Hempstead Park Nursing Home

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements for daily nursing staff coverage and supervision by a licensed nurse on all shifts.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that Resident #14’s drug regimen was free from unnecessary psychotropic medication when the resident’s Olanzapine dose was inadvertently reverted from 2.5 mg daily back to 5 mg daily after an EMR conversion. Resident #14 had diagnoses including Schizophrenia and Anxiety Disorder, and a significant change MDS documented a BIMS score of 3, indicating severely impaired cognitive skills for daily decision making. The resident had been ordered Olanzapine 5 mg daily on readmission, then the dose was lowered to 2.5 mg daily after a psychiatric consultation and physician order on 05/16/2025. The old EMR MAR documented the resident received Olanzapine 2.5 mg daily through 06/03/2025. When the facility changed to a new EMR system, the resident’s Olanzapine order was carried over as 5 mg daily, and the new EMR MAR documented administration of 5 mg daily from 06/04/2025 through 07/29/2025. The psychiatric consultation and physician progress notes continued to document the recommendation to lower Olanzapine to 2.5 mg once daily in the evening, but the new EMR order remained at 5 mg daily. During interviews, the pharmacy EMR specialist stated the original 5 mg order had been transferred to the new system and that someone from the facility should have manually entered the changed 2.5 mg order after the transfer. The primary physician stated they were not aware the resident was receiving 5 mg instead of 2.5 mg and that it was never their intention for the resident to return to the higher dose. The administrator stated the facility was not monitoring how pharmacy orders were carried over during the EMR change, and an LPN stated they did not double-check the order transfer before dispensing the medication.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that the resident representative and Ombudsman were notified for each resident discharged from the facility. This was identified for Resident #241, who had a planned discharge to another facility and for whom the medical record contained no documented evidence that the resident's representative or the Ombudsman was notified of the discharge. The facility policy titled Transfer and Discharge Planning and Documentation required written notice to the resident, family, and Ombudsman before a transfer or discharge, with the Social Worker responsible for resident/representative notice and the Director of Social Work responsible for Ombudsman notice. Resident #241 was admitted with diagnoses including Bipolar Disorder, Depression, and Chronic Obstructive Pulmonary Disease, and the admission MDS documented a BIMS score of 15, indicating the resident was cognitively intact. The care plan documented discharge planning with the resident's discharge status uncertain, and progress notes later documented the resident requested to return to the former facility and was accepted. The resident left to the requested facility via ambulette, but the record did not show notification to the resident's representative or the Ombudsman. During interviews, Social Worker #1 stated an email had been sent to the Ombudsman but could not locate it, and later stated the resident's representative was not notified; Social Work Director #1 stated there had been an oversight and the resident's name had been inadvertently removed from the discharge notification list for the Ombudsman.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that comprehensive care plans were developed and implemented for residents with identified needs, including measurable objectives and timeframes. During the recertification survey, this was identified for one resident with a right above-the-knee amputation who was in the process of obtaining a prosthetic limb, and for another resident with an order for a hand roll to the right hand at all times or as tolerated. For the resident with the amputation, the admission assessment documented diabetes mellitus, bipolar disorder, and acquired absence of limb, and the physician’s admission evaluation documented a right above-the-knee amputation. Although care plans were in place for limited physical mobility and fall prevention, they did not document the amputation. The resident stated they had been told a prosthetic leg would be arranged on admission and wanted to walk again, but were unsure of the status of the plan. Rehabilitation staff stated the department would not create a care plan until the prosthetic device was obtained, and that communications with the orthotic provider were kept in a book in the rehabilitation department rather than documented in the medical record. A prosthetic lab letter dated 07/31/2025 described difficulty obtaining components due to the resident’s weight and insurance coverage, and noted that casting, fabrication, and fit checks had occurred while authorization was pending. For the resident with the hand roll order, the quarterly MDS documented severe impairment in daily decision-making and impairment in range of motion of both upper extremities. The physician ordered a hand roll to the right hand at all times or as tolerated, and the care plan and Kardex both included that intervention. However, the resident was observed without the hand roll on two separate occasions. The assigned CNA stated the resident did not use a hand roll and was resistant to hand care, and could not recall seeing one in the room. The charge nurse stated she sometimes applied rolled gauze herself but did not instruct CNAs to do so, and acknowledged the hand roll should have been applied as ordered. The OT stated the resident had low potential for significant improvement and had only been able to tolerate a hand roll after trials of other devices.