Hempstead Park Nursing Home

Inspectors wroteBased on observation, interview and record review during a survey, the facility failed to ensure that the residents' right to personal privacy, including the right to send and promptly receive unopened mail and other letters, packages, and other materials delivered to the facility for the residents, including those delivered through a means other than a postal service, was maintained. This was identified for one (Resident #8) of seven residents reviewed Resident/Patient/Client Rights. Specifically, a mailed package for Resident #8 was delivered from outside to the facility; however, the package was not received by the resident.

Inspectors wroteBased on observation, interviews, and record review during the abbreviated survey, the facility failed to ensure resident rights to be free from abuse for two (Resident #11 and Resident #12) of three residents reviewed for Abuse. Specifically, Staff observed Resident #12 having a physical altercation with Resident #11. Resident #12 was on top of Resident #11 with both hands placed around Resident #11's neck. Resident #12 stated they were attempting to retrieve a belt they alleged Resident #11 had taken. Assessment of Resident #11 revealed bleeding from their nose, mouth, and the right second toe.

Inspectors wroteBased on observation, record review, and interviews during the survey, the facility failed to ensure that each resident had a clean, comfortable, and homelike environment. This was identified for four (2 North, 2 South, 3 North, and 3 South units) of six units observed for environment. Specifically, during observations the day rooms and hallways in units 2 North, 2 South and 3 North had ripped sheetrock and peeling wallpaper; the shower rooms in units 2 South, 3 North and 3 South had torn privacy curtains; Unit 3 South resident bathroom was in an unsanitary condition with debris on the floor and had a foul odor; and unit 3 North resident bathroom was observed with missing wall tiles.

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure that residents' drug regimens were free from unnecessary psychotropic medications. This was identified for one (Resident #14) of five residents reviewed for Unnecessary Medications. Specifically, Resident #14 had a Physician's Order to receive Olanzapine (an antipsychotic medication) 5 milligrams once a day from 04/16/2025 to 05/15/2025. On 05/16/2025, the Physician lowered the resident's Olanzapine dose to 2.5 milligrams once a day. On 06/04/2025, the facility changed its Electronic Medical Record (EMR) to another vendor company. Resident #14's Olanzapine order was inadvertently reverted to 5 milligrams of Olanzapine daily without the consent or knowledge of the resident or the resident's Physician. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified on one (1) (Unit 4 South) of six (6) units reviewed for the Sufficient Nursing Staffing Task. Specifically, the Centers for Medicare and Medicaid Services Payroll-Based Journal Staffing Data Report for Fiscal Year Quarter Two 2025 (January 1st-March 31st) indicated that the facility had a one (1)-star staffing rating. Additionally, there were multiple occasions when the facility had insufficient Licensed Practical Nurses assigned to Unit 4 South, as specified on the Facility Assessment. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey and Abbreviated Survey (Complaint #697429) initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure resident rights to be free from abuse. This was identified for two (Resident #83 and Resident #98) of three residents reviewed for Abuse. Specifically, on 04/25/2025, Resident #83, with intact cognition, was using a common bathroom. Resident #98, with severely impaired cognition, attempted to enter the same bathroom, and Resident #83 told Resident #98 to get out. Resident #98 made a fist and swung at Resident #83. Resident #83, in turn, punched Resident #98 in the right eye; Resident #98 was sent to the emergency room for evaluation for complained of pain and redness in the right eye. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure that the resident representative and Ombudsman were notified for each resident discharged from the facility. This was identified for one (Resident #241) of two residents reviewed for Discharge. Specifically, Resident #241 had a planned discharge from the facility on 04/20/2025 to another facility. There was no documented evidence that the resident's representatives and the Ombudsman were notified of the discharge. The finding is:The facility's policy titled Transfer and Discharge Planning and Documentation, effective 4/28/2025, documented notifying the resident/family/ombudsman in writing before a transfer or discharge. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure it developed and implemented a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (1) (Resident #65) of two (2) residents reviewed for Rehabilitation and one (1) (Resident #11) of two (2) residents reviewed for Positioning/Mobility. Specifically, 1) Resident #65 had a right above-the-knee amputation and was in the process of getting a prosthetic limb device. There was no comprehensive care plan regarding the amputation, including the status of the prosthetic device; [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was identified for one (1) (Resident #232) of three (3) residents reviewed for Choices. Specifically, Resident #232 returned to the facility from the hospital on [DATE] after a Pacemaker (a small implanted medical device that helps regulate a slow heart rate by sending electrical impulses to the heart) Implantation. Resident #232 had a recommendation from the hospital for a follow-up consultation with an Electrophysiologist (a Cardiologist who specializes in diagnosing and treating heart rhythm disorders) after three weeks. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 7/28/2025 and completed on 8/5/2025, the facility did not ensure that each resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. This was identified for one (Resident #6) of two residents reviewed for Respiratory Care. Specifically, Resident #6 had a Tracheostomy (a surgical procedure where a hole is made in the windpipe (trachea) to create an opening in the neck, allowing a tube to be inserted for breathing assistance). The facility converted to a different electronic medical record company in June 2025. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure that drugs and biologicals were stored in a locked compartment. This was identified for one (1) (Resident #208) of eight (8) residents reviewed for Accidents. Specifically, a tube of unlabeled Hydrocortisone (a steroid cream to treat inflammation and allergies) cream 0.5 percent, and a labeled Triamcinolone (a prescription steroid cream to treat allergies and inflammation), 0.1 percent, cream were observed on Resident #208's overbed table. [...]

