Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Seacoast Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions developed a contracture in the right hand after staff failed to recognize, document, and address a decline in range of motion. Despite observations of pain and functional limitations, there was no timely referral to therapy or notification of medical providers, resulting in the resident's condition worsening before appropriate intervention was initiated.
A resident with congestive heart failure and moderate cognitive impairment was given Lasix and spironolactone on multiple occasions despite physician orders to hold these medications if systolic blood pressure was below 110. Nursing staff and leadership confirmed that medication parameters were not followed, resulting in significant medication errors.
Staff failed to properly disinfect shared medical equipment, such as glucometers, between uses and did not follow manufacturer or facility guidelines for cleaning and disinfection. Additionally, Enhanced Barrier Precautions were not implemented for a resident with a stage 3 pressure ulcer, as required by policy, with staff not using gowns during wound care and lacking clear documentation or signage for EBP.
A resident with severe cognitive impairment and a history of Alzheimer's Disease and adjustment disorder received PRN trazodone for anxiety over several months without the required 14-day reassessment or documentation of a reassessment date, contrary to facility policy. Nursing staff and the DON confirmed that such reassessments are required but were not completed in this case.
A resident with severe cognitive impairment was found with a soiled, undated dressing on a skin tear, and staff interviews confirmed that a nurse applied the dressing several days prior without obtaining a physician's order. The medical record lacked documentation of the wound or treatment orders, and the required physician order was only obtained after the issue was identified by surveyors.
A resident with severe cognitive impairment and dependence on staff for meals experienced significant weight loss over two months, but the facility failed to identify and address this in a timely manner. Despite policy requiring prompt referral to a dietitian for notable weight changes, the resident was not assessed by the dietitian until over a month after the weight loss was documented. Staff interviews indicated a lack of awareness and insufficient communication regarding the resident's nutritional status.
A nurse prepared a dose of miralax for a resident and left the unlabeled cup unattended on the nurses' station counter during a medication pass. The cup, which resembled a regular cup of water, remained unsupervised for an extended period while several residents, including one with dementia who wandered behind the nurses' station, passed by and touched items on the counter. Staff interviews confirmed that medications should not be left unattended or tasted to confirm their identity.
A resident with protein-calorie malnutrition and dysphagia was repeatedly served foods such as eggs, white bread, toast, and broccoli, despite these being clearly listed as dislikes on the meal slip and care plan. Staff and dietary personnel acknowledged that food preferences should be honored and that the process requires checking meal slips, but the resident continued to receive these items multiple times per week without being offered substitutions or asked for preferences.
A resident with an indwelling catheter and a history of polyuria did not have urinary output documented as ordered on multiple shifts, despite facility policy and physician orders requiring regular monitoring and documentation. Review of records showed several missed entries, and the unit manager confirmed that documentation should have occurred.
A resident was observed self-administering medications without a proper assessment or physician's order, contrary to facility policy. Despite being cognitively intact, the resident had not been approved to self-administer medications. Nurse #2 left medications for the resident to self-administer without supervision, and interviews revealed a lack of adherence to the facility's policy. The DON confirmed that the resident was assessed as unable to self-administer medications, yet this was not reflected in practice.
The facility failed to implement care plans for two residents, resulting in non-compliance with physician orders. One resident did not receive prescribed compression stockings, and another was not provided with pressure-relieving boots, despite both having specific medical needs. Staff interviews confirmed these oversights, with no documentation of resident refusal.
A resident with Parkinson's, dysphagia, and impaired cognition was not provided with necessary assistance during meals, as required by their care plan and physician's orders. Observations showed the resident eating alone without staff supervision, despite needing help with utensils and ensuring proper nutrition. Interviews confirmed that staff were expected to follow the care plan, but this was not done, leading to a deficiency.