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that Resident #232 received treatment and care in accordance with professional standards of practice after returning from the hospital following a pacemaker implantation. The resident had diagnoses including left bundle branch block, congestive heart failure, hypertension, and severe cognitive impairment, and the hospital discharge summary documented a need for follow-up consultation with an electrophysiologist in three weeks. The resident’s MDS also identified an active diagnosis of presence of a cardiac pacemaker. After the resident returned to the facility, there was no documented evidence that the electrophysiology follow-up was scheduled, no physician’s order for pacemaker monitoring until later, and no evidence that the pacemaker site was monitored. The direct care nurses were not aware that the resident needed to be connected to the pacemaker transmitter, and the transmitter box remained sealed on the floor next to the resident’s bed during observations. The resident was unable to identify the contents of the box. The resident’s care plan did not include the pacemaker until later, despite the facility’s policies requiring review of pacemaker status, care planning, consultant follow-up, and communication of consultant recommendations. Staff interviews confirmed that the covering unit manager did not know the transmitter needed to be set up for remote monitoring, the LPN did not know the transmitter was in the room, and the physician assistant stated the transmitter ideally should have been set up when the resident returned from the hospital and that the resident needed an electrophysiology consult as soon as possible. The DON stated the pacemaker should have been added to the care plan, a physician order should have been in place, and the follow-up consultation should have been arranged by the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Safe and appropriate respiratory care was not provided for a resident with a tracheostomy, chronic respiratory failure, diabetes mellitus, and morbid obesity. The resident’s quarterly MDS documented moderate cognitive impairment and that the resident received tracheostomy care and oxygen therapy. The facility’s policy required tracheostomy care and stoma care each shift and as needed, suctioning as needed, daily inner cannula changes, and documentation of these treatments on the treatment administration record. The oxygen therapy policy required oxygen to be provided as ordered and the liter flow to be checked and signed for each shift. The resident had physician orders for tracheostomy care every shift, suction tracheal secretions every shift and as needed, daily inner cannula changes, and oxygen at 3 liters per minute as needed. After the facility changed electronic medical record systems in June 2025, these orders did not carry over into the new system, and nurses did not document the tracheostomy care, suctioning, inner cannula changes, or oxygen therapy from 06/04/2025 until 07/31/2025. A separate physician order for oxygen at 3 liters per minute via tracheostomy mask as needed for acute respiratory failure with hypoxia also was not carried over, and there was no order to monitor oxygen saturation. During observations, the resident was seen in bed with a tracheostomy and the oxygen concentrator set at 8 liters per minute, while the physician order was for 3 liters per minute. The resident stated having difficulty breathing at times and needing to call the nurse for attention, and later stated having a little trouble breathing. An LPN stated they provided daily tracheostomy care but could not identify where it was documented when no orders were present in the current EMR, and stated oxygen saturation was monitored during care but not documented. Staff interviews confirmed the orders were not transferred properly, that the nurse should have notified supervision when orders were missing, and that the oxygen saturation should have been checked every shift and documented.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Drugs and biologicals were not stored in a locked compartment for one resident who was reviewed for accidents. During the recertification survey, surveyors observed a tube of unlabeled Hydrocortisone 0.5% cream and a labeled Triamcinolone 0.1% cream on the resident’s overbed table. On the resident’s nightstand, surveyors also observed a labeled Chlorhexidine Gluconate 0.12% mouthwash, a labeled Fluticasone nasal spray, a labeled Patadine 0.1% eye drop bottle, and an unlabeled Refresh eye lubricant bottle. No nursing staff were in the vicinity of the room at the time of the observation. The resident had diagnoses including atrial fibrillation, COPD, and hypertension. The quarterly MDS documented a BIMS score of 15, indicating intact cognition, and documented that the resident’s vision was adequate. The resident was not assessed to self-administer medications. The resident’s record included orders for Flonase nasal spray, Peridex mouthwash, Olopatadine ophthalmic solution, and Triamcinolone topical ointment, but there was no physician order for the Hydrocortisone cream or the Refresh eye drops found in the room. The facility policy titled Storage of Drugs stated that all medications and treatment items were to be stored in a locked cabinet inaccessible to residents and visitors. During interviews, an LPN stated medications had already been administered outside the room and did not know the resident had medications in the room. The unit manager stated the resident should not have medications stored in the room and that medications should be stored in the medication cart. The resident stated nurses brought the medications and supervised administration, and that some medications from home were in the room but were never used. The DON stated nursing staff should not have left medications on the resident’s table and nightstand.