5 Reports
Inspection Report — Apr 23, 2025
Certification/complaint State
Date: Apr 23, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from 2022 to 2026 with citation and complaint history.
Complaint Details
The state logged 40 complaints about this facility; 7 led to on-site inspections. One citation resulted from those complaints.
Findings
Across 8 inspections, 4 had no citations and 4 resulted in 14 total citations including standard health and life safety code violations. The facility received 40 complaints with 7 on-site inspections and no formal enforcement actions.
Citations (13)
Standard Health Citation — quality of care: Dispose Garbage And Refuse Properly was cited with isolated minor potential harm.
Standard Health Citation — quality of care: Reporting Of Alleged Violations was cited with isolated minor potential harm.
Standard Health Citation — quality of care: Right To Be Free From Physical Restraints was cited with isolated minor potential harm in two inspections.
Standard Health Citation — quality of care: Right To Forms Of Communication W/ Privacy was cited with widespread potential for minimal harm.
Standard Health Citation — quality of care: Tube Feeding Mgmt/restore Eating Skills was cited with isolated minor potential harm.
Life Safety Code Citation — NFPA requirements: Stairways And Smokeproof Enclosures was cited with pattern minor potential harm.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan was cited with isolated minor potential harm.
Standard Health Citation — quality of care: Routine/emergency Dental Srvcs In Nfs was cited with isolated minor potential harm.
Life Safety Code Citation — NFPA requirements: Cooking Facilities was cited with widespread potential for minimal harm.
Life Safety Code Citation — NFPA requirements: Corridor - Doors was cited with isolated minor potential harm.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste was cited with widespread potential for minimal harm.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing was cited with pattern minor potential harm.
Standard Health Citation — quality of care: Reporting - National Health Safety Network was cited with widespread minor potential harm and not yet corrected.
Report Facts
Inspections on page: 8
Total citations: 14
Inspections with violations: 4
Inspections without violations: 4
Total complaints: 40
On-site complaint inspections: 7
Complaint citations issued: 1
Enforcement actions: 0
Inspection Report — Apr 23, 2025
Annual Inspection CMS
Date: Apr 23, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 04/15/2025 to 04/23/2025 to assess compliance with regulatory requirements for Sea View Hospital Rehabilitation Center and Home.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had reasonable access to communication methods (mail delivery on Saturdays), improper use of physical restraints, failure to timely report suspected abuse or injury to the state, inadequate verification of gastrostomy tube placement before medication administration, and improper disposal of garbage with uncovered compactors.
Citations (5)
Facility did not ensure residents had the right to send and promptly receive mail on Saturdays due to mailroom closure.
Facility did not ensure a resident was free from physical restraints imposed for discipline or staff convenience; Resident #153's bed was against the wall with side rails raised without proper orders or care plan.
Facility did not timely report an unwitnessed fall with major injury of Resident #264 to the New York State Department of Health.
Facility did not ensure appropriate care for a resident with a feeding tube; placement of gastrostomy tube was not verified before medication administration to Resident #44.
Facility did not ensure garbage and refuse were disposed of properly; waste compactor was uncovered when full, exposing garbage and attracting pests.
Report Facts
Residents sampled: 38
Residents affected by mail delivery deficiency: 8
Residents affected by physical restraint deficiency: 1
Residents affected by abuse reporting deficiency: 1
Residents affected by feeding tube medication administration deficiency: 1
Number of falls for Resident #153 in last year: 5
Medication administration observation date: Apr 17, 2025
Date of unwitnessed fall: Dec 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Observed Resident #153 and interviewed regarding bed placement and restraints | |
| Assistant Coordinating Manager | Interviewed regarding mail delivery procedures | |
| Administrator | Interviewed regarding mail delivery and restraint findings | |
| Resident Representative | Interviewed regarding mailroom hours and mail delivery | |
| Patient Care Technician #1 | Interviewed about Resident #153 bed placement | |
| Nurse Educator | Interviewed about restraint in-service and policy | |
| Chief Nursing Officer | Interviewed about restraint education, investigation of fall, and gastrostomy tube policy | |
| Certified Nursing Assistant #5 | Last saw Resident #264 before fall | |
| Director of Risk Management | Interviewed about investigation and reporting of Resident #264 fall | |
| Charge Nurse #4 | Interviewed about gastrostomy tube placement verification | |
| Registered Nurse #4 | Observed medication administration and interviewed about gastrostomy tube checks | |
| Assistant Director of Nursing #2 | Interviewed about gastrostomy tube placement verification and staff education | |
| Dietary Worker #1 | Observed removing garbage to compactor | |
| Food Service Director | Interviewed about garbage compactor condition and schedule | |
| Director of Environmental Service | Interviewed about garbage disposal and compactor maintenance | |
| Director of Facilities | Interviewed about compactor age and condition |
Inspection Report — Apr 7, 2025
Abbreviated Survey CMS
Date: Apr 7, 2025
Visit Reason
The abbreviated survey was conducted to investigate the use of physical restraints on residents, specifically regarding an incident where Resident #1 was found restrained with a bed sheet tied to the bed rail.
