Seagate Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Additionally, the facility did not provide the resident and their representative with a summary of the baseline care plan. The findings are:The facility's policy and procedure titled Resident's Baseline Care Plan, with review date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The comprehensive care plan was not reviewed until 09/09/2025. There were no revisions to the interventions after the incident.The findings are:The facility policy titled Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include but are not limited to: The facility Staffing policy and procedure dated [DATE], last reviewed [DATE] documented that the facility maintains adequate staffing on each shift to ensure that resident's needs and services are met; licensed registered nursing and licensed nursing staff are available to provide and monitor the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings are: The facility policy titled Therapeutic Recreation programs Scope of Services dated 6/17/2024 documented the activities program reflects the cultural interests of resident population and provides opportunities for continual enjoyment in areas of former leisure interests. The policy also documented that leisure programs were to enhance the social, emotional, intellectual, physical, creative, and spiritual wellbeing of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #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. The findings are: The facility policy titled Splints/Orthoses/Prostheses dated 8/17/2022 documented the nursing department will take responsibility for applying and removing devices. Resident #266 had diagnoses of Hemiplegia and hemiparesis on the left and right side and history of cerebral infarct. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #266 was severely cognitively impaired and did not document use of splinting devices. On 09/08/22 at 11:21 AM and 09/09/22 at 11:54 AM, Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: The facility policy titled Care Planning dated 12/14/2021 documented individualized CCPs for each resident based on assessments done at the time of admission, quarterly, annually, and when there is a change in condition. CCPs will be updated to reflect interval problems as they arise. Resident #312 had diagnoses of dementia, anxiety disorder, and schizophrenia. On 09/08/22 at 11:10 AM, Resident #312 was observed in a geri-chair in the dining area crying out mama and speaking in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings are: 1). Resident #39 was admitted with diagnoses that included Hypertension and End Stage Renal Disease. Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. Physician Order dated 10/28/19 documented the days of Dialysis on Tuesdays, Thursdays, and Saturdays. On 11/04/19 at 02:53 PM, an interview was conducted with Resident # 39 who stated he has not been invited to care plan meetings. Resident #39 stated meetings only happened for physical therapy and he could not recall the last time he attended a care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings are: The facility's policy and procedure Restraints-Use of revised 10/7/19 documented medical symptoms that warrant the use of restraints will be documented in the resident's medical record, ongoing assessments, and care plans. Resident #200 was admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Diabetes Mellitus and Dysphagia. The Quarterly Minimum Data Set (MDS) assessment dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). The findings are: Resident #283 was admitted to facility with diagnoses that included Non-Alzheimer's Dementia, Depression, Psychotic Disorder, Aphasia, and Gastronomy status. The facility document entitled Policy and Procedure: Subject: Minimum Data Set 3.0 dated effective 6/25/2019 documented under the section entitled Procedure for Completion: All disciplines that make entries on the MDS 3.0 are responsible to sign and date the sections they completed. The signature indicates that the section was reviewed and attest to the accuracy of the items. Significant Change Minimum Data Set (MDS) dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.