Inspection Reports for
Aaron Manor Rehabilitation and Nursing Center
100 St. Camillus Way, Fairport, NY, 14450
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
116% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Oct 24, 2024
Visit Reason
Complaint Survey with 7 health and 6 life safety citations, including bedrails, medication error rates, infection control, and multiple life safety code issues.
Findings
Complaint Survey with 7 health and 6 life safety citations, including bedrails, medication error rates, infection control, and multiple life safety code issues.
Deficiencies (13)
Bedrails
Free of medication error rts 5 prcnt or more
Infection control
Infection prevention & control
Label/store drugs and biologicals
Responsibilities of providers; required notif
Safe/clean/comfortable/homelike environment
Egress doors
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Gas and vacuum piped systems - information an
Number of exits - corridors
Sprinkler system - installation
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Oct 24, 2024
Visit Reason
The inspection was a Recertification Survey conducted from 10/17/2024 to 10/24/2024 to assess compliance with regulatory requirements for Aaron Manor Rehabilitation and Nursing Center.
Findings
The facility was found deficient in maintaining a safe, clean environment, proper assessment and consent for bed rail use, medication administration errors, improper storage of controlled medications, and infection prevention and control practices. Several residents were affected by these deficiencies, which were mostly categorized as minimal harm or potential for actual harm.
Deficiencies (5)
F 0584: The facility did not provide housekeeping and maintenance services necessary to maintain a clean and homelike environment, including an unrepaired 8-inch hole in the kitchen wall with water damage and fruit flies present.
F 0700: The facility failed to assess residents for safe use of bed rails, review risks and benefits with residents or representatives, obtain informed consent, and include bed rails in care plans for 6 of 12 residents reviewed.
F 0759: The facility did not ensure a medication error rate of 5 percent or less, with two medication errors for 27 opportunities including a narcotic given 8 hours late and a pre-poured unlabeled medication cream.
F 0761: The facility did not ensure that all drugs and biologicals were stored in locked compartments; a controlled medication cabinet was only single locked and the exterior door was unlocked.
F 0880: The facility failed to implement an infection prevention and control program, including staff not wearing gowns during enhanced barrier precautions, failure to perform hand hygiene between residents, improper disposal of used insulin syringes, and contaminated oxygen and urinary catheter equipment.
Report Facts
Medication error rate: 7.4
Residents reviewed for bed rail use: 12
Residents affected by bed rail deficiency: 6
Residents reviewed for infection control: 11
Residents affected by infection control deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Manager #1 | Named in medication administration errors and medication storage deficiencies | |
| Certified Nursing Assistant #4 | Named in infection control deficiencies for not wearing gown and improper hand hygiene | |
| Certified Nursing Assistant #5 | Named in infection control deficiencies for not wearing gown | |
| Director of Nursing | Provided statements on medication administration, bed rail assessments, medication storage, and infection control | |
| Maintenance Director | Provided information on kitchen wall damage | |
| Food Service Director | Provided information on kitchen wall damage and housekeeping | |
| Licensed Practical Nurse Manager #2 | Provided statements on bed rail assessments and use | |
| Licensed Practical Nurse #3 | Provided statements on bed rail assessments and use | |
| Maintenance Supervisor #1 | Provided statements on bed rail concerns | |
| Physical Therapist Assistant #1 | Provided statements on bed rail assessments | |
| Director of Rehabilitation | Provided statements on bed rail assessments and audits | |
| Administrator | Provided statements on bed rail assessments and facility practices | |
| Infection Control Nurse | Provided statements on infection control practices and deficiencies |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Sep 21, 2023
Visit Reason
Complaint Survey with 1 health citation for resident records identifiable information.
Findings
Complaint Survey with 1 health citation for resident records identifiable information.
Deficiencies (1)
Resident records - identifiable information
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 21, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with professional standards regarding resident medical records and documentation practices.
Findings
The facility did not ensure that agency Licensed Practical Nurses and Certified Nursing Assistants properly identified themselves in the electronic medical record following medication administration, progress notes documentation, and personal care provision. Staff used generic agency logins instead of individual names, which is not part of the resident record.
Deficiencies (1)
F 0842: The facility failed to safeguard resident-identifiable information by allowing agency nurses and CNAs to document care and medication administration using generic agency logins rather than their legal names in the electronic medical record.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding documentation practices and agency staff logins. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 14
Date: Jan 27, 2023
Visit Reason
Complaint Survey with 6 health and 8 life safety citations including baseline care plan, medication error rates, infection control, privacy, and multiple life safety code issues.
Findings
Complaint Survey with 6 health and 8 life safety citations including baseline care plan, medication error rates, infection control, privacy, and multiple life safety code issues.
