FAIRPORT, NY. Licensed Practical Nurse #10 hears the call bell ringing somewhere on the third floor, but she has no idea which resident needs help.
"Other than physically looking around the unit, there is no way to know which call bell is ringing," she told inspectors in May. "If you are busy and doing something, you will hear it go off but will not know where without having to go around and look at each door, so it is difficult at times."
Federal inspectors found that seven of 10 resident units at Fairport Rehabilitation and Nursing Center lacked functioning nurse call systems during a survey completed May 13. On multiple floors, nurses' stations had no central panels to show which rooms were calling for assistance. Staff carried no phones or pagers connected to the system.
The breakdown affects residents across the facility's first, second, and third floors.
On the second floor H-unit, inspectors found no centralized nurse call station panel or annunciator at the nurses' station. The second floor F-unit nurses' station also lacked any call system panel. The second floor A-unit had the same problem.
Clean utility rooms throughout the building had no nurse call annunciators. Inspectors documented missing systems in utility rooms on the third floor E-unit, second floor E-unit, first floor E-unit, and first floor F-unit. The first floor F-unit nurses' station also had no call system panel.
The Director of Environmental Services explained the system's gradual deterioration during an interview with inspectors. The original nurse call system was installed around 1995 with lights and audible tones. At some point, the facility added a phone system that would show which room was calling when a call bell was activated.
"It does not work anymore," he said.
The Assistant Administrator told inspectors the handheld devices were breaking down and the company that serviced them had gone out of business. The facility could not get the equipment repaired and would need to purchase a complete new system.
The Director of Nursing acknowledged that the Quality Assurance and Performance Improvement committee was aware of the call system issues but characterized them as problems with an "old" system.
For residents who need assistance getting to the bathroom, reaching medications, or responding to medical emergencies, the broken call system creates dangerous delays. When a call bell rings, nurses must leave whatever they are doing and physically check multiple rooms until they find the resident who needs help.
The facility's infection control program also drew scrutiny during the May inspection. Inspectors found confusion about who actually serves as the infection preventionist and how much time that person spends on infection control duties.
During the entrance conference on May 5, the Administrator told inspectors that Infection Prevention Nurse #2, a Licensed Practical Nurse, was a full-time employee serving as the facility's infection preventionist. The Administrator said Infection Prevention Nurse #1, a Registered Nurse, helped with infection control data.
But interviews revealed a more complex arrangement.
Infection Prevention Nurse #2 told inspectors during interviews on May 9 and May 12 that they worked 40 to 48 hours at the facility as an evening and night supervisor. They performed infection prevention work remotely from home and addressed infection prevention issues when they happened to be in the building as a supervisor.
Notably, Infection Prevention Nurse #2 said they did not participate in Quality Assurance and Performance Improvement meetings. Instead, Infection Prevention Nurse #1 attended those meetings.
The Director of Nursing offered different details about the arrangement. She said Infection Prevention Nurse #2 spent approximately 40 hours per week in the building, with a significant portion of that time working as the evening and night nursing supervisor. According to the Director of Nursing, Infection Prevention Nurse #2 had downtime during night shifts to work on infection control tasks, data review, checking orders, and antibiotic-related responsibilities.
She estimated that Infection Prevention Nurse #2 probably spent at least 12 hours on infection control responsibilities while in the building, and sometimes the facility approved additional remote work.
The Director of Nursing said Infection Prevention Nurse #1 worked on data entry and reports so that Infection Prevention Nurse #2 could focus on infection control by being present on the units.
During a telephone interview, Infection Prevention Nurse #1 described their role as helping with infection control by tracking antibiotics, monitoring residents' immunizations, handling reporting duties, and maintaining line lists of residents with current infections during outbreaks. They worked remotely and stayed in contact with Infection Prevention Nurse #2, who they identified as the infection preventionist actually in the building.
Infection Prevention Nurse #1 said they submitted infection control reports to either the Administrator or Director of Nursing, who then presented the reports at Quality Assurance and Performance Improvement meetings.
The Director of Nursing clarified that Infection Prevention Nurse #2 was "the go-to person for infection control" while Infection Prevention Nurse #1 "only did reporting and documentation since they were not in the building."
The inspection findings reveal an infection control program split between two nurses with overlapping but unclear responsibilities, and a call system breakdown that forces staff to hunt through hallways when residents need help. For Licensed Practical Nurse #10 on the third floor, every call bell means another search through the unit, checking door after door until she finds the resident who pressed the button.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fairport Rehabilitation and Nursing Center from 2025-05-13 including all violations, facility responses, and corrective action plans.
Additional Resources
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