Sheepshead Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Sheepshead Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 16, 2021

  Based on observation, interviews and record review conducted during an abbreviated survey (NY 648) from 06/14/2021 to 06/16/2021, the facility failed to provide adequate supervision to prevent elopement. This was evident in 1 out of 10 residents sampled. (Resident #1). Specifically, Resident # 1 was admitted into the facility and exhibited wandering behavior. Resident #1 was assessed, and the facility staff contacted the family to discuss wandering. A Wander guard was put in placed on 12/26/2020. The resident was placed on 30 min monitoring. Video Surveillance revealed on 6/12/21 at 4:48 AM, Resident #1 exited the elevator from the 4th floor to the basement undetected. The resident then exited the basement door and out of the facility. The resident was fully clothed. […]

• No harm, potential for more than minimal, patternF553Apr 24, 2024

  Based on record review and interviews conducted during the Recertification survey from 4/17/2024 to 4/24/2024, the facility did not ensure that resident and/or resident's designated representative were offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, resident and/or resident's designated representatives were not invited to participate in their care plan meetings. This was evident for 3 of 4 residents reviewed for Care Plan (Residents #82, #111, and #104). […]

• No harm, potential for more than minimal, patternF575Apr 24, 2024

  Based on observations and interviews conducted during the Recertification survey from 4/17/24 to 4/24/24, the facility did not ensure that information regarding the Ombudsman program and the New York State Nursing Home Complaint Hotline were posted in a manner accessible to residents and resident representatives. Specifically, notices were posted in a bulletin board on one side of the unit only that was frequently obstructed by medication carts. The findings are: On 04/19/24 at 10:02 AM, the Resident Council meeting was held with nine residents. Six out of nine residents who regularly attended the meetings stated that they did not know where the Ombudsman's contact information was posted and how to formally complain to the State about the care they are receiving. […]

• No harm, potential for more than minimal, patternF577Apr 24, 2024

  Based on observations and interview conducted during the Recertification survey from 4/17/24 to 4/24/24 the facility did not ensure that the most recent survey results and plan of correction were posted in a place readily accessible to residents, family members, and legal representatives of residents and did not post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. Specifically, survey results were posted in the Family Room on the 2nd Floor and notices regarding the availability of the survey results were not readily accessible. […]

• No harm, potential for more than minimal, patternF812Apr 11, 2022

  Based on observation and interviews, during the Recertification Survey 4/4/22 to 4/11/22, the facility did not ensure that food was served in accordance with professional standards for food service safety, proper sanitation, and food handling practices to prevent the outbreak of food borne illness. Specifically, during a lunch meal observation, nursing staff were observed using their bare hands to handle bread being served to residents. This was observed on 2 of 5 units during the Dining Observation task. (2nd floor and 3rd Floor) The findings include: The facility policy titled Meal Pass dated 1/2022 documented that each tray for patient is to be set up, i.e. that is open milk, bread, put sugar in coffee etc., in accordance with infection control prevention and control protocol. […]