Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elm Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Insufficient nursing staffing and delayed medication administration: The facility did not maintain the minimum RN/LPN and CNA coverage identified in its staffing assessment, with repeated shifts below required levels and reports of nurses working alone or without aide support. A resident with diabetes, ESRD, and transplant history, another with stage 5 CKD and anemia, and a third with CHF, CKD, and diabetes experienced repeated delays in ordered meds and treatments, including insulin, immunosuppressants, respiratory treatments, and cardiac/HTN meds, with delays ranging from over 1 hour to more than 24 hours. Staff and leadership interviews confirmed frequent understaffing and difficulty completing care tasks on time.
RN Coverage Not Maintained as Required: The facility failed to maintain RN coverage for at least 8 consecutive hours per day. Record review showed multiple days with no RN in the building within a 24-hour period and other days with less than 8 consecutive hours of RN coverage. Interviews confirmed the Staffing Coordinator and DON leadership understood the coverage expectation differently, and the facility sometimes relied on an on-call RN to come in if issues arose.
Systemic failures in staffing, med administration, food service, and resident care oversight were cited after surveyors found repeated and new deficiencies across multiple areas. Residents experienced missed or late meds, incorrect diet textures, delayed incontinence care, unmet grooming and shower needs, and dignity concerns, while kitchen staff were observed with poor hand hygiene and unsanitary food service conditions. The facility also did not consistently meet minimum staffing levels, and QA oversight was not aware of several of the cited issues.
The facility failed to give residents and/or their representatives the written Medicare Part D information needed to make informed enrollment and plan-change decisions, including plan comparisons, cost details, and reenrollment rights, even though the Administrator was authorized to act on their behalf. The facility also failed to preserve dignity when a resident’s urinary catheter bag was left uncovered in common areas, another resident was seen walking with visibly soiled pants, and a resident was referred to as a feeder in front of staff and other residents.
Failure to Provide ADL Assistance, Hygiene, and Incontinence Care: The facility did not document or consistently provide needed ADL support for multiple residents. One resident with stroke-related weakness and intact cognition was repeatedly observed with unwanted facial hair, another resident with dementia and incontinence was left without timely brief changes and was found saturated, and a third resident with COPD, malnutrition, and weakness had no documentation of receiving or refusing a shower. Care plans and Kardexes called for assistance with personal hygiene, toileting, and showering, but records and observations showed gaps in grooming, bathing, and incontinence care.
Incorrect Diet Texture and Consistency Served to Residents: Three residents with orders for mechanically altered diets were observed receiving food that did not match the ordered texture or consistency. One resident on a ground diet was served chopped chicken and coughed repeatedly while eating, another on a chopped diet was served a hamburger cut into quarters, and a third on a chopped diet was given a whole PB&J sandwich that was only cut in half before being further cut into smaller pieces by an LPN. Staff identified the mismatches, but the trays were not removed and the residents continued eating.
Multiple residents had significant medication errors, including missed or undocumented doses of insulin, transplant medications, antibiotics, anticoagulants, anticonvulsants, and cardiac medications, along with numerous doses given outside ordered timeframes. One resident with diabetes and transplant history was self-administering insulin without documented assessment or care plan support, while other residents had repeated late or omitted doses and staff reported medication availability and staffing problems, with no documented provider notification for the errors.
A resident with diabetes, kidney and pancreas transplant history, and end-stage kidney disease was allowed to manage insulin using personal supplies and a CGM without documented interdisciplinary assessment of whether self-administration was clinically appropriate. The care plan did not address self-administration, and the MAR lacked consistent documentation of BG checks and insulin doses; staff said they were unaware the resident was using their own insulin, did not regularly verify doses, and often charted refusals when meds were unavailable.
Incomplete care plans were identified for three residents. One resident receiving insulin did not have care plan interventions for glucose monitoring or insulin management, another resident with an indwelling urinary catheter had no related goals or interventions in the care plan or Kardex, and a third resident with dementia and frequent urine and bowel incontinence had no care plan goals or interventions for incontinence care. Interviews confirmed that insulin, catheter care, and incontinence care should have been included.
Missed sacral wound care and uncovered pressure ulcer: A resident with dementia and an unstageable sacral PU had a physician order for daily packing and dressing, but the treatment was not documented as completed on multiple occasions. During observation, the resident was incontinent of urine and stool and was found with no dressing or packing in place for hours after staff were notified; an LPN delayed addressing it, and the wound remained uncovered until the Wound Care MD applied a new dressing during wound rounds.
