Seabury

In the surveyor’s words

From the most serious findings on record at Seabury, in the surveyor’s own words.

• Immediate jeopardy, patternF689Dec 18, 2025

  Based on observations, interviews, review of facility documentation and policy, the facility failed to ensure residents were free from potential burns after high water temperatures were identified but the facility failed to take action directed toward resident safety resulting in immediate jeopardy. The findings include:Observation on 12/10/25 at 10:30 AM identified hot water temperatures exceeded 120 degrees Fahrenheit (F) in 30 out of 61 rooms observed. Water temperatures ranged from 120.2 degrees F to 131.2 degrees F.Interview with the Director of Engineering and Campus Safety on 12/10/25 at 11:46 AM identified that he was aware the facility had an ongoing issue with high hot water temperatures. […]

• Actual harm, isolatedF689Mar 23, 2021

  Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #1) reviewed for wandering, the facility failed to ensure the wanderguard system was checked for functioning which resulted in an accident with injuries. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], dementia, [CONDITION(S)], a history of falls and status post clavicle fracture. Hospice services were requested by the family. […]

• No harm, potential for more than minimal, widespreadF812Mar 21, 2024

  Based on observation in the Dietary Department, staff interview, and facility policy, the facility failed to ensure food items were labeled and dated, and failed to ensure an adequately clean water filter system for the steam receptacles. The findings include: During a tour of the Dietary Department on 3/15/24 at 10:38 AM with the Executive Chef the following was identified: a. A 40-gallon plastic bin containing loose sugar (approximately 1/4 full) failed to identify the date the sugar was poured into the bin and failed to identify the expiration date of the sugar. b. A 40-gallon plastic bin containing loose rice flour (approximately 1/3 full) failed to identify the date the rice flour was poured into the bin and failed to identify the expiration date of the rice flour. c. […]

• No harm, potential for more than minimal, patternF585Dec 18, 2025

  Based on interviews, observations, and facility policy, the facility failed to ensure the Grievance policy was in view for residents in wheelchairs, failed to ensure access to grievance forms, and failed to ensure residents had an awareness of the purpose of filing a grievance, and for the only sampled resident (Resident #32) reviewed for dignity, the facility failed to follow their grievance policy. The findings include:1.On 12/15/25 at 1:30 PM a meeting of residents who regularly attended Resident Council meetings (Resident #'s 21, 32, 45, 48, 58, 65, and 66), failed to identify awareness of the purpose or use of a grievance form. […]

• No harm, potential for more than minimal, patternF804Dec 18, 2025

  Based on observation, review of the clinical record, and facility policy during an observation of dining services, the facility to ensure meals delivered to residents on the unit were served at the appropriate temperature. The findings include: Resident #9's diagnoses included dysphagia (oral phase), vitamin D deficiency (unspecified), and vascular dementia.Interview on 12/10/25 at 11:37 AM with Resident #9 identified that the food that was served was noted to be cold on a hot plate.Observation in the kitchen on 12/16/25 at 7:30 AM identified the temperature of a ham and cheese frittata to be 187.9 degrees Fahrenheit ( F) prior to leaving the kitchen. […]