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that outside professional services were arranged under a proper agreement when it did not timely secure an Ophthalmology consult for a resident after an Optometrist recommended referral for cataract surgery. Resident #179, who had diagnoses including glaucoma, Parkinson’s disease, and hypertensive heart disease, had intact cognition, adequate vision, and wore corrective lenses. A comprehensive care plan identified potential visual impairment due to cataracts in both eyes. The Optometry consult documented cataracts in both eyes and recommended referral to an Ophthalmologist for cataract surgery, but no physician order for that consult was entered until several months later. The resident had reported needing new glasses because the prior pair had broken and had not been replaced. Nursing staff described a process in which consult forms were to be completed and forwarded for transportation arrangements, and the nursing supervisor was expected to review consultant recommendations and place referral orders when needed. However, the Medical Records/Transportation Coordinator stated they were not made aware of the Ophthalmology need until the day the appointment was finally scheduled. The DON stated the Ophthalmology consult should have been ordered and scheduled as soon as possible after the Optometrist’s recommendation was received.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that Resident #40 had a functioning call bell system at the bedside to allow the resident to call for staff assistance. Resident #40 was admitted with spinal stenosis, pain, and atrial fibrillation, and the Quarterly MDS documented a BIMS score of 12, indicating moderately impaired cognition. The resident was dependent for activities of daily living, including toileting, hygiene, upper and lower body dressing, and bed mobility, and was unable to walk ten feet. During observation, Resident #40 was heard shouting for help from the room while the call light above the door was not activated and no call bell sound was heard. The resident was observed in bed holding and pressing the call bell and stated they had been pressing it and calling for help for about 30 minutes because they were cold and could not turn off the air conditioner. On a later observation, the resident was again heard calling out for help, and the call light above the room did not activate. The nursing station annunciator did not register the call when the bell was pressed from the room. The call bell check log for the unit documented that the call bells in Resident #40's room required repairing.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that its Facility Assessment included specific staffing needs for each resident unit and each shift, as required. During the recertification survey, it was found that the Facility Assessment, last reviewed in June 2025, did not indicate the required number of Certified Nursing Aides for each unit and each shift (7:00 AM-3:00 PM, 3:00 PM-11:00 PM, and 11:00 PM-7:00 AM) on weekdays. Additionally, the assessment did not specify the staffing needs for Licensed Practical Nurses for each unit for the 3:00 PM-11:00 PM and 11:00 PM-7:00 AM shifts during the weekdays. Interviews with the Administrator revealed that both the Administrator and the Director of Nursing Services (DON) were involved in developing and reviewing the Facility Assessment, with the DON responsible for the nursing staffing portion. The Administrator acknowledged that the Facility Assessment should have clearly indicated specific nursing staffing needs by resident units for each shift and stated that the omission was an oversight. The DON responsible for this section was no longer employed at the facility at the time of the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure appropriate supervision and implementation of interventions to prevent resident-to-resident sexual abuse. Specifically, a cognitively impaired resident with a Brief Interview for Mental Status (BIMS) score of 11 was observed engaging in sexual activities with another resident who had a BIMS score of 0, indicating severe impairment for decision-making. The incident occurred behind closed doors, where a Certified Nurse's Aide (CNA) witnessed the cognitively impaired resident performing oral sex on the severely impaired resident. Both residents were known to have impaired cognition and were on 30-minute visual checks due to their behaviors. The facility's policy on abuse prevention states that residents have the right to be free from abuse, including non-consensual sexual contact. Despite this, the facility did not adequately evaluate the residents' capacity to consent to sexual activity, as both residents were confused and unable to consent. The incident was reported to the Nursing Supervisor, and both residents were placed on one-to-one supervision. The Director of Nursing and the Administrator acknowledged that both residents had impaired cognition and were not capable of consenting to sexual activities.

