Inspection Reports for
Sheepshead Nursing & Rehabilitation Center
2840 Knapp St, Brooklyn, NY, 11235
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
149% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Apr 24, 2024
Visit Reason
The survey was a Recertification annual inspection conducted from 4/17/2024 to 4/24/2024 to assess compliance with regulatory requirements for Sheepshead Nursing & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to ensure resident participation in care planning meetings, inadequate posting of Ombudsman and survey results information, failure to provide necessary assistance with activities of daily living such as fingernail care, delayed ophthalmology consults, failure to apply prescribed pressure ulcer devices, inaccurate documentation of care plan meeting attendance, expired medications found on medication carts, and failure to provide appropriate hand hygiene to residents prior to meals.
Deficiencies (10)
Failure to allow residents to participate in the development and implementation of their person-centered care plans, with inaccurate documentation of attendance at care plan meetings.
Failure to post Ombudsman program and Nursing Home Complaint Hotline information in accessible locations, with notices obstructed by medication carts.
Failure to post the most recent survey results and plan of correction in a place readily accessible to residents and family members.
Failure to provide necessary assistance with activities of daily living, specifically fingernail trimming for residents with long fingernails.
Failure to ensure timely ophthalmology consults as ordered by the physician.
Failure to apply prescribed pressure ulcer prevention devices (multipodus boot) consistently as ordered.
Failure to provide appropriate care to maintain and/or improve range of motion, specifically failure to apply left hand palm protector as ordered.
Failure to timely identify and remove expired medications from medication carts, including expired Heparin lock flush syringes.
Failure to accurately document resident and/or resident's designated representatives' attendance at care plan meetings.
Failure to provide and implement an infection prevention and control program, specifically failure to offer appropriate hand hygiene to residents prior to lunch meal being served.
Report Facts
Residents reviewed for Activities of Daily Living: 3
Residents reviewed for Pressure Ulcer: 3
Residents reviewed for Communication/Sensory: 1
Residents reviewed for Position/Mobility: 2
Residents observed during Dining observation: 18
Expired Heparin Lock Flush syringes found: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Named in fingernail trimming deficiency for Residents #169 and #171 |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in fingernail trimming deficiency for Resident #169 |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Named in fingernail trimming deficiency for Resident #171 |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Named in pressure ulcer device deficiency for Resident #150 |
| Certified Nurse Assistant #10 | Certified Nurse Assistant | Named in pressure ulcer device deficiency for Resident #150 |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including fingernail care, pressure ulcer device application, medication cart checks, and care plan documentation |
| Director of Discharge Planning | Director of Discharge Planning / Social Worker | Named in care plan meeting attendance and documentation deficiency |
| Administrator | Administrator | Interviewed regarding care plan meeting documentation |
| Registered Nurse #2 | Registered Nurse Supervisor | Interviewed regarding medication cart checks |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in expired medication deficiency |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Named in expired medication deficiency |
| Pharmacy Supervisor | Pharmacy Supervisor | Interviewed regarding expired medication deficiency |
| Certified Nurse Assistant #9 | Certified Nurse Assistant | Named in infection control deficiency for failure to provide hand hygiene |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed regarding infection control deficiency |
| Resident Representative | Multiple interviews regarding care plan meeting attendance and knowledge of Ombudsman and survey results postings | |
| Registered Dietician #1 | Registered Dietician | Named in care plan meeting attendance discrepancy |
| Director of Rehab | Director of Rehabilitation | Named in care plan meeting attendance discrepancy and palm protector refusal |
| Social Worker #1 | Social Worker | Named in care plan meeting attendance discrepancy |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Named in palm protector refusal |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Named in palm protector refusal and documentation deficiency |
| Registered Nurse #3 | Registered Nurse | Named in palm protector refusal and documentation deficiency |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 15
Date: Apr 24, 2024
Visit Reason
Inspection identified 11 standard health citations and 4 life safety code citations related to quality of care and safety issues, all corrected by June 2024.
Findings
Inspection identified 11 standard health citations and 4 life safety code citations related to quality of care and safety issues, all corrected by June 2024.
