Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
47% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Abbreviated Survey
Deficiencies: 3
Oct 8, 2025
Visit Reason
The inspection was conducted as an abbreviated survey to investigate resident-to-resident abuse incidents and to assess compliance with care planning and abuse prevention regulations.
Findings
The facility failed to protect residents from resident-to-resident abuse resulting in actual harm and death, failed to develop and provide baseline care plans within 48 hours of admission, and did not timely review and revise care plans after incidents. Immediate Jeopardy was identified and later lifted after corrective actions including policy revisions, staff education, and audits.
Complaint Details
The visit was complaint-related due to allegations of resident-to-resident abuse resulting in serious injury and death. The facility's investigation confirmed abuse by Resident #2 against Resident #1, and other altercations involving Residents #3, #4, #7, and #8. Immediate Jeopardy was declared and later lifted after corrective actions.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to create and implement a baseline care plan within 48 hours of admission for Resident #2, including failure to provide a summary of the baseline care plan to the resident or their representative. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop the complete care plan within 7 days of the comprehensive assessment and to have it prepared, reviewed, and revised by a team of health professionals. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled for abuse: 12
Residents assaulted: 4
Staff in-service attendance: 30
Staff in-service attendance: 38
Staff in-service attendance: 159
Resident wheelchairs inspected: 358
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #2 | Discovered Resident #1 bleeding after assault. | |
| Licensed Practical Nurse #1 | Responded immediately to Resident #1 after assault. | |
| Registered Nurse Supervisor #1 | Responded to Resident #1's room and applied first aid. | |
| Director of Nursing | Conducted investigation and reported abuse; involved in corrective action plans. | |
| Administrator | Notified of incident and involved in review of video surveillance and corrective actions. | |
| Registered Nurse Supervisor #5 | Assessed Resident #7 after altercation and documented findings. | |
| Registered Nurse Supervisor #2 | Admitted Resident #2 and initiated baseline care plan. | |
| Director of Social Work | Discussed baseline care plan responsibilities and family communication. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Oct 28, 2024
Visit Reason
Complaint Survey with 2 health and 7 life safety code deficiencies, all Level 2, mostly isolated and corrected by late 2024.
Findings
Complaint Survey with 2 health and 7 life safety code deficiencies, all Level 2, mostly isolated and corrected by late 2024.
Deficiencies (9)
| Description | Severity |
|---|---|
| Activities meet interest/needs each resident | Level 2 |
| Sufficient nursing staff | Level 2 |
| Electrical systems - essential electric system | Level 2 |
| Hazardous areas - enclosure | Level 2 |
| Illumination of means of egress | Level 2 |
| Maintenance, inspection & testing - doors | Level 2 |
| Means of egress - general | Level 2 |
| Physical environment | Level 2 |
| Subdivision of building spaces - smoke barrier | Level 2 |
Inspection Report
Complaint Investigation
Census: 353
Capacity: 360
Deficiencies: 1
Oct 28, 2024
Visit Reason
The inspection was conducted as a Recertification and Complaint Survey triggered by complaints regarding insufficient nursing staff and inadequate resident care.
Findings
The facility failed to ensure sufficient nursing staff to meet residents' needs, resulting in delayed care and inadequate supervision, especially on weekends and evening shifts. Multiple staff and residents reported shortages of Certified Nursing Assistants and nurses, leading to residents not receiving timely care and medication.
Complaint Details
Complaints included unsafe staffing levels with fewer Certified Nursing Assistants than required, residents left in soiled conditions, delayed medication administration due to nurse absence, and residents left sitting in hallways with a smell of urine. Resident #97 and Resident #443's representative reported inadequate care and pressure ulcers due to staffing shortages.
Deficiencies (1)
| Description |
|---|
| Insufficient nursing staff to meet the needs of every resident; licensed nurse not consistently present on each shift. |
Report Facts
Facility capacity: 360
Average daily census: 353
Certified Nursing Assistants needed per shift: 40
Licensed Practical Nurses needed per shift: 10
Registered Nurses needed per shift: 5
Certified Nursing Assistants needed per shift: 30
Licensed Practical Nurses/Registered Nurses needed per shift: 10
Registered Nurse Supervisors needed per shift: 2
Certified Nursing Assistants needed per shift: 22
Licensed Practical Nurses/Registered Nurses needed per shift: 10
Registered Nurse Supervisors needed per shift: 1
Certified Nursing Assistants on unit: 3
Certified Nursing Assistants short per unit: 1
Staffing rating: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Reported frequent absence of charge nurse and staffing shortages on evening shifts. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Reported frequent absence of nurse on unit and staffing shortages. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Reported short staffing on evening and night shifts and prioritizing residents needing most help. |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Worked day and evening shifts, reported staffing shortages when regular CNAs called out. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Reported consistent shortage of CNAs on weekends and delays in resident feeding and nurse relief. |
| Registered Nurse #1 | Registered Nurse | Reported scheduled CNAs sometimes reduced due to escorts or call outs and impact on resident care. |
| Corporate Staffing Manager | Corporate Staffing Manager | Described staffing policies, use of staffing agency, and efforts to cover call outs. |
| Director of Nursing | Director of Nursing | Described daily staffing review meetings, job fair efforts, and coverage during nurse absences. |
| Administrator | Administrator | Described response to staffing complaints and efforts to maintain adequate staffing levels. |
Inspection Report
Annual Inspection
Census: 353
Capacity: 360
Deficiencies: 2
Oct 28, 2024
Visit Reason
The inspection was conducted as a Recertification and Complaint Survey to assess compliance with regulatory requirements, including review of activities programming and nursing staff sufficiency.
