Seagate Rehabilitation and Nursing Center

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that each resident was screened for a mental disorder or an intellectual disability prior to admission. This was evident for one resident (Resident #373) of three residents reviewed for Preadmission Screening and Resident Review out of a total sample of 38 residents. Specifically, the Preadmission Screening and Resident Review was not completed for Resident #373 prior to admission to the facility.

Inspectors wroteNumber of residents sampled:7Number of residents cited:1 Based on observations, record review and interviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice that were based on the comprehensive assessment, person-centered care plan, and the resident's choice. This was evident for one of seven residents (Resident #129) reviewed for Accidents out of a total sample of 38 residents. Specifically, Resident #129 reported they fell during the early morning hours on 06/27/2026, however, Licensed Practical Nurse #3 did not inform the Registered Nurse Supervisor on duty during the shift. Resident #129 was not assessed until 11:00 AM when Resident #129 directly informed Registered Nurse #3 that they had had a fall earlier in the morning and felt pain to the left side upper back and hip.

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure that an allegation of abuse was reported to the New York State Department of Health. immediately, but no later than two hours after the allegation was made, as required. This was evident in one (Resident #1) of five sampled residents. Specifically, Resident #1's family member alleged that on 06/01/2026, two Certified Nursing Assistants verbally degraded the resident. The family member also alleged that one of the Certified Nursing Assistants snatched the resident's purse, squeezed water on the resident's face, and threw the remaining water on the resident's back. These alleged violations were not reported to the New York State Department of Health.

Inspectors wroteBased on observation, record reviews, and interviews conducted during an abbreviated survey (2616960, 439261, and 439285), the facility failed to ensure that residents are free from resident-to-resident abuse. This was evident for four (4) of 12 residents (Resident #1, #3, #7, and # 8) sampled for abuse. Specifically, 1) on [DATE] at 9:55 PM, Certified Nursing Assistant #2 discovered Resident #1 lying in bed bleeding from their head after being physically assaulted by Resident #2. Resident #1 was transferred to the hospital and later expired. 2) On [DATE] at 3:45 AM, Resident #4 was observed striking Resident #3 with their cane while Resident #3 was sitting on the floor in Resident #4's bathroom. Resident #3 was later diagnosed with an acute right hip fracture. 3) On [DATE] at 3:21 PM, Resident #7 reported Resident #8 wandered to their room and struck them with their walker. [...]

Inspectors wroteBased on observations, record review, and interviews during an Abbreviated Survey (ID# 2616960), the facility did not ensure a baseline care plan was developed within forty eight (48) hours of a resident's admission and implemented for the resident that includes the instructions needed to provide effective person-centered care that meets professional standards of quality of care. This was evident for one (1) out of twelve (12) residents (Resident #2) sampled for baseline care plan. Specifically, on [DATE], Resident #2 was admitted to the facility with the chief complaint of aggressive and paranoid behavior that was not addressed in a baseline care plan. On [DATE] at 9:55 PM, Resident #2 physically assaulted Resident #1 with their wheelchair footrest, who later expired in the hospital. [...]

Inspectors wroteBased on observations, record review, and staff interviews conducted during an abbreviated survey (439285), from 09/22/2025 to 10/01/2025 the facility did not ensure that a resident's care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This was evident in one (1) out of twelve (12) residents (Resident #7) sampled. Specifically, Resident #7 had a quarterly assessment conducted on 04/03/2025 and documented on the Minimum Data Set 3.0 ( a resident assessment tool). The resident was assessed as having wandering behavior, and agitation, with severely impaired cognition. The resident's comprehensive care plan was developed on 03/07/2025. On 04/27/2025 Resident #7 had a physical altercation with another resident after wandering in their room. [...]

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification and Complaint Survey (NY00325830 & NY00337223) from [DATE] to [DATE], the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility reported low weekend staffing and 1 star staffing rating for Fiscal Quarter 3, 2024 as confirmed by a review of the Daily Staffing and the Payroll Based Journal (PBJ) Staffing Data Report. This was evident for 2 of 2 residents reviewed for Sufficient and Competent Nurse Staffing out of a sample of 38 residents.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 10/21/2024 to 10/28/2024, the facility did not provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 1 (Resident #287) of 6 residents reviewed for Activities out of 38 sampled residents. Specifically, Resident #287 was not provided with activities that met their cultural preferences and were in their preferred language.

Inspectors wroteResident #266 Position, Mobility Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure a resident with limited range of motion received treatment and services to maintain or improve mobility. This was evidenced by 1 (Resident #266) of 1 residents reviewed for Mobility out of 38 sampled residents. Specifically, Resident #266 was observed on multiple occasions without elbow splint in place in accordnace with the physician order.

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification and Complaint (NY00273442) Survey, the facility did not ensure A resident who is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (Resident #312) of 1 residents reviewed for Mood/Behaviors out of 38 total sampled residents. Specifically, the CCP related to Resident #312's cognition was not reviewed and revised to address the resident calling out for mama.

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification survey from 9/07/22 to 9/13/22, the facility did not ensure residents received accurate assessments. This was evident for 2 (Resident #235 and Resident #337) of 38 total sampled residents. Specifically, 1) The Minimum Data Set 3.0 (MDS) assessment for Resident #235 did not accurately reflect the resident's use of a wander guard (WG) device; and 2) Resident #337 was discharged home and the MDS assessment documented Resident #337 was discharged to the acute hospital.

Inspectors wroteBased on record reviews and staff interviews conducted during the recertification survey, the facility did not ensure that residents participated in the development, review and revision of the Comprehensive Care Plan (CCP). Specifically, residents were not invited to comprehensive and quarterly care plan meetings. This was evident for 3 of 3 residents reviewed for Participation in Care Planning (Residents # 39, 234, 287) out of a sample of 38 residents.

Inspectors wroteBased on observations, record review, and staff interview conducted during the Recertification survey, the facility did not ensure that when the use of restraints is indicated, the facility used the least restrictive alternative for the least amount of time and documented ongoing re-evaluation of the need for restraints. Specifically, there was no documented evidence that the ongoing need for an abdominal binder was re-evaluated and behaviors necessitating use were documented. This was evident for 1 of 1 resident reviewed for Restraints (Residents #200) out of a sample of 38 residents.

Inspectors wroteBased on record review and staff interviews conducted during the recertification survey, the facility did not ensure assessment accurately reflected the resident status. Specifically, a resident with short-term and long-term memory problem was captured on the MDS as having no problem with memory. This was evident of 1 out 1 one resident reviewed for Closed Record -Death out of a sample of 38 residents. (Resident #283).