Seagate Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brooklyn, New York.
- Location
- 3015 W 29 St, Brooklyn, New York 11224
- CMS Provider Number
- 335513
- Inspections on file
- 17
- Latest survey
- October 8, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Seagate Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Multiple residents with cognitive impairments and behavioral health issues were involved in incidents of resident-to-resident abuse, including physical assaults that led to serious injury and death. The facility did not effectively monitor new admissions with known aggressive behaviors, failed to develop or implement adequate care plans for residents with wandering or aggressive tendencies, and lacked consistent documentation and intervention practices among staff, resulting in immediate jeopardy.
A resident with dementia and a history of aggressive, paranoid behavior was admitted without a baseline care plan addressing these issues, and neither the resident nor their representative received a summary of the plan. This omission led to the resident assaulting another resident, resulting in hospitalization and death. Staff interviews confirmed the care plan was incomplete and not communicated as required.
A resident with dementia and severe cognitive impairment was involved in a physical altercation with another resident after exhibiting wandering and agitation. Despite a recent behavioral incident and ongoing assessments documenting these behaviors, the care plan was not reviewed or updated by the interdisciplinary team to reflect new interventions, contrary to facility policy. Staff interviews confirmed that the care plan remained unchanged following the incident.
The facility experienced significant staffing shortages, particularly on weekends and evening shifts, resulting in inadequate care for residents. Reports from residents and staff indicated that there were often fewer CNAs than required, leading to delays in care and medication administration. Management acknowledged the issue and mentioned efforts to address it, but the measures were insufficient to prevent the deficiencies.
A resident with severe cognitive impairment and a preference for Cantonese language activities was not provided with appropriate cultural and linguistic activities. The facility's available television channels did not include Cantonese, and the resident was observed without suitable activities. Staff interviews confirmed the lack of Cantonese language options, despite the resident's known preferences.
Failure to Prevent Resident-to-Resident Abuse Resulting in Harm, Injury, and Death
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, resulting in multiple incidents of actual harm, serious injury, and death. In one case, a resident with severe cognitive impairment and a history of major depressive disorder was physically assaulted by their roommate, who had recently been admitted with a history of aggressive and paranoid behavior. The facility did not conduct effective monitoring or develop a baseline care plan for the new admission to identify and address potential aggressive behavior. There was no documented psychiatric consult or evidence of a completed psychotherapy evaluation, and staff failed to implement appropriate interventions despite the resident's recent psychiatric emergency department stay and medication orders for behavioral health issues. The assault resulted in the resident being found bleeding from the head and subsequently dying after hospital transfer. Another incident involved a resident with moderately impaired cognition and a history of wandering behavior who entered another resident's room and was struck with a cane, resulting in an acute right hip fracture. The care plan for the wandering resident did not include specific interventions for monitoring or preventing such behavior, and documentation of staff rounds was inconsistent or lacking. Staff interviews revealed that rounds were conducted but not always documented, and there was no clear system for monitoring or intervening in resident wandering or aggression, despite known behavioral risks. A third incident occurred when a resident with severe cognitive impairment was struck in the face with a walker by another resident who also had severe cognitive impairment and a history of wandering and combative behavior. The care plans for both residents lacked detailed interventions for monitoring or preventing aggressive or intrusive behaviors. Staff and supervisory interviews indicated that responsibility for monitoring residents was not clearly defined or consistently implemented, and there was insufficient documentation of behavioral monitoring and interventions. These failures resulted in immediate jeopardy to resident health and safety.
Removal Plan
- Policy and Procedure on Abuse, Mistreatment and Neglect was reviewed with no revision.
- An Audit was done. The Director of Nursing and Assistant Director of Nursing assessed 70 residents on the third floor with no injuries or signs of abuse. No additional concerns were identified.
- Facility admission policy was revised.
- The facility developed a policy titled Resident Rounding-Nursing. It is the policy for all nursing staff that states they are responsible for completing regular rounds of their assigned areas and the facility's common areas, at the start of their shift, twice during the shift, and at the end of their shift, to monitor resident well-being, maintain a safe environment, and respond promptly to resident needs.
