Fairport Rehabilitation and Nursing Center

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, the facility did not ensure they had an Infection Preventionist who was responsible for the facility's Infection Prevention Control Practices. Specifically, the facility could not provide verification and documentation of the Infection Preventionist designated onsite hours for the assessing, developing, implementing, monitoring, and managing the facility's Infection Prevention and Control Program.

Inspectors wroteBased on interview and record review conducted during the Recertification Survey 05/05/2025 to 05/13/2025, the facility did not appropriately label and store all medications in accordance with currently accepted professional standards of practice and in accordance with stated and federal laws for eight (8) of 14 medication carts and five (5) of eight (8) medication rooms reviewed. Specifically, medications were left unattended by staff, multiple expired medications were stored in medication carts and medication rooms, loose unlabeled and uncovered pills were stored in multiple medication carts, narcotic medications were kept for multiple deceased residents over an extended period of time (versus returning to pharmacy) and narcotic sheets were missing signatures to verify that the narcotic medication counts were completed, correct and signed by two nurses.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 05/05/2025 to 05/12/2025, for six (6) (Third Floor A, E, F, and G-units, Second Floor A and F-units) of 10 resident units, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there were undated and unlabeled food items, microwaves and a freezer were dirty, there were outdated food items, food warming/holding units were not functioning properly, cups and lids were stored below sink plumbing, and there were moldy bread items.

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, the facility did not maintain a Quality Assessment and Assurance Committee consisting at a minimum of the Director of Nursing Services, the Medical Director or his/her designee, at least three other members of the facility's staff, one of who must be an individual in a leadership role, and the Infection Preventionist. Specifically, the facility could not provide documented evidence the Infection Preventionist participated in the Quality Assurance and Performance Improvement meetings on a regular basis. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey from 05/05/2025 to 05/13/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for seven (7) (Residents #9, #41, #45, #87, #94, #121, and #384) of 12 residents reviewed. Specifically, for Residents #45, #87, and #94, a Licensed Practical Nurse tested their blood glucose (sugar) levels using a glucometer (a machine used to test blood glucose levels using a drop of blood from the resident's finger) without cleaning the glucometer between each resident's use or after. [...]

Inspectors wroteBased on observations and interview conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, for seven (7) (first floor E and F-units, second floor A, E, F, and H-units, and third floor E-unit) of 10 resident units, the facility did not properly maintain the resident call system. Specifically, the nurse call system did not function properly to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized work area from each resident's bedside and toilet/bathing facilities, and clean utility rooms lacked nurse call annunciators.

Inspectors wroteBased on record reviews and interviews conducted during a Recertification Survey from [DATE] to [DATE], for two (2) (Residents #124 and #332) of four (4) residents reviewed, the facility did not ensure that all residents had the right to request, refuse, or formulate an advance directive (a resident's wishes to be or not to be resuscitated in the event of an acute cardiac or pulmonary arrest) that would be honored. Specifically, Resident #124 and Resident #332 had current phyisician's orders regarding their advanced directive wishes in the event of cardiac or pulmonary arrest that was not consistent with their signed Medical Orders for Life Sustaining Treatment (MOLST) directives.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, for one (1) (Resident #110) of one (1) resident reviewed the facility did not ensure the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Specifically, Resident #121 who was able to self-propel (move themselves) in their wheelchair was observed on multiple occasions to have their wheelchair wheels locked, who was trying to self-propel, and was unable to.

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, for two (2) (Residents #43 and #131) of 12 residents reviewed, the facility did not ensure that all alleged violations involving potential abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health in accordance with state law. Specifically, for Resident #43, the resident reported potential abuse and neglect to a Licensed Practical Nurse who did not report the residents concerns to nursing leadership and the alleged incident was not reported to the Department of Health. For Resident #131, the facility did not report to the Department of Health an incident where the resident was found to have a femur fracture (broken thigh bone) of unknown cause.

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, for 1 (Resident #131) of 12 residents reviewed, the facility did not ensure that an incident was thoroughly investigated to rule out abuse, neglect, or mistreatment. Specifically, Resident #131 had complaints of hip pain, was found to have a femur fracture (broken thigh bone) and the facility was unable to provide documented evidence (including statements from all involved staff members or potential witnesses) that the incident was thoroughly investigated to rule out abuse, neglect, or mistreatment.

