Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brooklyn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saints Joachim & Anne Nursing And Rehab Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Sea Crest Nursing And Rehabilitation Center | 0.3 mi | ★★★★★ | 5 | 0 |
| Haym Solomon Home For The Aged | 1.2 mi | ★★★★★ | 0 | 0 |
| King David Center For Nursing And Rehabilitation | 1.3 mi | ★★★★★ | 12 | 0 |
| Shore View Nursing & Rehabilitation Center | 1.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.