- The facility policy titled Nursing/Rehabilitation/Maintenance was reviewed/revised to include storage for equipment (including wheelchair/footrests) not being used.
- Facility-wide inspection was conducted by the therapy department to assess durable medical equipment in residents' rooms that could present a potential safety hazard. Concerns will be addressed accordingly to ensure safety.
- Three Hundred and Fifty-Eight resident wheelchairs were checked for potential safety hazards. No concerns were found.
- In-service conducted on Rounding, Call Bells, and Daily Tasks. Lesson plan and sign-in sheets were reviewed/confirmed for staff in-service conducted on Rounding, Call Bells, and Daily Tasks.
- An Audit done of all new residents admitted within the 30 days prior to the date of the incident was reviewed by the Regional Nurse/Designee to determine if there were any documented or known behavioral concerns with an adjunct target behavior care plan with individualized monitoring in place. Three residents were admitted on psychoactive medications with physical aggression, anxiety and mood changes. Behavior care plans were developed.
- Facility policy on Behavioral Health and Dementia was revised to include that the facility will ensure a designated behavior health monitor will be assigned each shift to observe for residents having behaviors such as combative, aggressive impulsive and or assaultive behaviors. Any behaviors negatively affecting others will be documented on the behavioral monitoring log including interventions attempted. All behaviors will be reported to the Registered Nurse for follow up including documentation and notification to physician and psychiatry as needed. The Registered Nurse Supervisor will review and sign the behavior monitoring log each shift.
- Staff members received in-service on resident-to-resident abuse/prevention.
- The facility completed in-service of all admission staff on changes to the admission policy, including a need to conduct a thorough review of the Patient Review Instrument prior to acceptance of the hospital referral.
- Facility staff members including Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants were interviewed and stated they received in-service on documentation, reporting of resident's behavior, equipment storage including wheelchair footrests, resident to resident abuse prevention and call bell with no concerns identified.
- The remainder of the staff who did not receive in-services will be in-serviced prior to starting their duties. Staff on vacation or off duty will be in-serviced before going to the unit.
Failure to Develop and Communicate Baseline Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with a history of aggressive and paranoid behavior. Despite the resident being admitted with diagnoses including dementia and a documented chief complaint of aggression and paranoia, the baseline care plan did not address these behavioral concerns. There was also no evidence that the resident or their representative received a summary of the baseline care plan, as required by facility policy. Multiple staff interviews confirmed that the baseline care plan was either incomplete or not provided to the family, and that behavioral issues were not addressed because staff did not perceive them at the time of admission. As a result of these omissions, the resident physically assaulted another resident with a wheelchair footrest, leading to the second resident's hospitalization and subsequent death. Documentation and interviews revealed that the facility's process for reviewing admission documents, completing assessments, and distributing care plan summaries was not consistently followed. The lack of a comprehensive, person-centered baseline care plan and failure to communicate it to the resident and their family directly contributed to the incident.
