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 Sheepshead Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with schizophrenia, TIA, hypertension, and moderately impaired cognition later reported that staff had pulled their arm, causing pain, during a prior stay. After a detective from the Attorney General’s office notified the DON of this abuse allegation, the facility conducted an internal investigation and found no documentation of complaints, injuries, or signs of abuse in the clinical record, and staff denied receiving complaints. Although facility policy and state law required reporting suspected abuse to the State Survey Agency within specified time frames, the DON and administrator did not report the allegation to the Department of Health, believing it was unnecessary because the resident had been discharged and they understood that the Department of Health already had the complaint.
A facility failed to ensure residents and their representatives were involved in care planning, as required by policy. A resident with cognitive impairment was not invited to meetings, and staff provided conflicting accounts of their attendance. Another resident's representative received late invitations, and a cognitively intact resident was not invited to participate, with discrepancies in documentation of their attendance.
The facility did not ensure accessible posting of Ombudsman and complaint hotline information, as notices were obstructed by medication carts. Residents and their representatives were unaware of how to contact the Ombudsman, despite the administration's belief that information was adequately posted.
The facility did not ensure that survey results were easily accessible to residents and their families. Survey results were placed in a binder in a 2nd Floor Family Room, which was not easily accessible, and notices were not prominently displayed. Interviews revealed that residents and their representatives were unaware of the location of these results. The Director of Recreation and Assistant Administrator acknowledged the issue, but communication about the survey results' location was insufficient.
Two residents with medical conditions requiring assistance for personal hygiene were found with long fingernails, indicating a failure by the facility to provide necessary grooming support. Despite requests for help, staff did not trim the residents' nails, and there was no documentation of such care in the records. Interviews revealed confusion among staff about responsibilities, with the RN acknowledging an oversight in care provision.
A resident with a cataract did not receive a timely ophthalmology consult as ordered by the MD due to scheduling and communication issues within the facility. The lack of a clear schedule for consultant visits led to the resident being unavailable during the consultant's visits, delaying necessary vision care.
A resident with a pressure ulcer was not wearing the prescribed multipodus boot while out of bed, as observed during a survey. Facility staff, including CNAs and LPNs, failed to communicate and document the need for the boot, leading to its non-application. The Director of Nursing acknowledged the oversight in communication and documentation.
A resident with limited range of motion was not consistently wearing a prescribed left-hand palm protector, as observed during a survey. Despite a physician's order and care plan requiring the device to be worn, staff interviews revealed inconsistencies in its application. The resident, unable to apply the device independently, expressed a preference for rehab staff to assist, which was not communicated effectively among staff.
During a survey, expired Heparin lock flush syringes were found on medication carts on two floors of the facility. Despite a policy requiring nurses to check expiration dates and remove expired drugs, these syringes were not identified or removed in a timely manner. Interviews with staff revealed inconsistencies in the process of checking for expired medications, contributing to the deficiency.
During a survey, it was found that two residents were not offered hand hygiene before being served lunch, contrary to the facility's policy. A CNA wheeled the residents into the dining area and served them without ensuring their hands were washed or sanitized. Interviews revealed that staff were aware of the hand hygiene requirements, but the protocol was not followed in this instance.
The facility failed to accurately document care plan meetings, with records incorrectly showing residents and their representatives as present. A resident was not invited to meetings, another's representative received late invitations, and a third was marked present despite being in therapy. Staff interviews confirmed discrepancies, highlighting a deficiency in documentation practices.