Inspectors wroteBased on interviews and record review during the recertification survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure If the facility did not employ a qualified professional person to furnish a specific service to be provided by the facility, services were furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act for each resident. This was identified for one (1) (Resident #179) of one (1) resident reviewed for Vision/Hearing. Specifically, Resident #179 was seen by the Optometrist on 04/28/2025 and recommended a referral for an Ophthalmology consult for Cataract (a clouding of the lens of the eye) surgery. The facility did not arrange an appointment with the Ophthalmologist until 08/04/2025, approximately three (3) months after the recommendation was made. [...]

Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure each resident's bedside was adequately equipped to allow residents to call for staff assistance through a communication system that relayed the call directly to a staff member or to a centralized staff work area. This was identified for one (Resident #40) of three (3) residents reviewed during the Environmental Task. Specifically, on 07/28/2025 and 07/29/2025, Resident #40's call bell was not functioning, and the annunciator system at the nursing station did not register the calls from Resident #40's room. The finding is:The facility's policy, titled Resident's Use of Call Bells, last reviewed on 07/29/2025, documented call bell functioning will be checked monthly and as needed by the Maintenance Department. [...]

Inspectors wroteBased on record review and interview during the Recertification Survey initiated on 07/28/2025 and completed on 08/5/2025, the facility did not ensure the Facility Assessment considered specific staffing needs for each resident unit for each shift, such as day, evening, and night. This was identified during the Sufficient Nursing Staffing Task. Specifically, the Facility Assessment, last reviewed in June 2025, did not indicate staffing needs for Certified Nursing Aides, Monday to Friday, for each unit and each shift. Additionally, the Facility Assessment did not specify the staffing needs for Licensed Practical Nurses for each unit for the 3:00 PM-11:00 PM shift and the 11:00 PM-7:00 AM shift during the weekdays. [...]

Inspectors wroteBased on interviews and record review in an abbreviated survey (Complaint # NY00340378), the facility did not ensure that Residents were appropriately supervise and implement interventions to prevent resident to resident sexual abuse for one Resident (Resident #2) of three residents reviewed for sexual abuse. Specifically, Resident #1 (Brief Interview Mental Status score 11) who is cognitivly impaired was observed behind closed doors engaging in sexual activities with Resident #2 (Brief Interview Mental Status score 0)

Inspectors wroteBased on observation, record review and interviews during an abbreviated survey (Case #NY00321006) the facility failed to ensure that a resident identified as an elopement risk received adequate supervision to prevent elopement from the facility. This was evident in 1 out of 3 residents reviewed for elopement (Resident #1). Specifically, Resident #1 who was cognitively impaired, was initially assessed as an elopement risk on 07/07/2022. At that time, the resident was placed on 15-minute monitoring, and a wander alert device was placed on the left ankle. Subsequently, on 02/19/2024 at 4:54 PM, Resident #1 walked through the front door undetected, and was returned to the facility by relatives and local police on 02/20/2024 at 12:57 PM. This resulted in Immediate Jeopardy with the likelihood for a serious adverse outcome to Resident #1 and 31 other residents who were at risk for elopement.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 11/28/2023 and completed on 12/5/2023 the facility did not ensure the residents had a safe, clean, comfortable, and homelike environment. This was identified for one (Resident #29) of one resident reviewed for the Environment. Specifically, Resident #29's bed rail, wheelchair arm rest, and left side of the wheelchair were observed soiled with a cream colored and crusty substance on multiple occasions (11/28/2023, 11/29/2023 and 11/30/2023). The finding is: The facility's policy titled, Wheelchair/Gerichair/Cleaning Monitoring dated 10/12/2021 documented the 3 PM - 11 PM shift will prepare and have all wheelchairs and Geri chairs ready for cleaning. Any wheelchair designated by nursing which needs additional cleaning will be cleaned and returned to the unit by housekeeping staff. [...]