Failure to Prevent Decline in Range of Motion Leading to Contracture
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, apraxia, and polymyalgia rheumatica experienced a decline in range of motion (ROM) in the right hand, resulting in the development of a contracture. The facility's policy required that residents not experience avoidable reductions in ROM and that any changes be addressed with appropriate interventions, including therapy referrals and notification of medical providers. Despite these requirements, the resident's medical record did not document any limitation in ROM of the right hand prior to the surveyor's observations, nor was there evidence of timely assessment or intervention as the resident's condition changed. Surveyor observations revealed that the resident was unable to fully extend the third through fifth fingers of the right hand, with visible pain and functional limitations during attempts to open the hand. Interviews with staff indicated a lack of awareness regarding the resident's decline in ROM, and the resident's health care proxy reported noticing the issue weeks prior and informing nursing staff, but no documented follow-up or referral was made at that time. The occupational therapy screen from several months earlier noted full ROM, but no subsequent evaluation was performed until prompted by the surveyor's findings. Further interviews confirmed that key staff, including the unit manager, director of rehabilitation, and nurse practitioner, were not notified of the resident's change in status until the surveyor's intervention. The occupational therapist, upon evaluation, confirmed a new contracture affecting the right hand. The lack of timely recognition, documentation, and intervention for the resident's decline in ROM led to the development of a contracture, contrary to facility policy and professional standards.
Failure to Hold Medications for Low Blood Pressure
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure and moderate cognitive impairment was administered medications despite physician orders specifying blood pressure parameters. The resident's orders for Lasix and spironolactone included instructions to hold the medications if the systolic blood pressure (SBP) was less than 110. However, multiple entries in the Medication Administration Record (MAR) over several months showed that the resident received these medications even when their SBP was below the prescribed threshold. Nursing staff interviews confirmed that they were expected to check and follow medication parameters before administration. Despite this expectation, the MAR documented several instances where the resident was given Lasix and/or spironolactone when their SBP was less than 110, contrary to the physician's orders. Facility leadership, including the unit manager and Director of Nursing, acknowledged that these parameters should have been followed and that the medications should have been held when the resident's blood pressure was below the specified limit.
Failure to Maintain Infection Control Program and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper disinfection of shared resident medical equipment and non-adherence to infection control guidelines during medication administration. Specifically, a nurse was observed using a glucometer on multiple residents without proper cleaning and disinfection between uses. The nurse placed the glucometer and related supplies in a container that was set on uncleaned surfaces in resident rooms, and did not use the manufacturer-recommended bleach wipes or follow the required contact time for disinfection. Instead, alcohol hand wipes were used, and the nurse was unaware of the correct procedures for cleaning the glucometer and the importance of not bringing contaminated equipment into resident rooms. Interviews with staff revealed inconsistent knowledge and application of infection control policies, including the use of appropriate disinfectants and adherence to contact times. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage 3 pressure ulcer. The resident, who had intact cognition and was admitted with multiple diagnoses including a pressure wound, did not have EBP signage on the room door, and the care plan and physician orders did not indicate the use of EBP. During a wound dressing change, the nurse wore gloves but did not don a gown, contrary to facility policy and CDC guidelines for residents with wounds. Staff interviews revealed confusion regarding the criteria for EBP, with some staff believing it was only necessary for infected wounds, while facility policy and the DON stated that EBP should be used for any resident with wounds or indwelling devices. The findings were based on direct observation, staff interviews, and review of facility policies, manufacturer guidelines, and resident records. The lack of adherence to established infection control protocols and inconsistent staff knowledge contributed to the deficiencies identified in the infection prevention and control program.
Failure to Reassess PRN Psychotropic Medication Order After 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not reassessing a PRN (as needed) order for trazodone after 14 days, as required by facility policy. The policy states that PRN orders for psychotropic medications, excluding antipsychotics, must be reassessed after 14 days, and if continued, the physician must document the rationale and specify the duration. In this case, a resident with Alzheimer's Disease and adjustment disorder, who had severe cognitive impairment, was prescribed PRN trazodone for anxiety without a stop date. The medication administration records showed that the resident received PRN trazodone 19 times over several months, but there was no documentation in the physician or nurse practitioner notes indicating that the order was reassessed or that a reassessment date was added. Interviews with nursing staff and the DON confirmed that all PRN psychotropic medications should be reassessed after 14 days and have an end or reassessment date, but this was not done for the resident in question.
