipment, or utensils.
Soiled resident room flooring was observed in 4 of 21 sampled rooms, with yellow discoloration, wheelchair tire marks, and dark stains. The ESM stated the floors should be white, needed stripping and waxing, and had not been stripped and waxed since 2024 due to lack of proper equipment and enough staff. The NHA stated the floors needed deep cleaning, stripping and waxing, or replacement.
A resident with no cognitive impairment had prescribed eye drops and nasal spray left at the bedside during repeated observations, even though there was no order, interdisciplinary assessment, or care plan for self-administration. The resident said they self-administered the eye drops and nasal spray, and an LPN confirmed the meds were dropped off at the bedside despite no self-administration order; the DON also confirmed no assessment or order was in place.
A resident with DMII had repeated blood sugar readings far above the ordered sliding scale, including several values over 400 mg/dl, but multiple episodes had no nursing or MP documentation showing notification. The care plan directed staff to report abnormal blood sugars to the physician, yet staff and the DON stated there were no current written instructions for when to contact the MP when readings exceeded the sliding scale. The physician acknowledged that nursing should have had written guidance on when to report elevated blood sugars.
Inaccurate narcotic counts and missing signatures on controlled medication logs. Two LPNs failed to sign the narcotic reconciliation logs at shift change and also forgot to sign out controlled meds when they were administered. One cart showed a mismatch for a resident’s MS Contin 30 mg count, and another cart showed a mismatch for a resident’s oxycodone 10 mg count. The DON confirmed the facility policy required the count to be completed and signed at shift change and narcotics to be signed out when removed from the med cart.
Improper Storage of Unopened Insulin in Medication Carts: An LPN found unopened Humalog and Novolog insulin, as well as unopened insulin Kwik-Pens, stored at room temperature in medication carts even though the packaging said to keep refrigerated. None of the items had a delivery or received-on date, and the LPNs stated there was no way to tell how long the insulin had been at room temperature. The DON confirmed the facility policy required medications to be stored per manufacturer instructions, including refrigerated storage for unopened insulin.
Failure to Perform Hand Hygiene During Blood Glucose Checks: An LPN was observed sneezing in the hallway, then performing blood glucose checks on multiple residents without hand hygiene before donning gloves, between residents, or after glove removal. One resident had DM and moderate cognitive impairment, and the DON stated hand hygiene should be completed before entering a room and after removing gloves; the facility policy also required hand hygiene immediately before resident contact, between services, and immediately after glove removal.
The facility failed to maintain cleanliness of food service equipment, affecting 86 residents and increasing the risk of cross-contamination. Observations revealed misaligned water valves, leaking spray faucets, and soiled freezers and mixers. Record reviews showed non-compliance with established cleaning procedures.
The facility failed to maintain a clean and safe environment, affecting 86 residents. Observations revealed uneven concrete surfaces, missing atmospheric vacuum breakers, worn flooring, and soiled air purification units. Various areas, including nursing stations and shower rooms, were poorly maintained, increasing the risk of cross-contamination. The maintenance work order system showed no entries addressing these issues, indicating inaction in resolving the deficiencies.
A resident with limited ROM was not included in the facility's restorative program, despite recommendations from a discharging therapist. The resident, affected by conditions following a stroke, was not receiving therapy services or exercises. Interviews with staff revealed a lack of a formal restorative program and failure to implement the recommended ROM program, contrary to the facility's policy on restorative care.
A facility failed to prevent a resident with PICA from accessing nonfood items, leading to the resident swallowing gauze and requiring an emergency procedure. The resident, with severe cognitive impairment and a complex medical history, was not provided with adequate interventions to prevent such incidents, resulting in hospitalization.
Kitchen sanitation, cooling, and storage failures
Penalty
Summary
The facility failed to ensure proper cooling of cooked time-temperature control for safety foods. During a kitchen tour, a full-size pan of taco meat was identified as having been cooked the prior night, but no cooling log was available for it. A full-size pan of beef tips was also observed; the internal temperature was 43.7 F, and staff stated the beef tips finished cooking at 7 AM that morning. Staff further stated that the meat was not divided into smaller portions to facilitate proper cooling and that cooling temperatures were not documented. The facility also failed to consistently test the dish machine sanitizing solution, properly clean and air-dry pans before stacking, keep a mounted fan clean, and maintain the resident refrigerator properly. A dietary aide stated dishware sanitation was judged by visually observing the flow of sanitizing solution and that test strips were not used, while the dietary manager said the sanitizing solution was not always tested and no sanitizing log was being kept. Two wet and soiled full-size pans were stored in the clean pot/pan area. A wall-mounted fan blowing toward the clean side dish machine drain board was covered with dust and dirt on the cover, blades, and mounting bracket. In the Unit D resident refrigerator freezer, an opened container of strawberry ice cream and a boxed frozen entree were both not labeled with a resident's name, despite the facility policy requiring perishable foods to be stored in re-sealable containers and labeled with the resident's name, item, and use-by date.