Complaint Details
The visit was complaint-related, investigating an incident where Resident #1 was found restrained with a bed sheet tied to the bed rail. The incident was substantiated but determined to be without mal-intent and did not cause harm.
Findings
The facility failed to ensure that Resident #1 was free from physical restraints used for discipline or convenience rather than medical necessity. The incident was verified, but no physical, emotional, or psychological harm was found. Corrective actions were taken promptly, including staff suspension, resignation, re-education, and ongoing monitoring, resulting in substantial compliance at the time of the survey.
Citations (1)
Failure to ensure that a resident was free from physical restraints imposed for discipline or convenience and not medically required.
Report Facts
Residents affected: 1
Staff in-serviced: 127
Staff in-serviced: 22
Staff in-serviced: 72
Monthly audits: 30
Total staff in-serviced: 221
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patient Care Technician #1 | Admitted to restraining Resident #1; suspended and resigned | |
| Patient Care Technician #2 | Notified nurse and removed restraint; suspended and resigned | |
| Registered Nurse #1 | Responded to restraint incident and assessed Resident #1 | |
| Registered Nurse Supervisor #1 | Assistant Director of Nursing | Conducted assessment and supervised staff |
| Director of Nursing | Oversaw investigation and corrective actions | |
| Administrator | Received report and met with involved staff | |
| Risk Manager | Conducted investigation and interviewed staff | |
| Nurse Practitioner #1 | Assessed Resident #1 after restraint incident |
Inspection Report — Feb 9, 2023
Complaint Investigation CMS
Date: Feb 9, 2023
Visit Reason
The inspection was conducted as a recertification and complaint survey from 2/2/23 to 2/9/23 to evaluate compliance with care planning and dental service provision for residents.
Complaint Details
The complaint investigation revealed that Resident #175 did not have a dental care plan despite multiple missing teeth and had not received routine dental services or annual dental examinations since 2020. Staff interviews confirmed lack of awareness of the resident's dental issues and failure to schedule dental appointments.
Findings
The facility failed to develop and implement a person-centered Comprehensive Care Plan (CCP) addressing dental needs for Resident #175, who had multiple missing teeth. Additionally, routine dental services, including annual dental examinations and follow-up for partial dentures, were not provided to the resident since 2020.
Citations (2)
Failure to develop and implement a complete care plan that meets all the resident's needs, including dental concerns.
Failure to provide or obtain routine dental services, including annual dental examinations and follow-up for partial dentures.
Report Facts
Residents reviewed for dental: 40
Residents affected: 1
Date survey completed: Feb 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding care plan development and dental scheduling |
| RD | Registered Dietitian | Interviewed regarding nutritional care plan and observation of resident's dental status |
| DON | Director of Nursing | Interviewed regarding care plan creation and dental examination scheduling |
| PCT #1 | Patient Care Technician | Interviewed regarding resident's dental status and meal assistance |
| PCT #2 | Patient Care Technician | Interviewed regarding awareness of resident's dental issues |
Inspection Report — Jan 31, 2020
Annual Inspection CMS
Date: Jan 31, 2020
Visit Reason
The inspection was conducted as a standard recertification survey to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in developing comprehensive person-centered care plans, specifically failing to address a resident's hearing impairment. Additionally, food safety violations were noted due to improper storage durations of sliced meats in the refrigerator beyond recommended timeframes.
Citations (2)
Failure to develop and implement a complete care plan that meets all the resident's needs, specifically for a resident with hearing difficulty.
Failure to store, prepare, distribute and serve food in accordance with professional standards; sliced meats stored beyond recommended timeframes.
Report Facts
Residents sampled: 38
Days sliced meats stored: 6
Days turkey stored: 4
Recommended maximum days for leftovers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patient Care Technician (PCT) | Interviewed regarding resident's hearing aid use | |
| Registered Nurse (RN 1) | Interviewed regarding absence of hearing care plan for Resident #214 | |
| Assistant Director of Nursing | Interviewed regarding hearing care plan oversight | |
| Food Service Supervisor | Interviewed regarding food storage and discard procedures | |
| Food Service Director | Interviewed regarding monitoring and quality assurance of food safety |
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