Failure to Obtain and Implement Physician Order for Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to obtain and implement a physician's order for the treatment of a skin tear sustained by a resident with severe cognitive impairment, including Parkinson's disease and dementia. The resident was observed with a visibly soiled, undated foam dressing on the right forearm, and was unable to communicate details about the injury or the dressing. Review of the medical record from the relevant period showed no documentation of the skin tear, no physician's order for wound treatment, and no evidence that appropriate wound care was implemented. Interviews with staff revealed that the dressing was applied by a nurse several days prior without a physician's order, and the dressing may not have been changed since its initial application. The unit manager confirmed that the order for wound treatment was not obtained until at least three days after the injury, only after the issue was identified by the surveyor. Facility policy and state nursing guidelines require physician orders for wound treatments, which were not followed in this instance.
Failure to Timely Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify and address a significant weight loss in one resident who was severely cognitively impaired and dependent on staff for meals. Despite facility policy requiring referral to a dietitian for weight changes of 5% in one month or 10% in six months, the resident experienced an 8% weight loss over approximately two months. The resident's weight dropped from 126.3 lbs to 116.2 lbs between late December and late February, but the dietitian was not notified or did not assess the resident for this weight loss until early April, 39 days after the significant loss was first documented. During this period, the resident was prescribed nutritional supplements and appetite-stimulating medication, but there was poor acceptance of oral nutritional supplements and variable meal intake. Staff interviews revealed a lack of awareness of the resident's weight loss among CNAs and a reliance on electronic reports for communication between nursing and the dietitian, with minimal verbal communication. The dietitian stated she was unaware of the significant weight loss in February and had not assessed the resident until April. The delay in assessment and intervention was attributed to missed recognition of the weight loss in the electronic reporting and lack of timely communication between staff and the dietitian.
Unattended Medication Left at Nurses' Station
Penalty
Summary
A deficiency occurred when a nurse prepared a dose of miralax mixed in water for a resident during a morning medication pass and left the unlabeled cup on top of the medication cart. When the resident was unavailable to take the medication, the nurse placed the cup containing miralax on the counter at the nurses' station and left it unattended. The cup, which appeared to be a regular cup of water, remained on the counter for an extended period without supervision, during which time several residents, including one who walked behind the nurses' station and touched items on the counter, passed by the unattended medication. Interviews with the nurse, unit manager, and DON confirmed that medications should not be left unattended or unlabeled, and that staff should not taste medication to identify it. The nurse admitted to leaving the miralax unattended and to tasting the contents to confirm its identity after the surveyor pointed it out. The unit manager noted that residents on the unit have dementia and may wander, increasing the risk of accidental ingestion. The DON reiterated that medications must be stored securely and not left accessible to residents or staff.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the documented food preferences of a resident with a history of protein-calorie malnutrition and dysphagia. Despite clear documentation on the resident's meal slip and care plan indicating specific food dislikes—including eggs, white bread, toast, and broccoli—these items were repeatedly served to the resident. The resident reported that these foods were provided multiple times per week, and that staff did not offer substitutions or ask for meal preferences prior to serving. Observations confirmed that the resident was served scrambled eggs and white bread toast for breakfast, and broccoli for lunch, all of which were listed as dislikes on the meal slip. The resident expressed distress about receiving these foods, stating that eggs caused stomach upset and diarrhea, and that staff were aware of these preferences. The meal slips on the trays clearly indicated the resident's dislikes, yet the items continued to be served. Interviews with staff, including CNAs, the unit manager, dietary staff, the dietitian, and the DON, all confirmed that food preferences should be honored and that the process requires checking meal slips before serving trays. Staff acknowledged that disliked foods are sometimes missed and served, and that the expectation is to notify the kitchen if this occurs. The dietitian was unaware of the resident's specific reaction to eggs but confirmed that eggs should not have been served due to the documented dislike. There were no food shortages that would have necessitated serving the disliked items.