Failure to Report Alleged Abuse to State Agency as Required
Penalty
Summary
The facility failed to ensure that an alleged violation involving abuse was reported to the State Agency as required by 42 CFR 483.12(c)(1) and the facility’s own abuse policy. The facility’s policy, dated 01/2020, required that suspicions of abuse be reported to law enforcement and the State Survey Agency within two hours if serious bodily injury was involved, or within 24 hours if not, and referenced New York Public Health Law 2803-d requiring reports of physical abuse, mistreatment, or neglect to the New York State Department of Health. Resident #1, admitted with schizophrenia, transient cerebral ischemic attack, and hypertension, had a Minimum Data Set dated 12/03/2024 documenting moderately impaired cognition. After discharge to a group home, Resident #1 reported that between 01/09/2025 and 01/16/2025, two unknown males and one female at the facility pulled their arm, causing pain. On 01/31/2025, the DON received a call from a detective at the Attorney General’s office stating that Resident #1 had complained about staff pulling their arm during the specified period. The facility completed an internal investigation, including interviewing staff assigned to the resident, and documented in a Summary of Accident/Incident Report dated 02/02/2025 that the investigation concluded abuse did not occur. Review of nursing, medical, and social work notes from 12/2024 through 01/13/2025 showed no documentation of reported abuse, bruising, redness, or injuries of unknown source. Despite the allegation and the facility’s investigation, there was no documented evidence that the facility reported the alleged abuse to the New York State Department of Health. The DON stated they believed it was not necessary to report because they were informed that the Department of Health already had the complaint, and the Administrator stated that, based on the information and the resident’s discharge status, it was not necessary to report the complaint to the Department of Health.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure that residents and/or their designated representatives were given the opportunity to participate in the development and review of their comprehensive care plans. This deficiency was identified during a recertification survey, where it was found that three out of four residents reviewed for care planning were not invited to participate in their care plan meetings. The facility's policy requires that residents and their representatives be notified of care plan meetings, but this was not consistently followed. For Resident #82, who was moderately cognitively impaired, there was no documented evidence that they were invited to participate in their care planning meetings. Despite the care plan meeting reports indicating scheduled meetings, the resident stated they had not been invited, and the comprehensive care plan form was blank. Interviews with staff provided conflicting accounts of the resident's attendance, with some staff claiming the resident was present, while others stated they were not. Resident #111, also moderately cognitively impaired, had a representative who reported not being called to attend care plan meetings, despite receiving late letters of invitation. The facility could not provide evidence of when these notices were mailed. Similarly, Resident #104, who was cognitively intact, expressed a desire to participate in care planning meetings but was not invited. The resident's representative attended a meeting while the resident was in therapy, and the facility failed to document the resident's participation accurately. The facility's documentation practices were inconsistent, leading to discrepancies in recorded attendance at care plan meetings.
Inaccessible Ombudsman and Complaint Hotline Information
Penalty
Summary
The facility failed to ensure that information regarding the Ombudsman program and the New York State Nursing Home Complaint Hotline was accessible to residents and their representatives. During a Resident Council meeting, six out of nine residents expressed that they were unaware of where the Ombudsman's contact information was posted or how to file a formal complaint with the State. Observations conducted across all units revealed that the notices were placed in an enclosed bulletin board on one side of the unit, which was frequently obstructed by medication carts, making it difficult for residents and their families to access the information. Interviews with resident representatives further highlighted the issue, as they were unaware of how to contact the Ombudsman despite multiple admissions and visits to the facility. The Director of Recreation indicated that the administration was responsible for posting the signs, and the Assistant Administrator believed that residents were aware of the information due to signs on each floor. However, the lack of visibility and accessibility of the notices contributed to the residents' and their representatives' lack of awareness.
Inaccessible Survey Results for Residents and Families
Penalty
Summary
The facility failed to ensure that the most recent survey results and plan of correction were posted in a location that was easily accessible to residents, family members, and legal representatives. During the recertification survey, it was observed that the survey results were placed in a binder located in the Family Room on the 2nd Floor, which was not easily accessible to residents. Additionally, notices regarding the availability of these survey results were not prominently displayed, and the font used on the bulletin board was not easily readable from a distance or from a wheelchair. The bulletin board was also obstructed by a medication cart, further limiting access. Interviews with members of the Resident Council and several Resident Representatives revealed that they were unaware of where the survey results were posted. The Director of Recreation stated that the Family Room is used for various events and is usually closed, although not locked, and that residents are informed about the survey results only when they visit the 2nd floor. The Assistant Administrator confirmed that signs were placed on each floor indicating the location of the survey results, but this information was not effectively communicated to all residents and their representatives.
