Inspection Reports for
Fairport Rehab & Nursing Center
4646 Fairport Nine Mile Point Rd, Fairport, NY 14450, United States, NY, 14450
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
13.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
167% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jun 12, 2025
Visit Reason
One violation related to personnel sufficiency and qualifications.
Findings
One violation related to personnel sufficiency and qualifications.
Deficiencies (1)
487.9 (a) (1) — Personnel
Inspection Report
Annual Inspection
Deficiencies: 11
Date: May 13, 2025
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including honoring residents' advance directives, use of physical restraints, timely reporting and investigation of abuse, baseline care plan documentation, medication storage and labeling, provision of special eating equipment, food safety and sanitation, infection prevention and control practices, quality assurance committee participation, and nurse call system functionality.
Deficiencies (11)
F 0578: The facility did not ensure residents' advance directives and Medical Orders for Life Sustaining Treatment were consistent, risking honoring residents' wishes.
F 0604: Resident #110 was physically restrained by locking wheelchair wheels despite being able to self-propel, violating residents' rights to be free from unnecessary restraints.
F 0609: The facility failed to timely report suspected abuse and neglect incidents to the New York State Department of Health and did not thoroughly investigate an injury of unknown origin.
F 0655: The facility did not provide written summaries of Baseline Care Plans to residents or their representatives within 48 hours of admission as required.
F 0689: Medications were left unattended, expired, unlabeled, or improperly stored in medication carts and rooms, including narcotics for deceased residents and missing narcotic count signatures.
F 0810: Residents requiring special eating equipment were not provided adaptive utensils or lipped plates, impairing their ability to eat independently.
F 0812: Food storage and preparation areas had undated/unlabeled food, moldy items, dirty microwaves, nonfunctional warming units, and unlabeled frozen food cups.
F 0868: The Quality Assessment and Assurance Committee did not include the Infection Preventionist regularly, limiting oversight of infection control.
F 0880: Infection prevention and control program deficiencies included improper glucometer cleaning, failure to use personal protective equipment for residents on enhanced barrier precautions, and inadequate staff training.
F 0882: The facility lacked documentation verifying the Infection Preventionist's onsite hours and active role in managing the infection control program.
F 0919: The nurse call system was outdated and malfunctioning, lacking annunciators at nurses' stations and clean utility rooms, impairing staff response to resident calls.
Report Facts
Residents reviewed: 19
Medication carts reviewed: 14
Medication rooms reviewed: 8
Resident units reviewed: 10
Residents reviewed for infection control: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Left medication cart unattended with controlled substances |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Did not clean glucometer between residents' blood glucose checks |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Did not wear gown during enhanced barrier precautions |
| Certified Occupational Therapy Assistant #1 | Certified Occupational Therapy Assistant | Did not wear gown or gloves during care of resident on enhanced barrier precautions |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding infection control and quality assurance |
| Assistant Administrator | Assistant Administrator | Provided interview regarding nurse call system issues and infection control |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Feb 13, 2025
Visit Reason
Seventeen violations including inspection procedures, civil penalties, general provisions, admission standards, resident protections, resident services, personnel, environmental standards, and disaster planning.
Findings
Seventeen violations including inspection procedures, civil penalties, general provisions, admission standards, resident protections, resident services, personnel, environmental standards, and disaster planning.
Deficiencies (13)
486.2 (j) (1-2) — Inspection
486.5 (a) (4) (v) — Civil penalties
487.3 (g) (1-2) — General provisions
487.4 (a) — Admission standards
487.5 (d) (1) — Resident protections
487.7 (d) (1) (v) — Resident services
487.7 (d) (11) — Resident services
487.7 (d) (12-13) — Resident services
487.7 (g) (1) (ii-xiv) — Resident services
487.9 (a) (1) — Personnel
487.11 (f) (8) — Environmental standards
487.11 (k) (11) — Environmental standards
487.12 (a-b) — Disaster and emergency planning
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 8, 2025
Visit Reason
One violation related to records and reports access and provision.
Findings
One violation related to records and reports access and provision.
Deficiencies (1)
485.11 (b) — Records and reports
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Dec 3, 2024
Visit Reason
No violations found.
Findings
No violations found.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Aug 28, 2024
Visit Reason
One violation related to personnel notification of vacancy.
Findings
One violation related to personnel notification of vacancy.
Deficiencies (1)
487.9 (a) (16) — Personnel
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: Jun 21, 2024
Visit Reason
Four violations related to admission standards, resident services, and personnel case manager designation.
Findings
Four violations related to admission standards, resident services, and personnel case manager designation.
