Inspection Reports for
Aaron Manor Rehabilitation and Nursing Center
100 St. Camillus Way, Fairport, NY, 14450
Back to Facility Profile5 Reports
Inspection Report — Oct 24, 2024
State
Date: Oct 24, 2024
Visit Reason
State-compiled facility profile showing 9 inspections from 2022 to 2024 with citation and complaint history.
Complaint Details
The state logged 33 complaints about this facility; 12 led to on-site inspections. Six citations resulted from those complaints.
Findings
Across 9 inspections, 4 resulted in citations totaling 29, including 15 standard health and 14 Life Safety Code citations. The facility had 33 complaints with 12 on-site inspections and no formal enforcement actions.
Citations (29)
Standard Health Citation — quality of care: Bedrails issue noted with pattern scope.
Standard Health Citation — quality of care: Free Of Medication Error Rates 5 Percent Or More with isolated scope.
Standard Health Citation — quality of care: Infection Control deficiencies widespread.
Standard Health Citation — quality of care: Infection Prevention & Control issue isolated.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals issue isolated.
Standard Health Citation — quality of care: Responsibilities Of Providers; Required Notification with pattern scope.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment issue isolated.
Life Safety Code Citation — NFPA requirements: Egress Doors issue with pattern scope.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Power Cords And Extensions isolated issue.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System isolated issue.
Life Safety Code Citation — NFPA requirements: Gas And Vacuum Piped Systems - Information And isolated issue.
Life Safety Code Citation — NFPA requirements: Number Of Exits - Corridors with pattern scope.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation isolated issue.
Standard Health Citation — quality of care: Resident Records - Identifiable Information isolated issue.
Standard Health Citation — quality of care: Baseline Care Plan with pattern scope.
Standard Health Citation — quality of care: Department Criminal History Review isolated issue.
Standard Health Citation — quality of care: Free Of Medication Error Rates 5 Percent Or More isolated issue.
Standard Health Citation — quality of care: Infection Control deficiencies widespread.
Standard Health Citation — quality of care: Personal Privacy/confidentiality Of Records isolated issue.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment isolated issue.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Testing And Maintenance with pattern scope.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System with pattern scope.
Life Safety Code Citation — NFPA requirements: Gas And Vacuum Piped Systems - Maintenance Program with pattern scope.
Life Safety Code Citation — NFPA requirements: Gas Equipment - Cylinder And Container Storage isolated issue.
Life Safety Code Citation — NFPA requirements: Maintenance, Inspection & Testing - Doors widespread issue.
Life Safety Code Citation — NFPA requirements: Number Of Exits - Corridors with pattern scope.
Life Safety Code Citation — NFPA requirements: Rubbish Chutes, Incinerators, And Laundry Chutes with pattern scope.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing with pattern scope.
Standard Health Citation — quality of care: Request/refuse/discontinue Treatment; formulate Advance Directive isolated issue.
Report Facts
Inspections on page: 9
Total violations/deficiencies cited: 29
Inspections with violations: 4
Inspections without violations: 5
Total complaints: 33
On-site complaint inspections: 12
Citations issued from complaints: 6
Number of enforcement actions: 0
Inspection Report — Oct 24, 2024
Annual Inspection CMS
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.
Citations (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 — Sep 21, 2023
Abbreviated Survey CMS
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.
Citations (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 — Jan 27, 2023
Annual Inspection CMS
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.
Citations (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 — May 11, 2021
Annual Inspection CMS
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.
Citations (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 |
Viewing
Loading inspection reports...