Food Served at Unsafe and Unappetizing Temperatures: A resident reported that meals were typically cold and unappetizing, and observation of the lunch tray line showed trays placed on an open cart with cold items pre-portioned and pre-poured. A test tray found the hamburger and sweet potatoes lukewarm to cold and not palatable, while milk and juice were lukewarm. Several collected trays appeared largely untouched, and the RFD stated the kitchen had been short staffed and tray line took longer than it should have.
Food service sanitation and hand hygiene were not maintained when a liquid drained from kitchen sink plumbing during tray line, and a Dietary Aide cleaned it up, changed gloves, and continued handling food without washing hands. The ice scoop was stored in ice, the ice machine had visible debris with incomplete cleaning documentation, and the dumbwaiter was dirty while uncovered clean laundry and used meal trays were transported through it.
QAPI Committee Lacked Required IP Attendance: The facility failed to document that the Infection Preventionist attended QAPI meetings on a quarterly basis. Policies identified infection prevention as part of the QAPI process, but attendance records showed no documented evidence that the IP was present at the meetings, and the Administrator and Regional Administrator stated they knew the requirement but did not know why the IP had not attended.
Infection control failures occurred when a CNA provided care to a resident with dementia and an unstageable sacral pressure ulcer without changing gloves, performing hand hygiene, or using the required gown under EBP while touching multiple resident and hallway surfaces. In a separate event, a dietary aide handled a floor spill during tray line, changed gloves without washing hands, and then continued preparing resident meals. Staff interviews confirmed confusion about PPE, glove changes, and hand hygiene expectations.
The facility failed to develop Baseline Care Plans within 48 hours of admission for several residents, as required by policy. Interviews revealed that the Social Worker responsible was not trained on completing these plans, leading to a lack of documentation and provision of care plan summaries to residents or their representatives.
The facility did not ensure suction machines were ready for immediate use in emergencies, as observed during a survey. Suction machines lacked necessary tubing and reservoirs, posing a risk to residents on aspiration precautions. The Nurse Manager confirmed the equipment should be ready to use, highlighting a lapse in preparedness.
The facility experienced significant staffing shortages, resulting in inadequate care for residents. On multiple occasions, the staff-to-resident ratio was insufficient, leading to delays in essential care such as showers, toileting, and meal assistance. Residents and visitors reported long wait times for assistance, and staff interviews confirmed the challenges in maintaining adequate care levels. The Interim Director of Nursing acknowledged the staffing issues, which were not consistently aligned with the facility's expected staffing levels.
During a survey at Elm Manor Nursing and Rehabilitation Center, deficiencies were found in food storage and preparation. Milk was stored at over 50°F, exceeding safe temperatures, and chicken patties were improperly thawed without running water. The Food Service Director and Registered Dietician acknowledged these issues, noting occasional temperature discrepancies in test trays.
A resident with multiple health conditions was transferred from the facility without proper documentation or justification. Initial assessments showed the resident was alert and doing well, but a nursing note later indicated the resident left by ambulance without any documented reason or details about the transfer. Interviews revealed that staff were unaware of the lack of documentation, violating facility policy.
Two residents in the facility did not receive necessary assistance with personal hygiene and grooming, leading to deficiencies in care. One resident, with Alzheimer's and other conditions, had no documented showers or hair washing for months, despite a physician's order. Another resident, with osteoarthritis and dementia, also lacked documented hygiene care, expressing a need for a haircut and shower. Staff interviews revealed issues with documentation and care follow-up, exacerbated by staff shortages.
A survey identified a deficiency in medication management practices when an LPN was found with pre-poured medication cups labeled only with room numbers, contrary to professional standards. The DON confirmed that pre-pouring is against policy and emphasized adherence to the five rights of medication administration.