Deficiencies (4)
487.4 (a) — Admission standards
487.7 (d) (8) — Resident services
487.7 (g) (1) (ii-xiv) — Resident services
487.9 (d) (2) — Personnel
Inspection Report
Relicensure
Capacity: 60
Deficiencies: 9
Date: Jan 3, 2024
Visit Reason
Nine violations including operating certificates, general provisions, admission standards, resident services, food service, and personnel training.
Findings
Nine violations including operating certificates, general provisions, admission standards, resident services, food service, and personnel training.
Deficiencies (9)
485.5 (f) — Operating certificates
487.3 (b) — General provisions
487.3 (g) (1-2) — General provisions
487.4 (a) — Admission standards
487.7 (f) (5) — Resident services
487.7 (f) (11) (iii) — Resident services
487.7 (g) (1) (ii-xiv) — Resident services
487.8 (e) (1) — Food service
487.9 (a) (3) — Personnel
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Nov 30, 2023
Visit Reason
The abbreviated survey was conducted from 11/14/23 to 11/30/23 to investigate allegations of abuse, neglect, and mistreatment related to medication administration and to assess whether the facility met professional standards of quality in nursing services.
Findings
The facility failed to ensure investigations were completed to rule out neglect or mistreatment regarding inconsistent administration of physician-ordered pain medications for multiple residents. Additionally, the facility did not ensure that services and care met professional standards, with inconsistent medication administration documentation and lack of follow-up investigations.
Deficiencies (2)
F 0610: The facility did not ensure investigations were completed to rule out potential neglect or mistreatment related to inconsistent administration of pain medications for Residents #2, 4, 6, 8, and 10 on 10/22/22 evening shift.
F 0658: The facility did not ensure that nursing services met professional standards of quality, with inconsistent evidence of medication administration and lack of investigations or follow-up for medication errors involving Residents #2, 4, 8, and 10.
Report Facts
Residents reviewed for abuse, neglect, and/or mistreatment: 5
Residents reviewed for professional standards of quality: 9
Residents affected by deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Assigned nurse involved in medication administration incidents; did not return phone calls for interview. |
| LPN #2 | Licensed Practical Nurse | Described narcotic count procedures and medication administration documentation. |
| RNM #1 | Registered Nurse Manager | Described investigation procedures for narcotic medication discrepancies. |
| Director of Nursing (DON) | Director of Nursing | Current DON stated no investigations were found regarding narcotic administration discrepancies; prior DON reported medication found in medication cup. |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Nov 20, 2023
Visit Reason
The inspection was a Recertification Survey conducted from 11/13/23 to 11/20/23 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate assistance with meals, significant medication administration errors, improper medication storage including expired medications, failure to provide required adaptive eating equipment, unsafe food service conditions, ineffective facility administration particularly regarding medication management and infection prevention, and inadequate infection control practices including improper use of PPE and failure to isolate infectious residents properly.
Deficiencies (9)
F 0676: The facility failed to ensure residents #4 and #64 received appropriate assistance during meals to maintain their ability to perform activities of daily living, resulting in inadequate feeding assistance and weight loss.
F 0760: The facility did not ensure residents were free from significant medication errors; multiple medications were not administered as ordered on 9/2/23 for nine residents, and providers were not notified of missed or late doses.
F 0761: The facility failed to ensure all medications were stored and labeled properly; expired medications were found in medication carts and rooms across multiple units.
F 0810: The facility did not provide special eating equipment and utensils as required for Resident #82, impairing the resident's ability to eat and drink independently.
F 0812: The facility failed to maintain food service safety; the main kitchen dish machine leaked, the walk-in freezer had significant ice buildup, refrigerator gaskets were damaged, and floors were soiled with standing water and food debris.
F 0835: The facility was not administered effectively; it failed to ensure timely medication administration, lacked an Infection Preventionist working part-time onsite, and the Infection Preventionist did not attend required QAPI meetings.
F 0868: The facility did not maintain a Quality Assessment and Assurance committee with required members; the Infection Preventionist did not attend recent QAPI meetings and worked remotely without regular onsite presence.
F 0880: The facility failed to implement infection prevention and control; staff did not follow PPE guidelines for residents on transmission-based precautions and failed to isolate a resident with C-diff from a non-infected roommate.
F 0882: The facility failed to designate a qualified Infection Preventionist who worked at least part-time onsite to oversee the infection control program.