Deficiencies (15)
ADL care provided for dependent residents
Increase/prevent decrease in rom/mobility
Infection prevention & control
Label/store drugs and biologicals
Pharmacy srvcs/procedures/pharmacist/records
Required postings
Resident records - identifiable information
Right to participate in planning care
Right to survey results/advocate agency info
Treatment/devices to maintain hearing/vision
Treatment/svcs to prevent/heal pressure ulcer
Corridor - doors
Electrical systems - essential electric syste
Hazardous areas - enclosure
Sprinkler system - maintenance and testing
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 11, 2022
Visit Reason
The inspection was conducted as a recertification survey from 04/04/22 to 04/11/22 to assess compliance with Medicare/Medicaid regulations and facility policies.
Findings
The facility failed to ensure proper notification of Medicare Non-Coverage to beneficiaries, specifically lacking documented evidence that the notice was mailed on the date of telephone notification. Additionally, nursing staff were observed handling bread with bare hands during meal service, violating infection control protocols.
Deficiencies (2)
Failure to provide timely and documented Notice of Medicare Non-Coverage (NOMNC) to Medicare beneficiaries or their representatives.
Nursing staff observed using bare hands to handle bread during meal service, contrary to infection control and food handling standards.
Report Facts
Residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification: 38
Residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification with deficiency: 1
Units observed during Dining Observation task: 5
Units with observed bare hand bread handling: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Observed handling bread with bare hands and admitted to forgetting protocol |
| Registered Nurse Supervisor #2 | RNS | Provided interview regarding proper bread handling and staff monitoring |
| Licensed Practical Nurse #1 | LPN | Observed handling bread with bare hands and acknowledged oversight |
| Director of Clinical Reimbursement | DCR | Interviewed about NOMNC notification process |
| Social Worker/Discharge Planner | SW | Interviewed about NOMNC notification and mailing process |
| Registered Nurse Supervisor #1 | RNS | Interviewed about dining room supervision and food handling responsibilities |
| Director of Nursing Services | DNS | Interviewed about staff responsibilities for meal assistance and infection control |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Apr 11, 2022
Visit Reason
Inspection identified 3 standard health citations and 4 life safety code citations related to food sanitation, notification of changes, and building safety, all corrected by June 2022.
Findings
Inspection identified 3 standard health citations and 4 life safety code citations related to food sanitation, notification of changes, and building safety, all corrected by June 2022.
Deficiencies (7)
Food procurement,store/prepare/serve-sanitary
Medicaid/medicare coverage/liability notice
Notify of changes (injury/decline/room, etc. )
Building construction type and height
Gas equipment - cylinder and container storag
Sprinkler system - installation
Sprinkler system - maintenance and testing
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Oct 10, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with federal regulations related to care planning, medication management, psychotropic medication use, infection control, and other aspects of resident care.
Findings
The facility was found deficient in developing and implementing complete, person-centered care plans with measurable goals for residents with behavioral issues. There were failures in ensuring pharmacist-identified medication irregularities were addressed by physicians. Psychotropic medications were prescribed without adequate behavioral justification or gradual dose reductions, and infection control protocols were not consistently followed, including failure to wear PPE for residents on contact precautions.
Deficiencies (4)
Failure to develop and implement a complete care plan with measurable goals and interventions for a resident with physically aggressive behavior.
Failure to ensure pharmacist-identified medication irregularities were acted upon by the attending physician.
Failure to implement gradual dose reductions and non-pharmacological interventions prior to continuing psychotropic medications; residents received antipsychotic medications without documented behaviors or diagnoses supporting their use.
Failure to maintain an infection prevention and control program, specifically staff entering a resident's room on contact precautions without wearing appropriate PPE.
Report Facts
Residents reviewed for Unnecessary Medications: 5
Residents affected by care plan deficiency: 1
Residents affected by medication irregularity deficiency: 1
Residents affected by psychotropic medication deficiency: 2
Residents affected by infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding resident #77's behavior and care plan deficiencies |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding resident #77's behaviors and care |
| Social Worker | Interviewed regarding resident #77 and family involvement | |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding resident #22's behaviors and care |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding resident #22's care and behaviors |
| Psychiatrist | Interviewed regarding psychotropic medication use for residents #22 and #176 | |
| Primary Care Physician | Interviewed regarding psychotropic medication use for resident #22 | |
| Director of Nursing | Interviewed regarding medication management and infection control policies | |
| Registered Dietitian | Observed entering resident #18's room without PPE and interviewed about infection control | |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding infection control practices for resident #18 |
| RN #2 | Registered Nurse | Interviewed regarding infection control practices for resident #18 |
| Infection Control Nurse/Assistant Director of Nursing | Interviewed regarding staff education on PPE and infection control |
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