Failure to Document Urinary Output for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to document urinary output as ordered for one resident who had an indwelling catheter. According to the facility's own policies, residents with indwelling catheters are to have their urinary output assessed and documented at regular intervals. The resident in question was admitted with diagnoses including venous insufficiency and polyuria, and was cognitively intact. Physician orders and the resident's care plan specifically required monitoring and documentation of urinary output each shift. A review of the Treatment Administration Records (TAR) for April and May revealed multiple instances where the resident's urinary output was not documented as required. Specifically, there were missing entries for several shifts across both months. During an interview, the unit manager confirmed that staff should have been documenting the output as ordered, but this was not consistently done.
Failure to Assess and Approve Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #9, did not self-administer medications without a proper assessment and physician's order. Resident #9, who was admitted with diagnoses including arthritis, heart failure, and asthma, was observed self-administering medications on multiple occasions. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status exam, Resident #9 had not been assessed or approved to self-administer medications according to the facility's policy. The facility's policy requires an interdisciplinary team to assess a resident's ability to safely self-administer medications and document the outcomes. However, the most recent assessment for Resident #9, dated February 20, 2024, indicated that the resident did not wish to self-administer medications and was not approved to do so. Despite this, Nurse #2 was observed leaving medications for Resident #9 to self-administer without supervision on two separate occasions. The medications included a variety of prescriptions for conditions such as COPD, pain, hypertension, and depression. Interviews with Nurse #2 and the Director of Nursing (DON) revealed a lack of awareness and adherence to the facility's policy regarding self-administration of medications. Nurse #2 admitted to regularly allowing Resident #9 to self-administer medications without knowing if an assessment had been completed. The DON confirmed that a self-administration assessment should be conducted upon admission and quarterly, with updates to the resident's care plan and physician's orders if self-administration is deemed appropriate. However, the assessment for Resident #9 had determined the resident was unable to self-administer medications, yet this was not reflected in practice.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to implement resident-centered care plans for two residents, leading to deficiencies in care. For one resident, who was admitted with diagnoses including nephrotic syndrome and orthostatic hypotension, the facility did not apply thigh-high compression stockings as ordered by the physician. Despite the resident's intact cognition and no documented refusal, observations on multiple occasions showed the resident without the prescribed stockings while out of bed. Interviews with staff confirmed that the compression stockings should have been applied according to the care plan and physician's orders. Another resident, admitted with conditions such as Parkinson's disease and hemiplegia, was not provided with pressure-relieving boots while in bed, as ordered by the physician. This resident was at high risk for pressure ulcers, yet observations revealed the boots were not worn and were instead found on the floor in the closet. Staff interviews corroborated that the boots were necessary to prevent pressure ulcers and should have been applied as per the care plan. There was no documentation of the resident refusing the boots, indicating a lapse in following the prescribed care plan.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for a resident who required help with meals. The resident, admitted in August 2023, had diagnoses including Parkinson's disease, dysphagia, hemiplegia, and hemiparesis, and was assessed to have moderately impaired cognition. Despite these conditions, the resident was observed multiple times eating meals without any staff present to provide the required assistance or supervision, as outlined in their care plan and physician's orders. The resident's care plan and physician's orders clearly indicated the need for staff assistance during meals, including help with manipulating utensils, opening containers, and ensuring proper nutrition intake. However, observations on several occasions revealed that the resident was left alone during meal times, contrary to the care plan and physician's orders. Interviews with the Unit Manager and Director of Nurses confirmed that staff were expected to follow the care plan and physician's orders, yet this was not adhered to, resulting in a deficiency in care provided to the resident.
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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 Gloucester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oceanside Rehabilitation And Nursing Center | 4.3 mi | — | 0 | 0 |
| Care One At Essex Park | 10.1 mi | — | 0 | 0 |
| Blueberry Hill Rehabilitation And Healthcare Ctr | 10.6 mi | — | 12 | 0 |
| Ledgewood Rehabilitation And Nursing Center | 10.7 mi | — | 0 | 0 |
| Brentwood Rehabilitation And Healthcare Ctr (the) | 13 mi | — | 0 | 0 |
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