Failure to Timely Review and Revise Care Plan After Resident Altercation
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly reviews, as required by facility policy. Specifically, a resident with diagnoses of dementia, major depressive disorder, and agitation was assessed as having severely impaired cognition, wandering behavior, and agitation. The resident's comprehensive care plan was developed and later revised, but not in response to a significant incident. After a quarterly assessment documented the resident's ongoing behavioral issues, the resident was involved in a physical altercation with another resident following wandering into another room. Despite this incident, the care plan was not reviewed or updated to reflect new interventions until several months later. Record review and staff interviews confirmed that no new interventions were implemented following the altercation, and the behavior care plan remained unchanged. The facility's policy required care plans to be updated to reflect episodic issues or problems as they arise, including after significant changes in a resident's condition or behavior. Staff interviews revealed that the responsibility for updating the care plan was not clearly followed, as the nurse who completed the incident report did not update the care plan, and the behavior care plan was not reviewed or revised in a timely manner after the incident.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, particularly on weekends and during evening shifts. The report highlights that the facility had a 1-star staffing rating for Fiscal Quarter 3, 2024, and was consistently short of Certified Nursing Assistants (CNAs) on multiple occasions. This staffing shortage was confirmed through interviews with residents and staff, as well as a review of the Daily Staffing and Payroll Based Journal (PBJ) Staffing Data Report. Residents reported inadequate care due to the lack of staff, with some residents not receiving timely assistance or medication. Specific complaints were made by residents and their representatives, including one resident who reported that the facility often had fewer CNAs than required, leading to delays in care. Another resident's representative noted that residents were left in soiled conditions, indicating a lack of timely care. Interviews with CNAs and nurses corroborated these claims, with staff frequently reporting that they were working with fewer CNAs than scheduled, which affected their ability to provide adequate care to residents. The facility's management, including the Corporate Staffing Manager and the Director of Nursing, acknowledged the staffing issues and mentioned efforts to address them, such as working with staffing agencies and conducting job fairs. However, the report indicates that these measures were not sufficient to prevent the staffing shortages that led to the deficiencies observed during the survey.
Deficiency in Providing Culturally Appropriate Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the cultural preferences and language needs of a resident, identified as Resident #287, during a recertification survey. Resident #287, who was severely impaired in cognition and spoke only Cantonese and Taishanese, was not provided with activities in their preferred language. The facility's policy required that activities reflect the cultural interests of the resident population, but this was not implemented for Resident #287. Observations and interviews revealed that Resident #287 was not provided with a television or device to watch programs in Cantonese, despite their representative's request during care plan meetings. The facility's television channels were limited to English, Spanish, and Russian, with no Cantonese options available. Resident #287 was often observed sitting in the dining room with no activities in their preferred language, and the television in the dining room played English-language programs, which Resident #287 could not understand. Interviews with staff, including a CNA, a Recreation Therapist, and the Director of Recreation, confirmed the lack of Cantonese language activities and devices for Resident #287. The Recreation Therapist acknowledged awareness of Resident #287's preferences but stated that the facility only provided English and Spanish channels. The Director of Recreation mentioned the availability of devices like iPads for language-specific programs but was unsure if Resident #287 had access to such a device or could use it. This lack of culturally and linguistically appropriate activities for Resident #287 constituted a deficiency in meeting the resident's needs.
Latest citations in New York
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with Parkinson’s disease, dementia with behavioral disturbances, and known exit-seeking behaviors, care planned with a wander alarm, eloped through a 3rd floor stairwell door whose alarm had been disabled days earlier by maintenance and security while addressing a wandering system issue. A plastic barrier was placed in front of the door, but the door remained accessible and unrepaired. Video showed the resident repeatedly attempting to exit, bypassing the barrier, trying to remove the wander device, and ultimately opening the door, falling into the stairwell, and leaving the unit. Staff observed the resident at the door but did not consistently redirect them, and the resident was later found outside the building by a visitor after staff realized the resident was missing and discovered the wheelchair in the stairwell.
Two residents with psychiatric and behavioral histories were waiting by an elevator in a lobby when one, known to have prior aggressive behavior and a care plan noting risk for physical aggression, removed a wheelchair armrest and struck the other in the forehead, causing a bump and laceration that required ED evaluation. Video, staff, and security accounts confirmed that the aggressor resident was able to access and weaponize the removable armrest in a common area despite prior documented altercations and behavioral concerns, and was only on 30‑minute checks at the time, resulting in a failure to protect another resident from physical abuse.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
The facility did not ensure residents understood how to file grievances and failed to document and track grievances and their resolutions. Residents reported that they only voiced concerns during resident council and were unclear about the grievance process otherwise, and the designated Grievance Officer could not produce a grievance log or forms. The DON acknowledged the grievance process was informal and lacked clear documentation. In addition, a resident with significant cardiac and neurologic conditions and moderately impaired cognition had a representative who raised multiple concerns about care coordination, communication, discharge planning, call bell response, personal property, preferences, and nutrition, but these grievances were largely handled verbally, with no consistent documentation of how each concern was addressed or resolved.