Report Facts
Residents reviewed for dining: 12
Residents reviewed for medication errors: 9
Expired medication counts: 58
Medication administration errors: 22
Dates of survey: 2023-11-13 to 2023-11-20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Manager #1 | RN Manager | Interviewed regarding infection control and resident roommate C-diff precautions. |
| Director of Nursing | DON | Interviewed regarding medication administration issues, infection preventionist role, and adaptive feeding equipment. |
| Assistant Director of Nursing | ADON | Interviewed regarding meal assistance staffing and infection control. |
| Food Service Director | FSD | Interviewed regarding kitchen equipment issues and food safety. |
| Infection Preventionist | IP | Interviewed regarding infection control program and attendance at QAPI meetings. |
| Administrator of Record | AoR | Interviewed regarding facility administration, medication administration, and infection preventionist presence. |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Nov 20, 2023
Visit Reason
The inspection was conducted as a Recertification Survey from 11/13/23 to 11/20/23 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate assistance with meals, significant medication administration errors, improper medication storage including expired medications, lack of special eating equipment for residents, food service safety issues, ineffective facility administration particularly regarding infection prevention, and failure to maintain a qualified infection preventionist who works onsite and attends QAPI meetings. Infection control practices were also inadequate, including improper use of PPE and cohorting of residents with communicable diseases.
Deficiencies (9)
F 0676: The facility failed to ensure residents #4 and #64 received the recommended assistance at mealtime to maintain their ability to perform activities of daily living.
F 0760: The facility did not ensure nine residents were free from significant medication errors, with multiple medications not administered as ordered and no notification to medical providers.
F 0761: The facility failed to ensure all medications were stored and labeled properly, with expired medications found in medication carts and rooms across multiple units.
F 0810: The facility did not provide special eating equipment and utensils as required for Resident #82, impairing the resident's ability to eat independently.
F 0812: The facility's main kitchen did not prepare, store, distribute, and serve food in accordance with professional standards due to dish machine leaks, ice buildup in the walk-in freezer, refrigerator gasket disrepair, and soiled floors with standing water and food debris.
F 0835: The facility was not administered effectively and efficiently, failing to ensure timely medication administration, lack of infection preventionist presence, and failure of the infection preventionist to attend QAPI meetings.
F 0868: The facility did not maintain a Quality Assessment and Assurance committee with required members, specifically the infection preventionist, who did not attend recent QAPI meetings.
F 0880: The facility failed to implement infection prevention and control standards, including improper PPE use and failure to isolate a resident with C-diff from a roommate without infection.
F 0882: The facility failed to designate a qualified infection preventionist who worked at least part time onsite to oversee the infection control program.
Report Facts
Residents reviewed for dining: 12
Residents reviewed for medication errors: 9
Weight loss: 7.5
Expired medication counts: 58
Medication errors: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNM #1 | Registered Nurse Manager | Interviewed regarding infection control practices and resident cohorting. |
| Director of Nursing | Director of Nursing | Interviewed about medication administration issues and infection preventionist role. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about staffing and infection control. |
| Food Service Director | Food Service Director | Interviewed about kitchen equipment issues and food safety. |
| Infection Preventionist | Infection Preventionist | Interviewed about infection control program and attendance at QAPI meetings. |
| Administrator of Record | Administrator of Record | Interviewed about facility administration and infection preventionist presence. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 1, 2022
Visit Reason
One violation related to quarterly statistical information report submission.
Findings
One violation related to quarterly statistical information report submission.
Deficiencies (1)
487.10 (e) (2) — Records and reports
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Feb 17, 2022
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with Medicare/Medicaid regulations and facility standards.
Findings
The facility failed to provide required Medicare appeal notices to a resident prior to discharge, did not develop a comprehensive care plan addressing all resident needs including psychotropic medication use, and lacked handrails on certain corridor sections on two resident floors.
Deficiencies (3)
F 0582: The facility did not provide the required Notice of Medicare Non-Coverage (NOMNC) letter to Resident #194 prior to discharge, failing to notify the resident of appeal rights.
F 0656: The facility did not develop and implement a comprehensive care plan for Resident #2 that addressed depression, insomnia, and use of psychotropic medications with measurable goals and non-pharmacological interventions.
F 0924: The facility did not properly equip corridors on the second and third floors with firmly secured handrails on each side, leaving several sections without handrails.
Report Facts
Residents reviewed: 3
Residents reviewed: 5
Resident use floors: 4
Sections of corridor wall lacking handrails: 7
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 9, 2022
Visit Reason
One violation related to quarterly statistical information report submission.
Findings
One violation related to quarterly statistical information report submission.
Deficiencies (1)
487.10 (e) (2) — Records and reports
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 1, 2021
Visit Reason
One violation related to quarterly statistical information report submission.
Findings
One violation related to quarterly statistical information report submission.
Deficiencies (1)
487.10 (e) (2) — Records and reports
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Oct 1, 2021
Visit Reason
One violation related to records and reports access and provision.
Findings
One violation related to records and reports access and provision.
Deficiencies (1)
485.11 (b) — Records and reports
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Aug 12, 2021
Visit Reason
One violation related to records and reports access and provision.
Findings
One violation related to records and reports access and provision.
Deficiencies (1)
485.11 (b) — Records and reports
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