Deficiencies (14)
Baseline care plan
Department criminal history review
Free of medication error rts 5 prcnt or more
Infection control
Personal privacy/confidentiality of records
Safe/clean/comfortable/homelike environment
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Gas and vacuum piped systems - maintenance pr
Gas equipment - cylinder and container storag
Maintenance, inspection & testing - doors
Number of exits - corridors
Rubbish chutes, incinerators, and laundry chu
Sprinkler system - maintenance and testing
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jan 27, 2023
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for Aaron Manor Rehabilitation and Nursing Center.
Findings
The survey identified multiple deficiencies including breaches of resident privacy, inadequate cleanliness and maintenance of resident rooms, failure to develop and implement baseline care plans within 48 hours of admission, and a medication error rate exceeding 5 percent.
Deficiencies (4)
F 0583: The facility did not ensure residents' privacy and confidentiality when an intra-facility email containing names and health information of ten COVID-19 positive residents was posted in a common area accessible to staff, residents, and visitors.
F 0584: The facility failed to maintain a safe, clean, comfortable, and homelike environment for one resident, as evidenced by dirty bed frames, sheets, floors, and furniture, with inadequate cleaning practices.
F 0655: The facility did not develop and implement a Baseline Care Plan within 48 hours of admission for 10 of 16 residents reviewed, lacking necessary healthcare information and failing to provide a written summary to residents or their representatives.
F 0759: The facility did not maintain a medication error rate below 5 percent, with one resident experiencing three medication errors out of 25 opportunities, including incorrect dosing and improper administration instructions.
Report Facts
Residents affected: 10
Residents affected: 1
Residents affected: 10
Medication errors: 3
Medication opportunities: 25
Medication error rate: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Administered medications incorrectly to Resident #27 |
| LPN #2 | Unit Manager | Stated medications should be administered per physician orders |
| Nurse Practitioner #1 | Nurse Practitioner | Stated expectation that medications be administered per physician orders |
| Director of Nursing | Director of Nursing | Interviewed regarding privacy breach and baseline care plan deficiencies |
| Maintenance Director | Maintenance Director | Interviewed regarding room cleanliness issues |
| Housekeeper #1 | Housekeeper | Interviewed regarding cleaning of resident rooms |
| Registered Nurse Manager | Registered Nurse Manager | Interviewed regarding housekeeping expectations for resident room cleanliness |
| Admitting Registered Nurse | Registered Nurse | Interviewed regarding baseline care plan form usage |
| Administrator | Administrator | Removed posted email containing resident health information |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Oct 3, 2022
Visit Reason
Complaint Survey with 1 health citation for request/refuse/discontinue treatment and formalize advance directives.
Findings
Complaint Survey with 1 health citation for request/refuse/discontinue treatment and formalize advance directives.
Deficiencies (1)
Request/refuse/dscntnue trmnt;formlte adv dir
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 31, 2022
Visit Reason
Covid-19 Survey with 1 health citation for reporting to national health safety network.
Findings
Covid-19 Survey with 1 health citation for reporting to national health safety network.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 4
Date: May 11, 2021
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory standards for nursing care, medication management, dialysis services, food safety, and respiratory care at Aaron Manor Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including inconsistent monitoring of oxygen therapy for a resident, inadequate documentation and monitoring of dialysis care, improper medication labeling and storage, incomplete narcotic counts, and unsafe food cooling practices in the kitchen.
Deficiencies (4)
F 0695: The facility did not ensure consistent monitoring of oxygen liter flow and oxygen saturation levels for a resident on oxygen therapy as ordered by the physician.
F 0698: The facility failed to consistently document assessment of bruit and thrill on a resident's dialysis fistula and did not monitor fluid restriction as ordered.
F 0761: Medications and biologicals were not properly labeled or stored; medication rooms were found unlocked and unattended; narcotic counts were inconsistently documented.
F 0812: The facility did not store, prepare, distribute, and serve food under sanitary conditions; potentially hazardous food was not cooled properly according to policy.
Report Facts
Missed oxygen monitoring documentation: 84
Missed dialysis bruit and thrill assessments: 35
Missed narcotic count documentation: 23
Medication pills in unlabeled cup: 35
Weight of turkey breast: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) Manager | Stated nurses needed to check oxygen liter flow as ordered and that TAR omissions should be reported | |
| Licensed Practical Nurse (LPN) | Interviewed about TAR documentation and medication cart contents | |
| Registered Nurse (RN) Manager | Stated unlabeled medications should be disposed and described narcotic count monitoring responsibilities | |
| Certified Nursing Assistant (CNA) #1 | Described fluid intake recording practices for dialysis resident | |
| Licensed Practical Nurse (LPN) #1 | Described fluid provision and documentation for dialysis resident | |
| LPN Nurse Manager (NM) | Described fluid restriction monitoring and fistula assessment expectations | |
| Diet Technician (DT) | Described dietary fluid provision and documentation practices | |
| Registered Dietitian | Described nursing and dietary fluid intake documentation roles | |
| Director of Nursing (DON) | Described narcotic count monitoring and audit practices | |
| Director of Food Service (DFS) | Described food cooling practices and volunteered to discard improperly cooled turkey breast |
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