Surveyors found that the facility failed to provide timely toileting assistance and call bell response for multiple residents who were dependent on staff for ADLs. A resident with Parkinson’s disease and dementia, care planned for two-hour toileting checks, was found by family with urine-saturated clothing and wheelchair cushion after a CNA admitted not changing or checking on the resident for most of a shift, and documentation showed numerous missing toileting and check entries over several months. Another resident with a history of stroke and MI, requiring maximal assist for toileting, reported long waits for morning care while the call bell rang, with staff not responding for extended periods, and the resident’s representative described multiple episodes of call bell waits exceeding an hour. Resident Council minutes, call bell audits, and observations showed repeated long call bell wait times, including bells ringing for 15–45 minutes while various staff passed the rooms without responding, and a spouse reported frequent overnight calls from a resident seeking help because call bells were unanswered.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
Surveyors found that the facility’s most recent assessment of its 140-bed operation, including rehab, stepdown medically complex, and LTC dementia/chronic illness units, did not adequately specify how necessary resources are maintained for resident care. The assessment lacked a breakdown of bed capacity per unit and, under its staffing plan, only generally stated that staffing is based on census and acuity and reviewed each shift, with additional RNs scheduled for multiple admissions. It failed to identify contingency planning for non-emergency events that could affect direct care nurse staffing or other care resources, and it did not describe any plan to maximize recruitment and retention of direct care staff, resulting in a deficiency under 10NYCRR S415.26.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Prevent Resident-to-Resident Physical Abuse in Lobby Elevator Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite a known history of aggressive behavior. One resident with paraplegia, mood disorder, major depressive disorder, and anxiety disorder had an established care plan noting potential for physical aggression and risk of being abused. Prior documentation showed that this resident had been involved in a physical altercation with another resident in June of the previous year, during which they reported being punched and stated they hit the other resident back. The care plan was updated at that time to reflect that the resident was abused by peers, with interventions including relocation as needed and a psychiatry referral, but later updates reflecting another resident-to-resident altercation did not include new interventions. On the day of the incident, video surveillance and witness statements documented that the aggressive resident and another resident were waiting at the elevator in the lobby, along with other residents. The second resident, who had diagnoses including schizophrenia and bipolar disorder, approached and stood next to the first resident’s wheelchair. The first resident was seen making hand gestures, then removed the left wheelchair armrest and used both hands to swing it toward the second resident. When the second resident reached toward the armrest, the first resident struck them on the forehead with the armrest, causing bleeding and resulting in a bump and small laceration. Staff arrived immediately after the assault and separated the residents, and the injured resident was later assessed and transferred to the hospital for evaluation. Interviews conducted after the event revealed differing accounts of the interaction leading up to the assault. The first resident reported that the second resident had previously used a racial epithet toward them and, on the day of the incident, again stood close, touched their shoulder, and repeated the racial epithet, prompting them to remove the armrest and strike the other resident. The second resident stated they were standing at the elevator, heard the first resident saying something, ignored it, and were then struck without warning. A security guard reported hearing the first resident tell the second resident not to stand close and to stop touching them, then observed the first resident swinging the armrest and hitting the second resident. Facility staff, including the RN Supervisor and DON, acknowledged that the incident occurred off the unit, that the aggressive resident had a history of verbal and physical abusive behavior toward staff, and that this was the first documented physical altercation between these two specific residents. Despite prior behavioral incidents and care plan documentation of aggression risk, the resident was on 30‑minute checks and was able to access and weaponize a removable wheelchair armrest in a common area, resulting in physical abuse of another resident.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
Failure to Inform Residents of Grievance Process and Document Grievances and Resolutions
Penalty
Summary