Insufficient nursing staffing and delayed medication administration
Penalty
Summary
The facility failed to provide sufficient nursing staff each day to meet resident needs and to maintain a licensed nurse in charge on each shift. The facility policy stated licensed nursing staff were to be available 24 hours a day, and the Facility Assessment identified minimum staffing levels for the 37-bed facility. However, review of schedules and punch records from 12/01/2025 through 05/05/2026 showed repeated discrepancies between scheduled and actual staffing, including at least 26 day shifts, 7 evening shifts, and 4 night shifts where licensed nursing staffing was below the facility’s minimum, along with 32 day shifts and 43 evening shifts where CNA staffing was below the minimum. The staffing shortages affected residents whose records were reviewed, including a resident with diabetes, end stage renal disease, and kidney/pancreas transplant status; a resident with stage 5 CKD, anemia, and muscle weakness; and a resident with CHF, CKD, and diabetes. Medication Administration Audit Reports showed repeated delayed medication administration during periods when staffing records reflected shortages and discrepancies. Delayed medications included respiratory treatments, immunosuppressive medications, diabetic gastroparesis medication, CKD and hyperkalemia medications, anemia and hypertension medications, insulin and other diabetic medications, CHF and blood pressure medications, blood clot prevention medication, edema medication, and glaucoma eye drops. Delays ranged from more than 1 hour to more than 24 hours. Interviews supported the staffing concerns. A resident stated there were nights when staff could not be found and residents yelled for help for hours. CNAs reported there were often only two CNAs on the unit during the day and not enough time to complete duties when short staffed. LPNs stated there were times when no nurse was immediately available for medications, that some shifts had only one nurse and two aides, that nurses sometimes worked without aide support, and that they frequently worked alone or double shifts because staffing coverage was inadequate. The Staffing Coordinator stated expected staffing included two nurses on day and evening shifts, one nurse on night shift, four CNAs on day and evening shifts, and two CNAs on night shift. The Regional DON and Administrator acknowledged staffing coverage concerns and stated inadequate staffing could result in delayed medication administration and reduced assistance with ADLs.
RN Coverage Not Maintained as Required
Penalty
Summary
The facility failed to use the services of a registered nurse for at least eight consecutive hours per day, seven days per week. Review of Employee Paired Punches from 12/01/2025 to 05/05/2026 showed no registered nurse in the building within a 24-hour period on 12/15/2025, 12/16/2025, and 12/18/2025, and less than eight consecutive hours of registered nurse coverage on 12/17/2025 and 02/24/2026. During interviews, the Staffing Coordinator stated that a registered nurse had to be in the building for at least eight hours per day, but the hours did not have to be consecutive. The Regional Director of Nursing stated they were aware that there had to be a registered nurse in the building for eight out of 24 hours, were aware there were times with no registered nurse in the building, and that the facility occasionally used an on-call registered nurse who would come in if there were issues. The Administrator stated they were not aware of the lack of registered nurse coverage.
Systemic failures in staffing, medication administration, food service, and resident care oversight
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use resources effectively and efficiently to maintain residents’ highest practicable well-being. The report states that administrative systems, including staffing oversight, medication administration monitoring, and quality assurance processes, were not functioning to identify and correct deficient practices. This was identified in the context of repeated and new deficiencies across multiple areas of care, including sufficient nursing staffing, medication administration, food service, resident rights, accident hazards, and activities of daily living. Prior survey history showed repeat deficiencies from the prior recertification survey, including care provided for activities of daily living, accident hazards, sufficient nursing staff, and sanitary food procurement, storage, preparation, and service. During the abbreviated survey, additional deficiencies were cited for resident rights and significant medication errors. The report states that for three residents, the facility obtained authorizations allowing the Administrator to act regarding Medicare Part D enrollment and plan changes without ensuring the residents and/or their representatives received information about plan options, financial implications, reenrollment rights, and coverage changes. It also states that resident dignity was not maintained when a urinary catheter collection bag was exposed, a resident was observed ambulating with visibly soiled clothing, and a resident was referred to as a feeder in the presence of staff and other residents. The report further describes failures in direct care and service delivery. One resident was observed multiple times with long, thick facial hair despite verbalizing that the facial hair was unwanted and requiring staff assistance for removal. Another resident who was frequently incontinent waited long periods without incontinence care, and a third resident requiring shower assistance had no documented evidence of receiving or refusing a shower during a 10-day admission. Meal service errors were also observed, including residents being served incorrect texture consistencies, with one resident coughing and clearing their throat while eating. Medication administration issues involved multiple residents experiencing omissions of ordered medications and significantly late administrations, including high-risk medications. Food service observations included liquid draining onto the kitchen floor during meal service, staff not performing hand hygiene between glove changes before touching ready-to-eat food, a soiled dumbwaiter, and an ice scoop stored inside a cooler containing ice.