Inspectors wroteBased on observation, record review and staff interviews conducted during the Recertification Survey and Abbreviated Survey (NY003183311) initiated on 11/28/2023 and completed on 12/5/2023 the facility did not ensure that each resident was free from abuse. This was identified for three (Resident #61, Resident #71 and Resident #84) of eight residents reviewed for resident to resident altercation. Specifically, on 6/13/2023 Resident #61 threw a can of soda at Resident #71. Resident #71 then threw a can of soda at Resident #61. Resident #61 was assisted to their room by Certified Nursing Assistant (CNA) #9. CNA #9 exited Resident #61's room to get a Hoyer (Mechanical) lift. Resident #61 exited their room with a broomstick and hit Resident #71 and Resident #84 with the broomstick. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (NY00327941), initiated on 11/28/2023 and completed on 12/5/2023 the facility did not ensure that all incidents were investigated thoroughly. This was identified for one (Resident #16) of 12 residents reviewed for Abuse. Specifically, Resident #16 was observed with a discoloration to the lower left eyelid, an injury of unknown origin, on 11/11/2023 at approximately 4 AM. The facility investigation did not include the assigned Certified Nursing Assistant (CNA) #1's statement to determine the root cause of the injury. The finding is: The facility Accident and Incident Investigation and Reporting policy and procedure dated 10/20/2023 documented that investigation statements are to be obtained from the assigned CNA, any witnesses to the occurrence, and the person who reported the occurrence. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 11/28/2023 and completed on 12/5/2023 the facility did not ensure that all services provided by the facility met professional standards of quality. This was identified for one (Resident #140) of five residents reviewed for Medication Regimen Review (MRR). Specifically, Resident #140's Insulin injections sites and Nitroglycerin (Heart medication) transdermal (through the skin) 24-hour patch application sites were not documented on the Medication Administration Record (MAR) on multiple occasions. The finding is: [...]

Inspectors wroteBased on observations, record review and interviews conducted during a Recertification Survey initiated on 11/28/2023 and completed on 12/5/2023, the facility did not ensure that the residents' environment remained as free from accident hazards as possible, and each resident receives adequate supervision to prevent accidents. This was identified for one (Resident #186) of 14 residents reviewed for Accidents. Specifically, Resident #186 was observed on 11/28/2023 with multiple medication pills in a medication cup, including an antipsychotic medication, on their overbed table with no staff member in the vicinity. The resident was not assessed to safely self-administer medications. The finding is: The facility's policy titled Medication Administration dated 9/20/2023 documented a nurse will watch the resident swallow the medication and offer appropriate liquid. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 11/28/2023 and completed on 12/5/2023 the facility did not ensure that the medical care of each resident was supervised by the Physician including monitoring changes in the resident's medical status. This was identified for one (Resident #38) of four residents reviewed for Nutrition. Specifically, Resident #38 had an unplanned significant weight loss of 5.8% over a 30-day period. There was no documented evidence that the resident's weight loss was addressed by the Physician. The finding is: The facility's policy titled Notification of Clinical Nutrition Changes, last reviewed on 12/1/2023, documented to inform the resident and/or representative and the resident's Physician when there is a change in the resident's clinical nutrition status or diet. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 11/28/2023 and completed on 12/5/2023 the facility did not ensure each Pharmacy Consultant Medication Regimen Review (MRR) recommendation was addressed by the resident's attending physician. This was identified for two residents (Resident #140 and Resident #79) of five residents reviewed for Unnecessary Medications. Specifically, 1) Resident #140 was prescribed Lantus Solostar U-Insulin subcutaneously (beneath the skin) once daily, a Nitroglycerin (Heart medication) transdermal (through the skin) 24-hour patch, Budesonide suspension for nebulization (a mist that is inhaled into the lungs), and Fluticasone nasal spray on 7/18/2023. On 8/10/2023 the Pharmacy Consultant recommended the Lantus and Nitroglycerin patch application site should be documented and rotated. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 00325593), initiated on 11/28/2023 and completed on 12/5/2023, the facility did not ensure each resident obtained radiological services timely. This was identified for one (Resident #6) of 10 residents reviewed for Abuse. Specifically, Resident #6 complained of pain to the right leg on 9/29/2023 and 9/30/2023. STAT (immediate) x-rays were ordered on 10/1/2023; however, the x-rays were not completed as ordered. On 10/2/2023 Resident #6 was found on the floor and continued to complain of pain to their right leg. New orders for the STAT x-rays were obtained on 10/2/2023. The x-rays were not completed until after five days on 10/6/2023, after the original order on 10/1/2023. The x-ray results revealed a right hip fracture. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey completed on 11/8/2021, the facility failed to ensure that it maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for four (Resident #203, #86, #112, and#197) of four residents reviewed for Respiratory Care. [...]