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey from 05/05/2025 to 05/13/2025, it was determined that for one (1) (Resident #9) of one (1) resident reviewed, the facility did not ensure a resident's environment remained as free of accident hazards as possible. Specifically, there were multiple observations of medications left at the resident's bedside. The resident did not have an order for self-administration of medications, was not care planned for it, and had not been assessed by the interdisciplinary team to safely have medications left unsupervised at the bedside. In addition, Resident #9's room was directly next door from another resident who was identified as having wandering behaviors. This evidenced by the following: Resident #9 had diagnoses that included irritable bowel syndrome, deficiency of B group vitamins, and diabetes. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, for two (2) (Residents #110 and #335) of two (2) residents reviewed for adaptive equipment, the facility did not provide special eating equipment and utensils for residents who required them to maintain the ability to eat and drink independently. Specifically, Resident #110 had therapy recommendations and was care planned for built-up and curved utensils and was observed during meals without the adaptive equipment and had difficulty eating. Resident #335 was visually impaired, had a therapy recommendation and was care planned for a lipped plate (a plate with a lip to assist with scooping food on to silverware), and was observed during meals without the lip plate.

Inspectors wroteBased on interviews and record reviews conducted during a Recertification Survey from 05/05/2025 to 05/13/2025, for nine (9) (Residents #8, #18, #26, #53, #63, #128, #282, #332, and #383) of 19 residents reviewed, the facility did not provide a written summary of a Baseline Care Plan (care plan required to provide effective person-centered care that meets professional standards of quality for the immediate needs of the resident following admission). Specifically, there was no documented evidence that any of the listed residents or their representatives had received a written summary or review of their Baseline Care Plan that they were able to understand prior to their comprehensive care plan meeting.

Inspectors wroteBased on interviews, and record reviews conducted during an Abbreviated Survey (#NY00304693) 11/14/23 to 11/30/23, it was determined that for five (Residents # 2,4,6, 8, and 10) of five residents reviewed for abuse, neglect, and/or mistreatment the facility did not ensure that an investigation to rule out potential neglect or mistreatment was completed. Specifically, there was inconsistent evidence that Residents #2, 4, 6, 8, and 10 had received their physician ordered pain medications on 10/22/22 evening shift and the facility could not provide evidence that any medication error reports or investigations had been completed. The evidence includes but not limited to the following: The facility policy Abuse Prevention documented that the facility will not tolerate any form of resident abuse or exploitation and will maintain policies, procedures, training programs. [...]

Inspectors wroteBased on interviews, and record reviews conducted during an Abbreviated Survey (#NY00304693) 11/14/23 to 11/30/23, it was determined that for four (Residents # 2,4, 8, and 10) of nine residents reviewed the facility did not ensure that the services and care provided met professional standards of quality. Specifically, there was inconsistent evidence that the Residents had received their physician ordered pain medications on 10/22/22 evening shift and the facility could not provide any evidence that any medication error reports were initiated, or follow-up had been completed. The evidence includes the following: The facility Licensed Practical Nurse (LPN) job description documented that the primary purpose of the job position is to oversee the nursing duties of a household by implementing the plan of care as developed by the Primary Nurse, or designee. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Standard Recertification Survey completed 11/13/23 to 11/20/23, it was determined that for one of one main kitchen the facility did not prepare, store, distribute, and serve food in accordance with professional standards for food service safety. Specifically: the dish machine in the main kitchen had two leaks, there was a significant buildup of ice on the walk-in freezer floor, a refrigerator gasket was in disrepair, and floors were soiled with standing water and food.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey 11/13/23-11/20/23, it was determined that for 2 (Residents #4 and #64) of 12 residents reviewed for dining, the facility did not ensure the residents were given the appropriate treatment and services to maintain or improve their ability to carry out their activities of daily living (ADLs). Specifically, neither Residents #4 nor #64 were given the assist recommended at meal time to complete their meals. This is evidenced by the following: 1. Resident #64 had diagnoses including dysphagia (difficulty swallowing), macular degeneration (impaired eyesight), and heart failure. The Minimum Data Set (MDS) Assessment documented that the resident had severely impaired cognition and required assistance from staff with meals. [...]

Inspectors wroteBased on interviews, and record review conducted during the Recertification and Abbreviated (NY00323359) Surveys from 11/13/23 to 11/20/23, it was determined that for nine (#12, 36, 41, 59, 61, 63, 76, 83, and 84) of nine residents reviewed that were assigned to Neighborhood 3E on 9/2/23, the facility did not ensure that the residents were free from significant medication errors. Specifically, there was insufficient evidence in the residents' medical record to show that multiple physician ordered medications were administered to multiple residents at the scheduled times. Additionally, there was no documented evidence that the medical provider was notified of the late or not administered medications which included but is not limited to, anticoagulants (blood thinners), insulin, and multiple medications for blood pressure. This is evidenced by, but not limited to the following: [...]