Failure to Provide Medicare Coverage Information and Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure residents and/or their representatives received information needed to make informed decisions about Medicare coverage enrollment and plan changes. For three residents, the facility obtained authorizations allowing the Administrator to act regarding Medicare Part D enrollment and plan changes, but the record did not show that residents or representatives were given written comparisons of plan options, plan-specific cost information, copays, deductibles, financial implications of coverage changes, reenrollment rights, or information about loss of supplemental benefits. The CMS guidance cited in the report required nursing homes to explain resident rights orally and in writing in a language the resident understands, and required facilities to explain the impact of coverage changes. Resident #6 was cognitively intact and had Medicare Parts A, B, and D. The record showed a signed authorization permitting the Administrator to act as the resident’s legal representative for Medicare Part D enrollment and plan changes. A complaint intake documented that the resident’s representative attended a meeting with facility staff shortly after admission and was encouraged to change the resident’s health insurance after being told the resident’s insurance would cover only 20 days of therapy and additional days would cost more than $200 per day. The representative later reported changing the resident’s insurance to Plan F and learning afterward that other options were available. The facility could not provide documentation showing that written comparisons or financial explanations were provided. Resident #8 was cognitively intact and had Medicare Parts A, B, and D. The record included an authorization permitting the Administrator to act regarding Medicare Part D enrollment and plan changes, but the facility could not provide documentation showing that written comparisons, cost information, or reenrollment and supplemental benefit information were given. Resident #10 had severe cognitive impairment and also had Medicare Parts A, B, and D. The record included verbal acknowledgements by the resident’s representative permitting the Administrator to act regarding Medicare Part D enrollment and plan changes, but again the facility could not provide documentation showing that the required written or financial information was provided. The Business Office Manager stated residents and/or representatives were told they were being disenrolled and moved to Medicare coverage, and that written information was not provided. The facility also failed to maintain resident dignity for three residents. Resident #8, who was cognitively intact and had an indwelling urinary catheter, was observed seated in the dining room and later in the hallway with an uncovered catheter bag containing urine. The resident stated the uncovered bag bothered them and made them feel self-conscious, and an LPN stated an exposed catheter bag was a dignity issue. Resident #14, who had dementia, diabetes, arthritis, moderate cognitive impairment, and required assistance with toileting, dressing, and personal hygiene, was observed ambulating in the hallway with a brown substance on the back of their pants and later again near the nursing station with the soiled clothing still visible while multiple CNAs and nurses were present. Resident #12, who had Parkinson’s disease, CHF, major depressive disorder, severe cognitive impairment, and required total assistance with eating, was referred to as a feeder by the DON in the dining room doorway in the presence of staff and other residents. The DON stated the term was used because the resident required feeding assistance, and the Regional DON stated referring to a resident as a feeder in front of others was inappropriate and could be embarrassing.
Failure to Provide ADL Assistance, Hygiene, and Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for three residents who were unable to complete those tasks independently. The undated ADL policy stated residents unable to carry out ADLs were to receive appropriate care and services, including bathing, grooming, and toileting, and that refusals had to be documented in a progress note and care plan. The deficiencies involved bathing, incontinence care, and grooming/hygiene, and the record did not show documented refusals for the affected residents. One resident had diagnoses including difficulty swallowing, stroke, and muscle weakness, and was assessed as cognitively intact but needing supervision and/or touch assistance for personal hygiene. The care plan and Kardex directed limited assistance for personal hygiene, and documentation showed staff provided varying levels of assistance with hygiene and grooming. However, progress notes did not show any refusal of care, and the resident was observed on multiple occasions with long, thick facial hair on the chin. The resident stated staff were supposed to help remove the facial hair and that it had been allowed to grow for about two weeks before it was addressed. Staff and the Regional DON stated facial hair should be addressed weekly and that staff were expected to take care of it. Another resident had dementia, muscle weakness, and pressure ulcers, with severe cognitive impairment and frequent urinary and bowel incontinence. The care plan and Kardex directed extensive assistance with toileting, but the facility could not provide documentation of regular incontinence care or refusals. The resident was observed sitting in a geri-chair and later returned to bed without incontinence care until nursing staff were providing wound care, and on another occasion was found in bed with a saturated brief and yelling that they needed to use the bathroom. A CNA provided care and stated they were unsure when the resident had last been changed. A third resident had muscle weakness, COPD, and malnutrition, with moderate cognitive impairment and supervision needed for showering. The care plan and Kardex directed extensive assistance with showering, but the facility could not provide documentation that the resident received or refused a shower during the reviewed period.