Dish Machine Drain Lines Not Properly Positioned
Penalty
Summary
The facility failed to ensure the drain lines from the dish machine were maintained in a safe and sanitary operating condition. During the initial tour of the kitchen, the end of the drain lines from the dish machine were observed below the flood rim of the floor drain. The Dietary Manager stated maintenance would be contacted. The Nursing Home Administrator later stated the position of the drain line from the dish machine would be addressed and properly air gapped. The 2013 FDA Food Code was reviewed and cited that a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.
Soiled Resident Room Flooring Not Maintained
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant in four of 21 resident rooms sampled for a clean environment. During an environmental tour, the Environmental Services Manager observed resident room flooring that was soiled, yellow in color, and marked with wheelchair tire tracks and dark stains in multiple rooms. The Environmental Services Manager stated the flooring should be white, that the affected floors needed to be stripped and waxed, and that the heavy wheelchair markings had not been removed by regular housekeeping. The Environmental Services Manager also stated the facility had not been able to strip and wax the floors since 2024 because of a lack of proper equipment and insufficient staff, and that the resident room floors should be stripped and waxed at least once a month. The Nursing Home Administrator later stated the resident room floors needed to be deep cleaned, stripped and waxed, or replaced entirely. Review of the facility policy stated floors shall be maintained in a clean, safe, and sanitary manner.
Medication Left at Bedside Without Self-Administration Order
Penalty
Summary
The facility failed to follow standards of practice for medication administration for one resident who was reviewed for medication administration. The resident was admitted with diagnoses including atrial fibrillation, hypertension, chronic obstructive pulmonary disease, anemia, cognitive communication deficit, and peripheral vascular disease. The resident’s MDS assessment showed a BIMS score of 15/15, indicating no cognitive impairment. The physician orders in the electronic record directed the resident to receive Vysulta Ophthalmic Solution 0.024% one drop in the left eye at bedtime, Combigan Ophthalmic Solution 0.2-0.5% one drop in both eyes every 12 hours, and saline nasal spray as needed. There were no orders allowing self-administration of medications, no interdisciplinary assessment for self-administration, and no care plan interventions related to self-administration. During three observations, the prescribed eye drops and nasal spray were seen at the resident’s bedside. The resident stated they self-administered the eye drops and nasal spray while the nurse administered other medications. An LPN stated the resident administered their inhalers and eye drops, confirmed there was no self-administration order, and said the medications had been dropped off at the bedside and then removed. The DON stated residents would be assessed for cognitive ability and return demonstration before self-administration was allowed, that a physician order would be obtained, and that the care plan would be updated; the DON also confirmed this resident did not have an assessment or physician order to self-administer medications.
Failure to Notify Physician of Repeated Elevated Blood Sugars
Penalty
Summary
The facility failed to notify the physician regarding multiple elevated blood sugar readings for a resident with diabetes mellitus type 2, congestive heart disease, and chronic obstructive pulmonary disease. The resident’s record showed intact cognition and a physician-ordered insulin lispro sliding scale before meals and at bedtime. Recorded blood sugars included values of 484 mg/dl, 482 mg/dl, 404 mg/dl, 480 mg/dl, 532 mg/dl, 430 mg/dl, and 500 mg/dl, and several of these readings had no corresponding nursing note or medical provider note documenting notification or follow-up. One nursing note for a blood sugar of 482 mg/dl documented that 26 units of insulin were administered and that the MD was aware. The care plan identified the resident as at risk for blood sugar fluctuations and directed staff to report abnormal blood sugar levels or changes in pattern to the physician for review and adjustment of the plan of care as directed. A referral to endocrinology documented uncontrolled diabetes with fluctuating high blood sugars, and the endocrinology consult later noted an A1c of 10.4% and increased insulin orders. During interviews, nursing staff stated they generally contacted the medical provider when blood sugars were over 400 if no parameters were set, and the DON stated that if no parameters existed, the physician should be contacted when blood sugar was higher than the sliding scale to obtain an order for additional insulin if needed. The DON and regional nurse consultant determined there were no current written instructions or orders for nurses to follow when the resident’s blood sugar exceeded the prescribed sliding scale, and the physician acknowledged that written guidance should have been communicated to nursing regarding when to contact the medical provider.
