Fairport Baptist Homes

F-F868 - Quality Assessment and Assurance Committee.

During the Entrance Conference on 05/05/2025 at 9:15 AM, the Administrator stated Infection Prevention Nurse #2 (a Licensed Practical Nurse) was a full-time employee who was the facility's Infection Preventionist.

The Administrator said that Infection Prevention Nurse #1 (a Registered Nurse) helps Infection Prevention Nurse #2 with the infection control data.

During interviews on 05/09/2025 at 7:59 AM and on 05/12/2025 at 3:12 PM, Licensed Practical Nurse/Infection Prevention Nurse #2 said they worked at the facility 40-48 hours as an evening/night supervisor and they work as the Infection Prevention Nurse remotely from home. While they are not in the facility weekly as the Infection Prevention Nurse, they do address Infection Prevention issues when they are there (as evening/night supervisor). Infection Prevention Nurse #2 said they did not participate in Quality Assurance and Performance Improvement meetings, and that Infection Prevention Nurse #1 would attend

the meetings.

During an interview on 05/13/2025 at 9:31 AM, the Director of Nursing said Infection Prevention Nurse #2 was in the building approximately 40 hours (a week) and a significant amount of the time was as the evening/night nursing supervisor. The Director of Nursing stated Infection Prevention Nurse #2 had several hours of down time on the night shift and would work on infection control, data, checking orders, and antibiotic related tasks. The Director of Nursing said Infection Prevention Nurse #2 would probably spend at least 12 hours on infection control related responsibilities in house and sometimes they would approve work off-site (remote). The Director of Nursing said Infection Prevention Nurse #1 worked on data entry and reports for infection control, so Infection Prevention Nurse #2 could focus on infection control by being out on

the units.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 29 335576 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335576 B. Wing 05/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fairport Rehabilitation and Nursing Center 4646 Nine Mile Point Road Fairport, NY 14450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 During a telephone interview on 05/13/2025 at 11:02 AM, Registered Nurse/Infection Prevention Nurse #1 said they helped with infection control by tracking antibiotics, residents' immunizations, reporting and they Level of Harm - Minimal harm or maintained the line lists (lists of residents with current infections) for outbreaks. Infection Prevention Nurse potential for actual harm #1 stated they worked remotely (were not onsite) and they were in touch with Infection Prevention Nurse #2, who was the Infection Preventionist in the building. Infection Prevention Nurse #1 stated they submitted Residents Affected - Many Infection Control reports to either the Administrator or the Director of Nursing and then they presented the reports at the Quality Assurance and Performance Improvement meetings.

During an interview on 05/13/2025 at 11:19 AM, the Director of Nursing said Infection Prevention Nurse #2 was the go-to person for infection control and Infection Prevention Nurse #1 only did reporting and documentation since they were not in the building.

10 NYCRR 415.19(a)(1-3)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 29 335576 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335576 B. Wing 05/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fairport Rehabilitation and Nursing Center 4646 Nine Mile Point Road Fairport, NY 14450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or 49447 potential for actual harm Based on observations and interview conducted during the Recertification Survey from 05/05/2025 to Residents Affected - Some 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. The findings are:

During an observation on 05/06/2025 at 10:27 AM, there was no centralized nurse call station panel or annunciator at the second floor H-unit nurses' station, and staff did not carry phones or pagers connected to

the nurse call system.

During an observation on 05/06/2025 at 10:59 AM, there was no centralized nurse call station panel or annunciator at the second floor F-unit nurses' station.

During an interview on 05/08/2025 at 11:42 AM, the Director of Environmental Services stated the nurse call system was installed around 1995 with lights and an audible tone, and a phone system connected to the nurse call was put in at some point where an activated call bell would initiate a call to a nurse station phone that would show which room called, but it does not work anymore.

During an observation on 05/08/2025 at 1:03 PM, there was no nurse call station annunciator at the second floor A-unit nurses' station.

During an observation on 05/08/2025 at 1:05 PM there was no nurse call system annunciator in the third floor E-unit clean utility room.

During an observation on 05/08/2025 at 1:06 PM, there was no nurse call system annunciator in the second floor E-unit clean utility room.

During an observation on 05/08/2025 at 1:28 PM, there was no nurse call system annunciator in the first floor E-unit clean utility room.

During observations on 05/08/2025 at 1:30 PM, there was no nurse call system annunciator in the first floor F-unit clean utility room or at the nurses' station.

During an interview on 05/13/2025 at 12:49 PM, Licensed Practical Nurse #10 (third floor F-unit) stated other than physically looking around the unit, there is no way to know which call bell is ringing and there is not a panel on this floor for us to look at. Licensed Practical Nurse #10 stated 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 29 335576 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335576 B. Wing 05/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fairport Rehabilitation and Nursing Center 4646 Nine Mile Point Road Fairport, NY 14450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 During an interview on 05/13/2025 at 3:00 PM with the Director of Nursing and the Assistant Administrator,

the Director of Nursing stated the call light system was old, and the Quality Assurance and Performance Level of Harm - Minimal harm or Improvement (QAPI) committee was aware of the issues. The Assistant Administrator stated the handhelds potential for actual harm were breaking, the company that serviced them had gone out of business, and the facility could not get them fixed. The Assistant Administrator stated the facility would have to buy a complete new system. Residents Affected - Some 10 NYCRR: 415.29, 415.29(b); 415.29(j)(1),

10 NYCRR: 713-3.25(g)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 29 335576