The facility failed to ensure residents were informed about the grievance process and that grievances were documented and tracked in accordance with its grievance policy. The Social Services/Admissions Coordinator, identified as the Grievance Officer, reported that while they interviewed residents and emailed Administration about complaints they could not resolve, they were unable to provide a grievance log or grievance forms. During resident council, multiple residents stated they voiced concerns in the meeting but did not know how to file grievances outside of that setting, and there was no documented evidence listing grievances or the facility’s responses. The DON stated that grievances should be monitored by Social Services with documentation of the nature of the complaint and the resolution, but acknowledged that the process was informal, dependent on circumstances, and not completely clear, with no forms or documentation used to track grievance progress and resolution. For one resident reviewed for care planning, the facility did not consistently address and document multiple grievances raised by the resident’s representative. This resident had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, with the admission MDS indicating moderately impaired cognition and involvement of the resident and family in assessment and goal setting. The representative reported numerous concerns regarding miscommunication between nursing and rehabilitation, discharge planning, appointment scheduling, call bell response time, personal property, resident preferences, nutrition, and proper diet, all of which were communicated to Administration via email and paper copies. Although a family meeting was held to discuss these concerns, the Social Services/Admissions Coordinator and the DON confirmed there was no documented evidence of how each grievance was addressed or resolved, and that most concerns were handled verbally without formal documentation or investigation of every complaint.
Failure to Provide Timely Toileting Assistance and Call Bell Response
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide necessary assistance with toileting and timely response to call bells for residents who were unable to perform activities of daily living independently. Facility policy on Activities of Daily Living required that residents receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including elimination and toileting, and the facility’s No Pass policy required all staff to respond to call lights and obtain help if they could not provide it themselves. Despite these policies, multiple observations, interviews, and record reviews showed that residents did not consistently receive timely toileting care or call bell responses. One resident with Parkinson’s disease, dementia, heart disease, severely impaired cognition, and total dependence on staff for toileting and hygiene was care planned to be checked for incontinence and changed as needed, and to have toileting needs anticipated every two hours with assistance to the toilet. Kardex instructions for several months reiterated two-hour toileting checks and assistance, and CNA documentation reports for January through March showed numerous missing entries for toileting and two-hour checks across multiple shifts. A nursing home investigative report documented that a family member found this resident with urine-saturated clothing and wheelchair cushion in the afternoon, and the Administrator confirmed the saturation. The CNA identified as responsible for ADLs and accountability tasks for that shift stated they did not change the resident at all during the eight-hour shift, did not perform end-of-day care, and did not inform anyone that they were unable to care for the resident, and also stated they did not check on the resident until late morning. There was conflicting documentation on the assignment sheet, and another CNA reported that the resident was checked every two hours and could indicate when cleaning was needed, while a second family member reported having observed a strong urine smell on three Sunday visits in recent months, which staff addressed when notified. Another resident with a history of stroke and myocardial infarction, and moderately impaired cognition, required maximal assistance with toileting and moderate assistance with bathing and dressing. During one observation, this resident’s call bell was ringing, and the resident reported having waited a long time for care and stated they had been waiting since early morning; staff did not respond until several minutes after the surveyor’s observation began, at which time morning care was provided. On another day, the shared room call bell was ringing while two residents in the room reported they were still in bed, unwashed, undressed, and waiting to get out of bed, stating they had been waiting about half an hour; staff arrived to assist approximately 18 minutes after the surveyor’s initial observation. The resident’s representative reported multiple episodes when call bell response times exceeded one hour and had communicated these concerns to staff. The DON stated that call bells should be responded to when heard and that 30–60 minutes was not acceptable, but also indicated that response time depended on staffing. Additional evidence of delayed call bell response and unmet toileting needs came from Resident Council minutes, call bell audits, and direct observations. Resident Council minutes over several months documented ongoing resident reports that call bell wait times were “on the longer side” and “too long,” and that more nursing staff were needed, particularly on weekends when residents reported only three CNAs were often scheduled. Facility call bell audits conducted in response to complaints documented 23 observations, including one call bell active for 45 minutes and another for 15 minutes in the same room. During one observation, a room call bell rang for at least 14 minutes while multiple staff, including a CNA, a medication nurse, a social work/admissions coordinator, and a unit clerk, passed the room without entering; when the CNA finally entered, the resident requested a bedpan and the CNA left and did not return with the bedpan for another 10 minutes. In another observation, a room call bell rang for at least 27 minutes while a medication nurse, social work/administration staff, and a unit clerk were present in the hallway or nearby but did not respond to the bell. A spouse reported receiving at least 10 overnight phone calls from a resident asking them to call the nurses’ station because no one was responding to the call bell, and also reported that it took a long time for the nurses’ station to answer the phone.