Findings
The facility failed to provide activities that met the cultural and language preferences of Resident #287, specifically lacking Cantonese language programming and devices. Additionally, the facility did not ensure sufficient nursing staff on all shifts, with documented low weekend staffing and a 1-star staffing rating, resulting in delayed care and unmet resident needs.
Complaint Details
The complaint investigation revealed concerns about unsafe staffing levels, residents not receiving timely care, lack of nurse presence on some shifts, and residents being left in soiled conditions. The complaint was substantiated with evidence of low staffing and care deficiencies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility did not provide an ongoing program to support residents in their choice of activities, specifically Resident #287 was not provided activities in their preferred language (Cantonese). | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure sufficient nursing staff to meet the needs of residents, with low weekend staffing and 1-star staffing rating, resulting in delayed care and inadequate supervision. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Total licensed capacity: 360
Average daily census: 353
Number of television channels: 50
Certified Nursing Assistants needed per shift: 40
Certified Nursing Assistants needed per shift: 30
Certified Nursing Assistants needed per shift: 22
Licensed Practical Nurses needed per shift: 10
Registered Nurses needed per shift: 5
Registered Nurse Supervisors needed per shift: 2
Registered Nurse Supervisors needed per shift: 1
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #11 | Certified Nursing Assistant | Interviewed regarding Resident #287's activities and language preferences |
| Recreation Therapist #2 | Recreation Therapist | Interviewed about recreation assessments and activity programming for Resident #287 |
| Director of Recreation | Director of Recreation | Interviewed about facility television channels and activity devices for Resident #287 |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about staffing shortages and nurse availability on shifts |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed about staffing shortages and nurse availability on shifts |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed about staffing shortages and nurse availability on shifts |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Interviewed about staffing shortages and nurse availability on shifts |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about staffing shortages and impact on resident care |
| Registered Nurse #1 | Registered Nurse | Interviewed about staffing shortages and impact on resident care |
| Corporate Staffing Manager | Corporate Staffing Manager | Interviewed about staffing policies and efforts to address shortages |
| Director of Nursing | Director of Nursing | Interviewed about staffing reviews, shortages, and corrective actions |
| Administrator | Administrator | Interviewed about staffing concerns and facility efforts to maintain adequate staffing |
Inspection Report
Capacity: 60
Deficiencies: 1
Mar 11, 2024
Visit Reason
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
Feb 20, 2024
Visit Reason
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
Feb 12, 2024
Visit Reason
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
Feb 6, 2024
Visit Reason
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
Jan 30, 2024
Visit Reason
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
Jan 22, 2024
Visit Reason
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
Jan 8, 2024
Visit Reason
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Capacity: 60
Deficiencies: 1
Jan 2, 2024
Visit Reason
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting - national health safety network | Level 2 |
Inspection Report
Annual Inspection
Deficiencies: 4
Sep 13, 2022
Visit Reason
The inspection was conducted as a Recertification survey from 09/07/2022 to 09/13/2022 to assess compliance with regulatory requirements for Seagate Rehabilitation and Nursing Center.
Findings
The facility was found deficient in ensuring accurate resident assessments, appropriate care to maintain or improve range of motion, and providing appropriate treatment and services for residents diagnosed with dementia. Specific deficiencies included inaccurate Minimum Data Set (MDS) assessments for two residents, failure to provide a prescribed left elbow splint to a resident with limited range of motion, and failure to update care plans to address verbally disruptive behaviors related to dementia.
Severity Breakdown
Level of Harm - Potential for minimal harm: 2
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| The Minimum Data Set (MDS) assessment for Resident #235 did not accurately reflect the resident's use of a wander guard device. | Level of Harm - Potential for minimal harm |
| The MDS assessment for Resident #337 incorrectly documented discharge to an acute hospital instead of home. | Level of Harm - Potential for minimal harm |
| Resident #266 was observed without a left elbow splint in place despite a physician order to wear it at all times. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #312's care plan related to dementia was not reviewed or revised to address verbally disruptive behaviors such as calling out for 'mama'. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Total sampled residents: 38
Residents affected: 2
Residents affected: 1
Residents affected: 1
Inspection Report
Annual Inspection
Deficiencies: 3
Nov 8, 2019
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with regulatory requirements for Seagate Rehabilitation and Nursing Center.
Findings
The facility was found deficient in ensuring proper use and documentation of physical restraints, accurate resident assessments, and resident participation in care planning. Specific deficiencies included failure to document ongoing re-evaluation of restraint use, inaccurate Minimum Data Set (MDS) cognitive assessments due to data entry errors, and lack of documented resident invitations or participation in care plan meetings.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure that when restraints are used, the least restrictive alternative is applied and ongoing re-evaluation is documented, specifically regarding the use of an abdominal binder for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure assessments accurately reflected resident status, including a data entry error on the MDS cognitive section for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents participated in the development, review, and revision of the Comprehensive Care Plan, with residents not invited to care plan meetings. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 38
Residents affected: 1
Residents affected: 1
Residents affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding restraint use and resident behavior |
| CNA #1 | Certified Nursing Aide | Interviewed regarding observations of resident behavior related to restraints |
| NP | Nurse Practitioner | Interviewed regarding use of abdominal binder and resident behavior |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS documentation and data entry error |
| SW #1 | Social Worker | Interviewed regarding cognitive assessment and MDS data entry error |
| SW #2 | Social Worker | Interviewed regarding resident invitations and refusals to care plan meetings |
| SW #5 | Social Worker | Interviewed regarding resident invitations and refusals to care plan meetings |
| DSW | Director of Social Work | Interviewed regarding care plan meeting invitations and documentation |
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