Inaccurate narcotic counts and missing signatures on controlled medication logs
Penalty
Summary
The facility failed to maintain accurate reconciliation records for controlled medications in two medication carts. During inspection of the 500 hall E-South cart with an LPN, the 2/11/26 narcotic reconciliation log was not signed by the on-coming nurse, and the count for R37’s MS Contin 30 mg was inaccurate: 12 pills were observed in the blister pack while the controlled substance reconciliation sheet documented 13 pills. The LPN stated she had given the medication to the resident that morning but forgot to sign it out, and confirmed that medications should be signed out when administered. Review of R37’s MAR showed the MS Contin 30 mg was prescribed and administered at the 9:00 AM dose. During inspection of the 200 hall B-North cart with another LPN, the 2/11/26 narcotic reconciliation log was also not signed by the on-coming nurse, and the count for R47’s oxycodone 10 mg was inaccurate: 5 pills were observed in the blister pack while the reconciliation sheet documented 6 pills. The LPN stated she had given the medication and forgot to sign it out, and confirmed that medications should be signed out when administered. Review of R47’s MAR showed the oxycodone 10 mg was prescribed and administered at the 9:00 AM dose. The DON later confirmed the facility’s policy required the narcotic count to be completed and signed at shift change, and that the nurse should sign out any narcotic at the time it is removed from the med cart.
Improper Storage of Unopened Insulin in Medication Carts
Penalty
Summary
The facility failed to store unopened insulin at the proper temperature in two medication carts reviewed for safe storage of medications and biologicals. On 2/11/2026 at 8:51 AM, during inspection of medication cart #1 on C-South Hall with an LPN, an unopened bottle of Humalog insulin was found in the cart at room temperature inside an unopened box and plastic bag labeled to keep refrigerated. Neither the box nor the bag had a delivery or received-on date. The LPN stated the insulin should be refrigerated and that there was no way to tell how long it had been at room temperature, adding that the bottle would have to be wasted. Later that same day at 9:54 AM, during inspection of medication cart #2 on E-South Hall with another LPN, an unopened bottle of Novolog insulin was found in the cart at room temperature inside an unopened box and plastic bag labeled to keep refrigerated, with no delivery or received-on date. A two-pack of unopened insulin Kwik-Pens was also found inside a plastic bag labeled to keep refrigerated, and neither the pens nor the bag had a delivery or received-on date. The LPN stated those items were supposed to be in the refrigerator and that there was no way to tell how long they had been at room temperature. The DON later confirmed the facility policy was to store medications according to manufacturer recommendations, including unopened insulin at proper temperature controls to maintain potency and effectiveness.
Failure to Perform Hand Hygiene During Blood Glucose Checks
Penalty
Summary
The facility failed to ensure appropriate hand hygiene was completed during resident care for one resident, R60, during blood glucose testing. On 2/10/2026 at approximately 11:20 AM, an LPN was observed performing blood glucose checks on the 500-unit hallway. The LPN sneezed in the hallway, did not perform hand hygiene, and continued down the hallway with a medication cart that had gloves, lancets, and a glucometer on top. Upon arriving at R60's room, the LPN donned gloves without performing hand hygiene, entered the room, and performed a blood glucose test on R60. After exiting the room, the LPN removed the gloves but did not perform hand hygiene. The same LPN then went to two additional resident rooms, and before entering each room to conduct blood glucose testing, did not perform hand hygiene and donned gloves. After each test, the LPN removed the gloves and again did not perform hand hygiene. R60 was admitted with diagnoses including type 2 diabetes mellitus, bipolar disorder, osteoarthritis, dementia, generalized anxiety disorder, and metabolic encephalopathy. The MDS with an ARD of 1/18/2026 showed a BIMS score of 9/15, indicating moderate cognitive impairment. The facility's Infection Preventionist/DON stated that hand hygiene should be completed before putting on gloves and entering a resident room, and after removing gloves when coming out of the room. The facility policy on Hand Hygiene stated that hand hygiene should be performed immediately before touching a resident, between all services to residents, after touching a resident or the resident's immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal.
