Sheepshead Nursing & Rehabilitation Center has received 10 citations for violations of public health code between 2018 and 2021, according to New York State Department of Health records accessed on February 4, 2022. The Brooklyn nursing home’s citations resulted from a total of two surveys by state inspectors. The deficiencies they describe include the following:
1. The nursing home did not provide adequate supervision to prevent elopement. Under Section 483.25 of the Federal Code, nursing homes must ensure residents receive adequate supervision to prevent accidents. A June 2021 citation found that Sheepshead Nursing & Rehabilitation failed to ensure such. The citation states specifically that in December 2020, a resident on wandering precautions “exited the elevator from the 4th floor to the basement undetected,” then “exited the basement door and out of the facility.” The citation goes on to explain that while the resident’s wander guard device set off an alarm in the facility’s basement, “it did not relay to the annunciator at the security desk in the lobby,” and that staff were not aware of the basement’s emergency exit door alarm and did not respond “until a kitchen staff coming into the building alerted security. According to the citation, the resident exited around 4:48AM, and was found by family members on a local boardwalk at 12:00pm. The citation states that this incident resulted in “immediate jeopardy to resident health or safety.” A plan of correction undertaken by the facility included the termination of a security guard and education of all staff.
2. The nursing home did not ensure residents were protected from the use of unnecessary medications. Section 483.45 of the Federal Code states that nursing home residents should not be administered psychotropic medications unless medically necessary, and that those who use such drugs should receive gradual dose reductions (when clinically feasible) in an effort to discontinue their use. An October 2019 citation found that Sheepshead Nursing & Rehabilitation failed to ensure such. The citation states specifically that residents were prescribed unspecified medications “with no evidence of behaviors to support” their ongoing use. The citation goes on to describe that in the case of two residents, “there were no gradual dose reductions (GDR) attempted within the last year.” A plan of correction undertaken by the facility included the discontinuation of the use of one resident’s antipsychotic medication.
3. The nursing home did not take adequate measures to prevent infection. Section 483.80 of the Federal Code stipulates that nursing homes must establish and maintain an infection prevention and control program in order to ensure residents receive “a safe, sanitary and comfortable environment.” An October 2019 citation found that Sheepshead Nursing & Rehabilitation failed to ensure such. The citation states specifically that staff were observed entering the room of a resident on contact precautions “without wearing appropriate Personal Protective Equipment (PPE). It goes on to describe an instance in which a Registered Dietitian entered the room with a lunch tray but without first putting on PPE. In an interview, the RD said she forgot to don PPE, and “realized her mistake after the fact.” A plan of correction undertaken by the facility included the education and counseling of relevant staff.
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