Inspection Reports for
Seagate Rehabilitation and Nursing Center

The state logged 105 complaints about this facility; 10 led to on-site inspections. Nine citations resulted from those complaints.

Across 39 inspections in the reporting period, 58 citations were issued including standard health and Life Safety Code violations. The facility had 105 complaints with 10 on-site inspections and one enforcement action involving fines.

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.

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.

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.

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.

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.

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.

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.

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.