Deficiency in Resident Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the necessary assistance to maintain grooming and personal hygiene. This deficiency was identified during a recertification survey, where it was observed that two residents had long fingernails that were not trimmed by the staff. The facility's policy required care staff to provide support in activities of daily living when residents could not maintain autonomy and independence. Resident #169, diagnosed with Chronic Obstructive Pulmonary Disease and Anxiety Disorder, reported having long fingernails and needing assistance to trim them. Despite requesting help, the resident was informed by a Certified Nursing Assistant (CNA) that it was not their responsibility to trim fingernails. The resident's care plan indicated a need for supervision or touching assistance for personal hygiene, yet there was no documentation of fingernail trimming in the CNA accountability records or nursing progress notes. Interviews with the CNA and Registered Nurse (RN) revealed a lack of clarity regarding responsibility for trimming fingernails, with the RN acknowledging an error in not ensuring timely care. Similarly, Resident #171, with diagnoses of Unspecified Atrial Fibrillation and knee pain, had not had their fingernails trimmed since admission two months prior. The resident was dependent on staff for personal hygiene, as documented in their care plan, but there was no evidence of fingernail care in the records. Interviews with the CNA and RN assigned to the resident indicated a misunderstanding of roles, with the RN admitting oversight in addressing the resident's grooming needs. The Director of Nursing was unaware of the issue, despite making regular rounds, highlighting a communication gap in the facility's care processes.
Failure to Provide Timely Ophthalmology Consultation
Penalty
Summary
The facility failed to ensure that a resident received timely ophthalmology consultation as ordered by the medical doctor. The resident, who had a small cataract and reported decreased vision, did not receive the necessary ophthalmology consult in a timely manner. The medical doctor had ordered the consult on February 13, 2024, but the resident was not seen due to being unavailable during the consultant's visits on March 5, 2024, and March 25, 2024. The facility's policy requires that consultations be arranged to maintain or improve residents' functional status, but this was not effectively implemented for the resident in question. Interviews with facility staff revealed a lack of communication and scheduling regarding consultant visits. The Registered Nurse MDS and the Director of Nursing both indicated that there was no advance notice or schedule for when consultants would visit the facility, making it difficult to prepare residents for their appointments. This lack of coordination resulted in the resident not being informed or prepared for the ophthalmology consult, contributing to the delay in receiving necessary vision care.
Failure to Apply Prescribed Pressure Ulcer Prevention Device
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent pressure ulcers. This deficiency was identified during a recertification survey, where it was observed that a resident with a diagnosis of an unstageable pressure ulcer on the left heel was not wearing the prescribed multipodus boot while out of bed. The facility's policy on heel protectors, revised in January 2024, mandates the use of such devices to prevent skin irritation and maintain proper skin hygiene. Despite this, the resident was observed multiple times without the boot, which was supposed to be worn when out of bed for heel pressure relief. Interviews with staff revealed a lack of communication and documentation regarding the resident's need for the multipodus boot. A Certified Nurse Assistant (CNA) stated that they were not informed during the morning report about the requirement for the boot, and a Licensed Practical Nurse (LPN) admitted to not being the regular nurse for the resident and was unaware of the need for the boot until later. The Director of Nursing acknowledged that the nurse should verify orders and communicate the need for special devices to CNAs, and that this information should be documented in the kiosk. The failure to apply the boot as ordered was attributed to a possible oversight in communication during staff handovers.
Failure to Ensure Proper Use of Assistive Device for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This deficiency was identified during a recertification survey, where it was observed that a resident with a physician's order for a left-hand palm protector was not wearing the device on multiple occasions. The resident, who has diagnoses including atrial fibrillation, coronary artery disease, coronary vascular accident, and hemiplegia, was noted to have a contracture of the left hand. The resident's care plan and physician's order specified that the palm protector should be worn at all times except during hygiene, range of motion exercises, and skin checks. Interviews with staff revealed a lack of consistent application of the palm protector. The resident expressed that they were unable to apply the device independently and expected the CNA to assist. However, the CNA reported that the resident preferred the rehabilitation staff to apply the device. The LPN acknowledged that the resident's refusal to wear the device should have been documented, and the RN stated that any refusal should be reported to initiate a refusal care plan. The Director of Rehabilitation was unaware of the resident's preference for rehab staff to apply the device, and the Director of Nursing Services emphasized the need for staff to ensure compliance with physician orders and care plans.
