Sheepshead Nursing & Rehabilitation Center

Inspectors wroteBased on record review and interviews conducted during an Abbreviated Survey (538273), the facility failed to ensure that an alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later that two (2) hours after the allegation is made, if the events that caused the allegation involved or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Agency and adult protective services where state law provides for judications in long term care facilities) set forth at S483.12(c)(1). This was evident for one (1) out of three (3} residents sampled (Resident #1). [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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. In addition, members of the Resident Council were interviewed and reported that they did not know where survey results were posted or accessible for residents to review.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification survey from 4/17/2024 to 4/24/2024, the facility did not ensure residents unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. This was evident for 2 (Resident #169 and Resident #171) of 3 residents reviewed for Activities of Daily Living out of 38 total sampled residents. Specifically, Resident #169 and Resident #171 were observed with quarter to one-third inch fingernails beyond fingertips and did not receive staff assistance for trimming of long nails.

Inspectors wroteBased on interview and record review conducted during a Recertification survey from 4/17/2024 to 4/24/2024, the facility did not ensure that residents received proper treatment and assistive devices to maintain vision abilities. This was evident for 1 (Resident #82) of 1 resident reviewed for Communication/Sensory out of 38 total sampled residents. Specifically, Resident #82 did not receive an Ophthalmology consult in accordance with Medical Doctor order in a timely order.

Inspectors wroteBased on observations, record reviews, and staff interviews, during the Recertification survey from 4/17/2024 to 4/24/2024, the facility did not ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers. This was evident for 1 (Resident #150) of 3 residents reviewed for Pressure Ulcer. Specifically, during multiple observations, Resident #150 was observed without multipodus boot/brace in place as ordered.

Inspectors wroteBased on observations, record reviews and interviews conducted during the Recertification survey from 4/17/24 to 4/24/24, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 (Resident #60) of 2 residents reviewed for Position/Mobility out of a sample of 38 residents. Specifically, Resident #60 had an active Physician order for a left hand palm protector and was observed without left hand palm device on multiple occasions.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 4/17/2024 to 4/24/2024, the facility did not ensure timely identification and removal of expired medications. Specifically, seven individual expired Heparin lock flush syringes were stored on medication carts. This was evident on 2 of 5 units. (2nd and 4th floor)

Inspectors wroteBased on observation, record review and interview conducted during the Recertification survey from 4/17/2024 to 4/24/2024, the facility did not ensure that infection prevention and control program was maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, residents were not offered appropriate hand hygiene prior to lunch meal being served. This was evident for 2 (Resident #39 and Resident #111) of 18 residents observed during the Dining observation on Unit 2. Resident #39 and Resident #111 were observed being wheeled into the dining area, placed at the dining table, and served a lunch meal without being offered or provided hand hygiene.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 4/17/2024 to 4/24/2024, the facility did not ensure that clinical records were accurately documented in accordance with accepted professional standards and practices. Specifically, resident and/or resident's designated representatives who did not participate in their care plan meetings were documented as present in the care plan meetings. This was evident for 3 of 4 residents reviewed for Care Plan (Residents #82, #111, and #104).

Inspectors wroteBased 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)

Inspectors wroteBased on interviews and record review conducted during the recertification survey from 4/4/22 to 4/11/22, the facility did not ensure that ensure that liability notices were provided appropriately to Medicare beneficiaries. This was evident for 1 of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification out of a total sample of 38 residents. (Resident #462)

Inspectors wroteBased on observations, record reviews and staff interviews during a recertification survey, the facility did not ensure that the resident's drug regimen was free of unnecessary medications. Specifically, the residents were prescribed psychotropic medications with no evidence of behaviors to support the ongoing use of psychotropic medications and residents received antipsychotic medication without specific diagnoses, and documented condition. In addition, there were no gradual dose reductions (GDR) attempted within the last year for the two residents. This was evident for 2 of 5 residents reviewed for the use of Unnecessary Medications (Resident # 176 & Resident # 22).

Inspectors wroteBased on staff interviews and record review conducted during the recertification survey, the facility did not ensure that a person-centered care plan with measurable goals, time frames and interventions were developed to address resident's concerns. Specifically, there was no documented evidence that the comprehensive care plan included measurable goals, objectives and interventions to address a resident with physically aggressive behavior. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of a sample of 53 residents. (Resident # 77)

Inspectors wroteBased on record review and staff interviews conducted during the recertification survey, the facility did not ensure that irregularities identified by the pharmacist and forwarded to the attending physician, the facility's medical director and director of nursing were acted upon. Specifically, the attending physician failed to document in the resident's medical record that an irregularity identified by the consultant pharmacist had been reviewed and what, if any, action had been taken to address the issue. This was evident for 1 out of 5 residents reviewed for Unnecessary Medications out of a sample of 53 residents. (Resident # 22) Resident #22 is [AGE] years old and was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation and interview conducted during the recertification survey, the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help the development and transmission of communicable diseases and infections. Specifically, staff was observed entering a resident's room who was maintained on contact precautions without wearing appropriate Personal Protective Equipment (PPE). This was evident for 1 of 1 resident reviewed for Infections (#18) out of a total sample of 49 residents.