Fordham Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not ensure infection control practices were followed. This was evident during the Dining Task for 1 of 5 dining rooms. Specifically, 1. The kitchen did not ensure that food items were discarded by the use/expiration date. This was evident for the Kitchen Task. 2. Certified Nursing Assistant #8 did not perform hand hygiene in between residents while assisting multiple residents with hand hygiene prior to lunch being served this was evident for the 5th floor. The findings are: The facility policy titled Standard Precautions for Infection Control that was revised on 11/2017 and reviewed 07/23/2024 documented, It is the policy of the facility to follow and apply standard precautions as infection prevention measure during all resident care regardless of suspected or confirmed infection status of the resident. Standard precautions is based on the principle that all blood,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for 1 (Resident #209) out of 5 residents reviewed for Accidents out of 37 total sampled residents. Specifically, the facility did not report an incident when Resident #209 was found on the floor with laceration on the hand and a head contusion, to the New York State Department of Health. The findings are: The facility's policy and procedure titled, Reporting and Investigation of Resident Abuse, Neglect,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews conducted during the Recertification survey from 10/21/2024 through 10/28/2024, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status for 2 ( Resident #170 and #79) residents out of total 38 sampled residents. Specifically, (1) Resident #170 who was not receiving anticoagulant medication was coded as receiving anticoagulant medication. (2) Resident #79 was coded as receiving hospice services after hospice services were ordered disconinued . The findings include are: The facility policy titled MDS Assessment Version 3.0 effective 10/2023 documented the facility will conduct initially and periodically a comprehensive, accurate, standardize reproducible assessment of each resident's functional capacity. The assessment must reflect the status of the resident including resident strengths and needs that must be addressed in an individualized care plan. The Minimum Data Set Assessment Version 3.0 Correction /…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews conducted during Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not provide, based on the comprehensive assessment, interests, and the preferences of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not appropriately assess interests and activity preferences for non-English speaking resident and provide an ongoing program of activities designed to meet their interests for Resident #209. This was evident for 1 (Resident #209) resident reviewed for Activities out of 37 total sampled residents. The findings are: The facility's policy and procedure entitled Activity Recreation Program and Assessment revised 11/2016 documented that facility shall provide for an ongoing program of activities designed to meet the interest and the physical, mental, psychosocial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility failed to ensure that the physician reviewed the resident's total program of care at each visit. This was evident for 1 (Resident #74) of 1 resident reviewed for an Optometry consult. Specifically, there was no documented evidence that the recommendations by the Optometrist to see the Ophthalmologist was carried out. Additionally, the Optometry consult was dated 04/05/2024 and attending physician reviewed and signed the consult on 09/07/2024 which was 5 months later then the consult date. The findings are: The facility policy titled Medical and dental Consults dated 05/2024 documented it is the policy of the facility to arrange for services of qualified professional personnel to render specific medical services. An order for consultation shall be placed in the electronic medical record (EMR) with the reason for consultation. Consultations shall be completed within 30 days of the initial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in 1 of 1 resident observed for tube feeding. Specifically, Enhanced Barrier Precautions were not maintained during tube feeding administration for residents with gastrostomy tubes. (Residents #187) The findings are: The Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group memorandum titled Enhanced Barrier Precautions in Nursing Homes, Ref: QSO-24-08-NH dated 03/20/2024 documented that effective 04/01/2024, Centers for Medicare and Medicaid Services is issuing a new guidance for long term care facilities on the use of enhanced barrier precautions to align with nationally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the Recertification and Abbreviated Survey (NY00354048) from 10/21/2024 to 10/28/2024, the facility did not ensure that it promoted and facilitated resident self-determination through the support of residents choice for 1 (Resident #190) of 2 residents reviewed for Choices out of 38 sampled residents. Specifically, the preferred number of showers per week were not obtained and not provided in accordance with Resident #190's wishes. The findings are: The facility's policy and procedure titled Showers and Bed Bath reviewed 08/2020 documented, It is the policy of the facility that each resident is to have a minimum of two baths/showers each week and all residents shall receive a bath between scheduled showers or tub/whirlpool bath unless otherwise requested by resident. Resident #190 was admitted with diagnoses of Hypertension, Depression and Cervical Disc Disorder with Myelopathy (is a serious condition that occurs when the spinal cord in the neck is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review conducted during the Recertification and Complaint survey (NY00293567) from 9/7/22 to 9/14/22, the facility did not ensure that in accordance with accepted professional standards and practices, medical records were maintained that were complete and accurately documented for each resident. Specifically, medication administration was not documented for scheduled medication and there was no documented evidence that medication had been refused by the resident. This was evident for 1 of 3 resident reviewed for Pain Management out of 38 sampled residents. (Resident # 361) The finding is: The policy and procedure titled Medication Administration Guidelines effective 6/17 documented medication are given only with a physician's order. Medication are to be administered no more than one hour on either side of time. STAT and as needed (PRN) medications are to be entered on the EMAR/MAR along with the date, dose and time of administration and medication nurse's initials and the reason for the as needed medications. All medication administered are to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, staff did not identify and address a resident's abrasions/injuries during skin assessments. This was evident for 1 of 2 residents reviewed for Skin Conditions. (Resident #22) The findings are: A facility policy and procedure related to Skin Inspection Treatment dated 4/16 documented that a thorough inspection of the resident's skin surface, particularly all areas over bony prominence, on each shift by the assigned Certified Nursing Assistant (CNA) and weekly by the licensed nurse. The CNA reports all changes to the licensed nurse. The licensed nurse documents weekly observation in the medical record. Resident #22 was admitted to the facility on [DATE] and had a diagnosis of viral hepatitis and depression. The most recent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews conducted during the recertification survey, the facility did not ensure that a resident received devices to prevent pressure ulcers. Specifically, a resident was observed on multiple occasions without heel booties or diabetic shoes as ordered by the Physician. This was evident for 1 of 2 residents reviewed for Pressure Ulcers. (Resident #37) The findings are: Resident #37 had a diagnosis of diabetes mellitus and dementia. On 12/08/19 at 10:34 AM and 12/10/19 at 10:33 AM, Resident #37 was observed to be laying in bed in her room. Two blue heel booties were observed to be on the resident's bedside table in the far-right corner of the room and no heel booties were observed on the resident's feet. On 12/10/19 at 11:00 AM and 12/11/19 at 11:35 AM, the resident was observed to be dressed, groomed, and out of bed to her wheelchair. The resident was observed to be wearing black regular sneakers. There were no diabetic shoes observed in the resident's room on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and staff interviews during the recertification survey the facility did not maintain infection control practices to help prevent the development and transmission of communicable diseases and infections. Specifically, one resident receiving oxygen by a nasal cannula with the oxygen tubing coming from the oxygen concentrator was resting on the floor in the residents room. This was evident for 1 of 1 resident reviewed for oxygen therapy. (Resident #81). The facility policy titled, Oxygen Therapy dated 6/17 documents: General Instructions- 2) The Nursing staff will set up, check and supervise all treatments. Procedure - 6) Oxygen tubing and masks will be changed weekly unless soiled by the 11PM - 7AM staff and as necessary if cleanliness is compromised. On 12/08/19 at 9:53 AM and 12:54 PM, Resident #81 was observed lying in bed. The resident was receiving oxygen via nasal cannula from an oxygen concentrator on the left side of the bed. The oxygen tubing coming from the oxygen concentrator was running along the floor and up the side of the bed to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.