Plan Of Correction

Plan of Correction: Approved January 31, 2025 Hempstead Park Nursing Home P(NAME) F689 1. Immediate Correction: 1) On 2/03/2025 the DNS reviewed plan of care for Resident # 1 to ensure that all measures were in place to provide adequate supervision to prevent any future incidents of sexual abuse. The P(NAME) included redirecting residents to high visibility areas, day room monitoring, re-direction of peers from entering room, ensuring that room door is always kept open, staff education on special care needs, monitoring and reporting of inappropriate sexual behaviors, psychological services, and regular psychiatric evaluations. 2) On 2/03/2025 the DNS reviewed plan of care for Resident # 2 to ensure that all measures were in place to provide adequate supervision to prevent any future incidents of sexual abuse. The P(NAME) included redirecting residents to high visibility areas, day room monitoring, re-direction of peers from entering female rooms, ensuring that room door is always kept open, staff education on special care needs, monitoring and reporting of inappropriate sexual behaviors, Resident 1 to remain on psychological service and regular psychiatric evaluations for both residents. II. Identification of Others: 1) The facility respectfully states that all residents with impaired cognition could potentially be at risk for sexual abuse. 2) A list of all residents that triggered for behaviors of wandering and inappropriate behaviors towards others was generated from MDS data submitted in the last 90 days. 3) A list of all residents that display or displayed inappropriate sexual behaviors was obtained from RN Unit Manager for each floor. 4) The identified residents were audited to ensure that a plan of care was in place to provide adequate supervision to prevent incidents of sexual abuse: to include enhanced monitoring, day room supervision, staff education, and awareness. III. Systemic Changes: 1) The DNS and ADMIN reviewed the Policy and Procedure for Accident and Incidents, and found same to be in compliance. 2) The DNS and ADMIN reviewed the Policy and Procedure on Abuse and found same to be in compliance. 3) All Nursing Staff will receive In-service Education by the In-service Coordinator on the need for adequate supervision and interventions to prevent resident to resident sexual abuse. Highlights of the Lesson Plan include: - The definition of sexual abuse - The responsibility to supervise and safeguard residents with behaviors in order to prevent abuse - Resident behaviors that indicate a sexual preoccupation - Residents that have a history of sexually inappropriate behaviors - Residents that display signs of affection towards peers - The responsibility of staff to communicate any of the above behaviors to the Charge Nurse - The responsibility of the IDT to review these behaviors and the interventions that will provide adequate supervision and safeguarding to prevent sexual abuse - The importance of re-directing residents that wander to a common area and the need to engage them in activities - The need to ensure that resident room doors are open unless otherwise care planned for - The importance of having cognitively impaired residents meet in a common area rather than in their rooms - The responsibility of the IDT to identify residents that have a friendship with each other and implement a plan of care for this. - The process involved in care planning when 2 residents are able to consent to sexual intimacy IV. Quality Assurance: 1) The DNS developed 2 audit tools to monitor the facility’s compliance with ensuring that each resident displaying wandering, sexually preoccupied behaviors, and/or displaying fondness for a peer have a plan of care in place to provide adequate supervision to safeguard them from sexual abuse and that all staff are aware of behaviors and actions to take in order to safeguard and supervise residents that may be at risk for sexual abuse. 2) Audits will be done by RNs weekly x 4 weeks on all residents that have these behaviors documented in the progress notes followed by monthly x 5 months. 3) Audits will be done by RNs weekly on 6 random nursing staff members weekly on safeguarding and monitoring residents to prevent sexual abuse followed by 6 random nursing staff members monthly x 5 months. 4) Findings from the audits that require corrective actions will immediately be rectified and brought to the Morning QA Meeting for review. 5) Findings will be reviewed during the Quarterly QA Meeting to ensure sustainability. IV. Person Responsible for this FTag: DNS

Penalty

Inspection fine: $15,445

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident identified as an elopement risk received adequate supervision to prevent elopement. Resident #1, who was cognitively impaired and assessed as an elopement risk, was placed on 15-minute monitoring and equipped with a wander alert device. Despite these measures, Resident #1 was able to leave the facility undetected on 02/19/2024 and was returned by relatives and local police the following day. The visual monitoring sheet documented that Resident #1 was last seen on the unit at 4:45 PM, but there were no further entries after that time. Video surveillance revealed that Resident #1 exited the building at 4:54 PM, passing the main security desk where the security guard disarmed the alarm without verifying the resident's identity or notifying the nursing supervisor. The resident was discovered missing at 6:15 PM when the dinner tray was served, and a facility-wide search and notification process was initiated, including calling the local police and the resident's representative. Interviews with staff indicated that the visual checks were not completed due to a busy unit, and the security guard was unaware of the resident's status and did not follow proper protocol when the alarm sounded. The Director of Nursing and the former Facility Administrator confirmed that there was no mechanism in place to identify if a resident was off the unit other than staff observation, and the security guard should have notified the supervisor immediately when the alarm sounded. The Maintenance Director stated that the alarm sounds but does not impede the door from opening or closing, and there is no mechanism on the elevator to detect a wander guard. The Medical Director stated that residents on 15-minute monitoring should be visualized by staff, but they did not know how Resident #1 was able to get out.