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Incomplete and Inaccurate Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. For this cognitively intact resident with essential hypertension, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and dementia, standing medication orders included multiple daily and twice-daily medications such as antihypertensives, antidepressants, an anticoagulant, a diuretic, an antianginal patch, an inhaler, and other agents. The facility’s medication administration policy required that medications be administered in accordance with physician orders, that documentation of administration be completed on the computer immediately after administration with the nurse’s initials at the corresponding date and time, and that at the end of each shift the medication nurse review the MAR, 24‑hour report, and nurses’ notes to ensure documentation is accurate and complete. Record review of the medication administration audit report for multiple dates in December 2024 showed discrepancies between the scheduled 9:00 a.m. administration times and the times documented as administered for this resident’s medications. On thirteen separate dates, all medications scheduled for 9:00 a.m. were documented as being administered after 12:00 p.m. but before 1:00 p.m. when a particular RN was passing medications to this resident. These documented times did not align with the scheduled administration time and were inconsistent with the policy requirement that medications be given at the right time and documented immediately after administration. The pattern of late documentation occurred on each of the identified dates when that RN was responsible for the medication pass for this resident. In interviews, the RN who administered the medications stated that the resident received most medications at 9:00 a.m. and some at 5:00 p.m., and described issues such as the computer timing out after about 10 minutes, logging the nurse out, and situations where medications might have been given earlier but not clicked off in the system. The RN reported that the documented times (for example, showing around 12:00 p.m.) might not be accurate, could reflect late documentation, and could be affected by computer glitches, but could not recall specific details from the December dates. The Assistant DON reported that one nurse on the unit was responsible for administering medications to approximately 38–40 residents, that the incoming nurse’s start of shift included a narcotic count and report that delayed the start of the medication pass to about 8:30 a.m., and that this left about two minutes per resident to complete the pass by 10:00 a.m. The Administrator stated that their expectation was that nurses review the MAR at the end of the shift and that unit managers run a monthly report, while the Pharmacy Consultant stated they did not review MARs and assumed nursing conducted internal auditing. These practices and conditions contributed to incomplete and inaccurate medication administration documentation for the resident on the identified dates.
Inadequate Facility-Wide Assessment of Resources and Staffing Contingency Planning
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document an adequate facility-wide assessment that determines what resources are necessary to care for residents competently during day-to-day operations and emergencies. During an Abbreviated Survey, record review of the most recent facility assessment, dated on an unspecified date and reviewed by the QAPI Committee on 09/04/2025, showed that the assessment did not sufficiently identify how the facility maintains necessary resources for resident care. The assessment described the facility as a 140-bed SNF with four nursing units (one rehabilitation unit, one stepdown medically complex unit, and two LTC units for residents with dementia and other chronic illnesses), but it did not provide a breakdown of bed capacity per unit. Under the staffing plan section, the assessment stated that staffing is based on resident census and acuity, is reviewed prior to each shift, and that the facility intends to assign the same staff to units and schedule additional RNs for multiple admissions. However, the assessment did not adequately identify contingency planning for events that do not trigger the formal emergency plan but could still affect resident care, such as issues with availability of direct care nurse staffing or other needed resources. Additionally, the assessment did not identify how the facility develops or maintains a plan to maximize recruitment and retention of direct care staff, as required by 10NYCRR S415.26.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
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