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey 11/13/23 to 11/20/23 it was determined for four (2E, 2F, 2G, and 3E) of nine residential care units reviewed, the facility did not ensure that all medications used in the facility were stored and labeled in accordance with currently accepted professional standards. Specifically, expired medications were stored with active medications in two medication carts (2E and 2F) and expired stock (standard medications that may be used for multiple residents) medications were stored in three medication rooms (2E, 2G, 3E). This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 11/13/23 to 11/20/23, it was determined that for 1 (Resident #82) of 11 residents reviewed for dining that the facility did not provide special eating equipment and utensils for a resident who required them to maintain the resident's ability to eat and drink independently. Specifically, Resident #82 was observed on several occasions consuming meals without a two handled mug with concave anti-splash lip, a lip plate, or an angled utensil (all adaptive eating equipment) as recommended. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY00323359) from 11/13/23 to 11/20/23, the facility was not administrated in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to ensure that all residents were free from significant medication errors, did not have the Infection Preventionist (IP) working at least part time in the facility, and did not have the IP attend Quality Assurance and Performance Improvement (QAPI) meetings. Refer to the following tags: F760: Residents are Free of Significant Medication Errors F868: QAA Meetings F882: [...]

Inspectors wroteBased on interviews and record review conducted during a Recertification Survey 11/13/23 to 11/20/23, the facility did not maintain a quality assessment and assurance (QAA) committee consisting at a minimum of the Director of Nursing services, the Medical Director or his/her designee, at least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role, and the infection preventionist (IP). Specifically, the facility could not provide evidence that the IP attended the last two Quality Assurance Improvement Performance (QAPI) meetings. This is evidenced by the following: Review of the facility's Quality Assurance and Performance Improvement (QAPI) meeting minutes dated 7/28/23 and 11/13/23 did not include the presence of the IP. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey from 11/13/23 to 11/20/23, it was determined that for two (Resident # 21 and #23) of two residents reviewed for infection control, the facility did not ensure compliance with infection prevention and control national standards such as transmission-based precautions (TBP). Specifically, staff did not follow the guidelines for appropriately applying and removing Personal Protective Equipment (PPE) when encountering transmission-based precautions (TBP) residents and their environment or isolate a resident (Resident #23) with a communicable disease from a resident (Resident #21) who did not have a communicable disease. This is evidenced by the following: [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey, it was determined that the facility failed to ensure they had an Infection Preventionist (IP) who was responsible for the facility's Infection Control Program. Specifically, the facility failed to ensure that the IP worked at least part time in the facility. This is evidenced by the following: Review of the Facility assessment dated [DATE] listed an IP as a key staff member for the facility to provide support and care to the residents. During an interview on 11/16/23 at 11:17 AM the IP stated they are a full-time employee at another facility and only comes into the facility as needed. During a follow up interview on 11/16/23 at 2:07 PM the IP stated they have not been in the facility since August of 2023. [...]

Inspectors wroteBased on observations conducted during the Standard Recertification Survey completed on 2/17/22, it was determined that for two (second and third floors) of four resident use floors the facility did not properly equip corridors with handrails on each side. Specifically, there were sections of corridor wall that lacked handrails.

Inspectors wroteBased on observations, interviews and record reviews conducted during a Recertification Survey completed on 2/17/22, it was determined that for one (Resident #2) of five residents reviewed, the facility did not ensure a comprehensive care plan (CCP) was developed and implemented for each resident to meet their preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs as identified in the comprehensive assessment. Specifically, Residents #2 's CCP did not address diagnoses of depression or insomnia and did not address use of a psychotropic medication (medications that that affect behavior, mood, thoughts and/or perceptions that may have severe side effects). This was evidenced by: [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, completed on 2/17/22, it was determined that for one (Resident #194) of three residents reviewed, the facility did not provide the appropriate appeal notice to the Medicare beneficiary in order to notify them of their appeal rights under the regulations. Specifically, the facility did not provide the Medicare A beneficiary with a Notice of Medicare Non-Coverage (NOMNC) letter prior to discharge from the facility. This is evidenced by: Resident #194 was admitted to the facility 10/25/21 under Medicare benefits and was discharged to the community on 11/8/21. There was no documented evidence that the resident or responsible party was provided with the required appeal notice prior to discharge. [...]