Failure to Maintain Cleanliness of Food Service Equipment
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment, impacting 86 residents and increasing the likelihood of cross-contamination and bacterial harborage. During an initial tour of the food service area, several deficiencies were observed. The hand sink's water valves were misaligned, causing the handles to invade the sink basin. The garbage disposal's overhead spray faucet assembly had a leaking hot water supply valve and was covered with duct and electrical tape. Additionally, the Magic Cup chest freezer had accumulated ice, and the Frigidaire Freezer #6 was soiled with dirt and food residue. The Univex stand mixer and convection oven side panel were also found with encrusted food residue. The mechanical dish machine's exterior surfaces were heavily soiled with dust and dirt deposits. Record reviews of the facility's policies and procedures for freezer and mixer sanitation revealed that the equipment was not being cleaned and maintained according to the established guidelines. The freezer policy outlined a monthly defrosting and cleaning process, while the mixer policy detailed steps for thorough cleaning and sanitizing. These observations and record reviews indicate a failure to adhere to professional standards for food service equipment maintenance, as required by the 2017 FDA Model Food Code.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, staff, and visitors, as evidenced by multiple observations of unclean and poorly maintained areas throughout the facility. During an environmental tour, it was noted that the main entrance had uneven concrete surfaces, creating a tripping hazard. Additionally, several areas, including nursing stations, shower rooms, and dining rooms, were found to have missing or damaged components such as atmospheric vacuum breakers, flooring, and window screens. These deficiencies increase the risk of cross-contamination and bacterial harborage. In various halls, including B-Hall, C-Hall, D-Hall, and E-Hall, numerous issues were identified, such as worn and stained flooring, damaged cabinet drawers, loose and corroded grab bars, and heavily soiled air purification units and fans. The janitor closets and utility rooms were also found to be in poor condition, with missing tiles, soiled sinks, and non-functional ventilation systems. These conditions contribute to an unsanitary environment that could potentially affect the health and safety of the residents. The facility's maintenance work order system, TELS, did not have any specific entries related to these maintenance concerns over the past 60 days, indicating a lack of action in addressing these issues. The facility's policy on maintaining a clean and sanitary environment was not adhered to, as evidenced by the accumulated dust, dirt, and grime in various areas. This lack of effective cleaning and maintenance poses a significant risk to the well-being of the 86 residents affected by these deficiencies.
Failure to Implement Restorative ROM Program for Resident
Penalty
Summary
The facility failed to include a resident with limited range of motion (ROM) in the restorative program, as observed during a survey. The resident, who was unable to communicate effectively due to conditions following a stroke, was seen in a wheelchair with a right-hand splint. The resident's legal guardian reported that the resident was not receiving therapy services or exercises. A review of the resident's electronic health record showed a diagnosis of hemiplegia and hemiparesis, among other conditions, and a physical therapy discharge summary recommended a ROM program. However, there were no orders or care plans for such a program in the resident's records. Interviews with facility staff, including a CNA and the Director of Rehab, revealed that no ROM exercises were being performed with the resident, and there was no formal restorative program in place at the facility. The Director of Nursing confirmed the absence of a formal restorative program and acknowledged that the recommended ROM program was not implemented. The facility's policy on restorative care emphasized the need for interdisciplinary care planning and staff training, which was not followed in this case.
Failure to Prevent Resident with PICA from Accessing Nonfood Items
Penalty
Summary
The facility failed to ensure the safety of a resident with a known history of PICA, an eating disorder involving the consumption of nonfood items. The resident, who was nonverbal and had severe cognitive impairment, was observed in a reclining wheelchair in a common area. Despite the resident's complex medical history, including cerebral palsy, antiphospholipid syndrome, and dysphagia, the facility did not implement adequate interventions to prevent the resident from accessing nonfood items. This oversight led to the resident swallowing gauze, which required an emergency procedure to remove the foreign body from the esophagus. The incident occurred when the resident aspirated on gauze that had been around the PEG tube insertion site, leading to hospitalization. The Director of Nursing acknowledged that the potential for the resident to swallow the gauze had not been considered, and the care plan review revealed a lack of interventions to prevent contact with nonfood items. The facility's failure to address this risk resulted in the resident's emergency room visit and subsequent medical intervention.
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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 Monroe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monroe Springs Skilled Nursing And Rehab | 0.6 mi | ★★★★★ | 8 | 0 |
| Medilodge Of Monroe | 0.6 mi | ★★★★★ | 0 | 0 |
| Fountain View Of Monroe | 1.1 mi | ★★★★★ | 4 | 0 |
| Ihm Senior Living Community | 1.2 mi | ★★★★★ | 0 | 0 |
| Wellspring Lutheran Nursing And Rehab Services | 2.1 mi | ★★★★★ | 18 | 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 October 2026) and official state health department websites.