Seal Rock Healthcare

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that the resident and/or resident representative was provided with written information, concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, was completed for 10 of 23 residents reviewed for advance directives (Resident #1, #6, #8, #17, #36, #50, #89, #103, #107, and #110). 1. Resident #1 was admitted to the facility in January of 2026. A review of the resident's electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 2. Resident #6 was admitted to the facility in May of 2015. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident remained free of misappropriation of property in the form of theft of a resident's personal credit card and multiple unauthorized purchases for 1 of 27 residents screened for abuse and misappropriation in the initial pool.

Inspectors wroteBased on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to a patient lift on 1 of 1 unit and the storage of chemicals being properly secured for 1 of 1 observation for 1 of 4 days of survey. (3/30/26 through 4/2/26)

Inspectors wroteBased on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to ensure that the CNA attended the mandatory yearly Abuse and Neglect along with Resident Rights training for 1 of 6 CNA's reviewed. Furthermore, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training for 1 of 6 randomly selected CNAs employed greater than 1 year. (CNA #1)

Inspectors wroteBased on observations and interviews, the facility failed to adequately maintain maintenance services necessary to maintain in good repair. On 4/1/26 at 12:40 an environmental tour was done with the Administrator and the Director of Maintenance and the following were found and confirmed at that time. First floor - room [ROOM NUMBER] - the floor threshold between the room and the bathroom has duct tape on each side, creating an uncleanable surface. Second floor - room [ROOM NUMBER], the wall on the right upon entrance has many small gouges in it from her wheelchair. The are also abrasions on the wall behind her lift chair from it rubbing the wall when it rises. room [ROOM NUMBER], the wall in the bathroom has a hole just below the towel rack.

Inspectors wroteBased on observations, interviews and record review, the facility failed to identify and implement isolation/contact precautions for residents who were exhibiting symptoms of gastroenteritis and failed to follow the Nurse Practitioner's recommendation to ensure that Personal Protective Equipment (PPE) supplies were available for use for these residents. In addition, the facility failed to ensure all staff were knowledgeable about which residents were experiencing these symptoms and ensure PPE were used while providing care. This resulted in the spread of gastroenteritis [nflammation that spreads from your stomach into your intestines, causing pain, vomiting and diarrhea symptoms] (GI) symptoms creating an immediate jeopardy situation to 17 out of 90 residents', on 6 of 7 units: Eagle Island, Ram Island, Bluff Island, [NAME] Islan, Beach Island and Gooseberry Island. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure nursing staff immediately initiated isolation/contact precautions for residents who were exhibiting symptoms of gastroenteritis (GI) (i.e. diarrhea, vomiting, abdominal pain, and/or fever) and ensure that Personal Protective Equipment (PPE) supplies were available for use for these residents. This has resulted in the spread of GI symptoms throughout the facility which began on 3/24/25 and Norovirus being confirmed on 4/2/25.

Inspectors wroteBased on interviews, observations and record review the Administration failed to follow the facility's Infection - Clinical Protocol policy and procedures by not following the Family Nurse Practitioner's (FNP) recommendation of isolation/contact precautions for residents who were exhibiting symptoms of gastroenteritis (GI) (i.e. diarrhea, vomiting, abdominal pain, and/or fever) and ensure that Personal Protective Equipment (PPE) supplies were available for use for these residents. In addition, Administration failed to ensure the infection Preventionist was following the facilities Infection prevention and Control Program which included oversight, outbreak management, prevention of infection and monitoring employee health and safety. This has resulted in the spread of GI symptoms throughout the facility. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that resident's Power of Attorney (POA) was notified of a significant change in medical condition for 1 of 2 residents reviewed for Respiratory Syncytial Virus (RSV) (Resident #29).

Inspectors wroteBased on record review and interviews, the facility failed to ensure a physician order was followed for 1 of 1 resident reviewed for diabetes management. (Resident #29)

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition on 2 of 7 units, for 1 of 1 Environmental Tours. (Bluff Island and [NAME] Island).

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 8 of 27 residents reviewed for care plans (#24, #31, #52, #57, #58, #65, #324 and #374).

Inspectors wroteBased on record review, observation and interviews, the facility failed to adequately store controlled substances in a permanently affixed compartment and double locked in 1 of 2 medication rooms observed, failed to date and/or store biological's after opened and according to manufacturer specifications and failed to dispose of expired medications on 3 of 3 units observed. (Eagle Island/Ram Island, Bluff Island/[NAME] Island and Beach Island/Gooseberry Island)

Inspectors wroteBased on record reviews and interviews, and Facility Reported Incident review, the facility failed to ensure that clinical records were complete and contained accurate information for 4 of 4 sampled residents reviewed for medications (Resident(s)#24, #31, #48 and #374).

Inspectors wroteBased on review of the 8/17/2022 statement of deficiencies and plan of correction (POC) in effect from the annual Long Term Care Survey Process, record review and interview, the facility's Quality Assurance Performance Improvement committee failed to ensure that the plan of correction was followed and effective for F761.

Inspectors wroteBased on observations and interview, the facility failed to maintain a clean/sanitary environment on 3 or 7 units observed (Ram Island, Bluff Island and [NAME] Island) for 3 of 3 days of survey.

Inspectors wroteBased on observation and record review, the facility failed to ensure that Activity of Daily Living (ADL) assistance was provided to 1 of 1 Resident (#374) reviewed for ADLs on 2 of 3 survey days.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide respiratory services as directed by physician orders related to humidification for 1 of 4 residents reviewed who received oxygen services (Resident #48).

Inspectors wroteBased on record reviews and interviews, the facility failed to issue a written transfer/discharge notice to a resident or their legal representative for a facility-initiated transfer/discharge for 2 of 2 sampled residents transferred/discharged to an acute care facility (#58 & #374).

Inspectors wroteBased on record reviews and interviews, the facility failed to issue a written bed hold notice to a resident, known family member or legal representative for 2 of 6 sampled residents who had been transferred to an acute care facility (#58, #374). Findings 1. Documentation in Resident #58''s clinical record indicated that he/she transferred to an acute care hospital on 7/10/22 and subsequently admitted . The clinical record contained no evidence that the facility issued a written bed hold notice to the resident, a family member, or legal representative upon transfer. On 7/27/22 at 11:12 a.m., a surveyor confirmed the finding in an interview with the Director of Social Services. 2. Documentation in Resident #374's clinical record indicated that he/she was transferred to an acute care facility on 7/15/22 and subsequently admitted . [...]

Inspectors wroteBased on observation and interview, the facility failed to post the current daily nurse staffing information that includes the facility name, day of the month, a breakdown of the number of registered and licensed nursing staff responsible for direct resident care and indicate which shifts the numbers corresponded to for facility census for 3 of 3 survey days.

Inspectors wroteBased on observations and interviews, the facility failed to safely secure drugs and biologicals on 3 of 7 wings during 2 of 4 survey days. Furthermore, the facility failed to ensure that drugs and biologicals were dated when opened, and expired medication removed, from 2 of 4 medication storage refrigeration units on 1 of 4 days of survey.

Inspectors wroteBased on record review and interviews, the facility failed to inform a resident or their representative, in advance, of treatment risks and benefits, options, and alternatives related to use of an antipsychotic medication for 1 of 25 sampled Residents (#47).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident's choice in the area of bathing frequency were being followed for 1 of 15 resident/family interviewed (Resident #65).

Inspectors wroteBased on observations and interview, the facility failed to provide services to a resident necessary to attain the highest practicable level of care related to positioning during 1 of 4 observed meal services (Resident #19).