Inspectors wroteBased on record review and interview during the Recertification Survey and the Abbreviated survey (Complaint #NY00283512), completed on 11/8/2021, the facility did not ensure that all resident representatives were informed of significant change in the resident's status for 1 (Resident #355) of 1 resident reviewed for change in condition. Specifically, Resident #355 had a decline in ambulatory status identified on 7/7/2021. The resident was referred to physical therapy and was placed on rehabilitation services. The resident representative was not notified of the resident's change in condition which resulted in a need to commence physical therapy treatment. The finding is: [...]

Inspectors wroteBased on observation, interviews, and record review during the Recertification Survey and Abbreviated Survey (Complaint #NY00284403), the facility did not ensure resident rights to be free from abuse for two (Resident #57 and Resident #70) of four residents reviewed for Abuse. Specifically, Resident #57, who had Dementia, kicked Resident #70. Resident #70, who was assessed with intact cognition, in turn threw a garbage can at Resident #57 which resulted in two small lacerations to Resident #57's legs. The finding is: The facility Abuse Prevention Policy and Procedure, dated 11/2018 and revised 10/2020, documented the resident has the right to be free from abuse in the facility. Physical abuse is inappropriate physical contact resulting in injury or harm to a resident. It includes the willful infliction of injury with resulting physical harm. [...]

Inspectors wroteBased on record reviews and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00261845 and # NY 00270792) completed on 11/8/2021, the facility did not ensure that injuries of unknown origin were reported immediately (no later than 24 hours) for one (Resident #304) of three residents reviewed for Change of Condition, and did not ensure that an accident and injury involving potential staff neglect was reported immediately (no later than 24 hours) for one (Resident #305) of 10 residents reviewed for Accidents. Specifically, 1) Resident #304 was identified by facility staff on 7/13/2020 and 7/16/2020 to have injuries of unknown origin; however, the injuries were not reported to the New York State Department of Health (NYSDOH) until 8/7/2020; and 2) Resident #305 was injured while being transferred by staff via a mechanical (Hoyer) lift on 1/8/2021; [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey completed on 11/8/2021, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that includes measurable objectives and timeframes to meet a resident's medical and nursing needs. This was identified for one (Resident #148) of five residents reviewed for Unnecessary Medications. Specifically, Resident #148 received Clopidogrel, an anticoagulant; however, there was no Comprehensive Care Plan (CCP) developed for anticoagulant medication use. The finding is: Resident #148 was admitted with diagnoses including Myocardial Infarction, Essential Hypertension, and Atherosclerotic Heart Disease. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 00273149), the facility did not ensure that each resident receives adequate supervision to prevent accidents for one (Resident #75) of one resident reviewed for Physical Restraints and that the resident environment remained free of accident hazards for one (Resident #112) of four residents reviewed for Accidents. Specifically, 1) Resident #75, who was assessed at high risk for falls, sustained a fall with injury when left unsupervised in a facility dining room on 3/16/2021; and 2) two Intravenous (IV) kits with 23-gauge needles and one IV kit with an 18-gauge needle was observed unattended in Resident #112's room.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey completed on 11/8/2021, the facility did not ensure that each resident who needs respiratory care is provided with such care, consistent with professional standards of practice for one (Resident #196) of 6 residents reviewed for Respiratory Care. Specifically, Resident #196, with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), was administered oxygen without a Physician's order. Additionally, the resident's oxygen saturation rate was not monitored to assess the resident's respiratory status and need for oxygen use. The finding is: The facility's policy titled Oxygen Therapy, dated 7/30/2021, documented the Primary Medical Doctor (PMD) will order supplemental oxygen therapy. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey completed on 11/8/2021, the facility did not label drugs and biologicals used in accordance with currently accepted professional principles, including dating the medication when first opened. This was identified during the medication storage task for two of six medication storage room/medication cart observations. Specifically, Resident #4, #177, and #29 had medications in the unit medication cart that were not dated when first opened.

Inspectors wroteBased on record reviews and staff interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY00261845 and NY 00270792) completed on 11/8/2021, the facility did not report an injury of unknown origin and an incident involving a mechanical lift to the New York State Department of Health (NYSDOH) in accordance with the NYSDOH Nursing Home Incident Reporting Manual for one (Resident #304) of three residents reviewed for Change of Condition and for one (Resident #305) of 10 residents reviewed for Accidents. Specifically, 1) Resident #304 was identified by facility staff on 7/13/2020 and 7/16/2020 to have injuries of unknown origin; however, the injuries were not reported to the NYSDOH until 8/7/2020; [...]