Fordham Nursing and Rehabilitation Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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 .

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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)

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased 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. [...]