Expired Medications Found on Medication Carts
Penalty
Summary
The facility failed to ensure the timely identification and removal of expired medications during a recertification survey. Specifically, seven expired Heparin lock flush syringes were found on medication carts on the 2nd and 4th floors. The facility's policy requires nurses to check expiration dates before administering medications and to remove expired drugs from medication carts, rooms, and refrigerators. However, observations revealed that expired syringes were still present on the carts, indicating a lapse in adherence to the policy. Interviews with staff, including a Registered Nurse Supervisor, Licensed Practical Nurses, the Pharmacy Supervisor, and the Director of Nursing, highlighted inconsistencies in the process of checking for expired medications. The Pharmacy Supervisor mentioned that their staff conducts monthly reviews, but the expired syringes were not removed in a timely manner. The Director of Nursing acknowledged that while checks are supposed to be conducted, there is no set timeframe for these checks, and random checks are infrequent. This lack of consistent monitoring and adherence to policy led to the presence of expired medications on the units.
Inadequate Hand Hygiene Before Meals
Penalty
Summary
During a recertification survey conducted from April 17 to April 24, 2024, it was observed that the facility failed to maintain an effective infection prevention and control program. Specifically, two residents on Unit 2 were not offered appropriate hand hygiene before being served their lunch meal. The facility's policy, revised in January 2024, mandates that hands should be washed before eating. However, during the dining observation, a Certified Nursing Assistant (CNA) wheeled the residents into the dining area and served them lunch without ensuring their hands were washed or sanitized. Interviews conducted on April 22, 2024, revealed that the CNA acknowledged the requirement for hand hygiene before and after meals but was unsure why it was not performed in this instance. The Infection Control Preventionist confirmed that staff had been educated on hand hygiene practices and reiterated the facility's policy of sanitizing residents' hands before and after meals. The Preventionist also stated that residents should be assessed for hand hygiene upon entering the dining room, but this protocol was not followed for the observed residents.
Inaccurate Documentation of Care Plan Meetings
Penalty
Summary
The facility failed to ensure accurate documentation of care plan meetings in accordance with accepted professional standards and practices. Specifically, the medical records inaccurately documented the attendance of residents and their representatives at care plan meetings. This deficiency was identified during a recertification survey conducted from April 17, 2024, to April 24, 2024, affecting three out of four residents reviewed for care plans. Resident #82, who was moderately cognitively impaired, reported not being invited to any care plan meetings. Despite this, the Care Plan Meeting Report inaccurately documented their attendance along with several staff members. Interviews with staff confirmed that Resident #82 did not attend the meeting, and only the Director of Rehab and Social Worker #1 were present. Similarly, Resident #111's representative stated they had not been called to attend care plan meetings, although the records falsely indicated their presence at multiple meetings. The Director of Discharge Planning admitted that the documentation might not reflect actual attendance, as residents or family members were informed about the meetings afterward. Resident #104, who was cognitively intact, expressed a desire to participate in care planning meetings but was not invited. The Care Plan Meeting Report inaccurately recorded their attendance, although they were at therapy during the meeting. The Director of Discharge Planning acknowledged that Resident #104 did not attend the meeting but was marked as present because they discussed the care plans later in the day. The facility's Administrator confirmed that documentation should reflect actual events, and if not documented, it is considered not done. This discrepancy in documentation practices led to the identified deficiency.
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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) |
|---|---|---|---|---|
| Menorah Home & Hospital For Aged & Infirm | 0.7 mi | ★★★★★ | 4 | 0 |
| The Chateau At Brooklyn Rehab And Nursing Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Shore View Nursing & Rehabilitation Center | 1.9 mi | ★★★★★ | 1 | 0 |
| Sea Crest Nursing And Rehabilitation Center | 3.3 mi | ★★★★★ | 5 | 0 |
| Seagate Rehabilitation And Nursing Center | 3.3 mi | ★★★★★ | 3 | 1 |
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