Incorrect Diet Texture and Consistency Served to Residents
Penalty
Summary
The facility failed to ensure residents on mechanically altered diets received food with the ordered texture and consistency. Resident #8 had diagnoses including difficulty swallowing, weakness, and blindness, and was ordered to receive a low potassium, mechanical soft, ground-texture diet. During a dining room observation, the resident was served a tray labeled soft ground consistency, but the entree was a chicken patty cut into small cubes. While eating, the resident repeatedly coughed and cleared their throat, and the LPN stated the food was chopped rather than ground and that the tray presented an aspiration and choking risk. The tray was not removed and the resident continued eating it. Resident #11 had diagnoses including difficulty swallowing, stroke, and muscle weakness and was ordered to receive a mechanical soft, chopped-texture diet. During an observation, the resident was served a whole hamburger cut into quarters with a meal ticket indicating mechanical soft consistency. The CNA stated the hamburger was not chopped, and the DON observed that it was cut into quarters and was a choking risk, but the tray was not removed and the resident continued eating. Resident #10 had diagnoses including difficulty swallowing, stroke, and dementia, and was ordered to receive a mechanical soft, chopped-texture diet. During an observation, the resident requested a sandwich, was given a whole peanut butter and jelly sandwich, and after the DON cut it in half, the resident began taking large bites. An LPN later stated the sandwich was not mechanically soft because it was dry and then cut it into smaller pieces.
Significant Medication Errors and Late Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for five of seven residents reviewed. The report states that multiple ordered medications were not documented as administered for Residents #1, #8, #9, #10, and #13, and that several medications for multiple residents were administered outside the ordered timeframes without documented provider notification. The cited policy required medications to be administered in accordance with prescriber orders and within one hour of the prescribed time, and the provider notification policy required nursing staff to notify a provider of medication errors with potential adverse outcome, refusal of essential medications, and conditions requiring new or revised orders. Resident #1 had diabetes, end stage renal disease, and was a kidney and pancreas transplant recipient. The resident was cognitively intact and had orders for CellCept, prednisone, tacrolimus, lispro insulin before meals, glargine insulin at bedtime, and ipratropium-albuterol nebulizer treatments. The MAR showed 25 occurrences where transplant-related medications were not documented as administered, two additional refusals, 30 occurrences where insulin was not documented as administered, and 51 additional refusals. The medication audits showed 276 occurrences where medications were administered more than one hour late, and 11 occurrences where the nebulizer was given less than two hours apart, including eight times only two minutes apart. The care plan did not include education, training, evaluation, or mention of the resident self-directing blood glucose monitoring or insulin administration, and there was no documented evidence that the resident had been assessed to safely self-administer medications or keep medications at bedside. The resident stated staff did not give medications unless asked, that transplant medications were sometimes not received, and that the resident had been checking blood glucose and administering insulin three to four times daily. Resident #8 had stage five chronic kidney disease, anemia, and muscle weakness, and was cognitively intact. The resident had orders for cefdinir, cefpodoxime proxetil, doxycycline hyclate, and hydralazine hydrochloride. The MAR showed six occurrences where the antibiotics were not documented as administered and seven occurrences where hydralazine was not documented as given. The medication audits showed 516 occurrences where medications were administered at least one hour late. Resident #10 had dementia, myoclonus, and an unstageable sacral pressure ulcer, with severely impaired cognition and orders for apixaban, baclofen, and divalproex sodium. The MAR showed 13 occurrences where baclofen was not documented as administered, nine occurrences where divalproex sodium was not documented as administered, and two occurrences where apixaban was not documented as administered. Nursing notes documented that baclofen was on order and not available, and the audits showed 741 occurrences where medications were administered at least one hour late. Resident #9 had a history including TIA, hemiplegia, and neuropathy, and was cognitively intact. The resident had orders for gabapentin, levothyroxine, fluoxetine, trazodone, and warfarin. The medication audits showed 285 occurrences where medications were administered at least one hour late, and gabapentin doses were given within three hours of each other on 25 occasions, including four times within three minutes. On one day, all medications scheduled for administration were signed out as given at 4:01 PM. Staff interviews indicated that medications were often passed late because of staffing issues, that some medications were unavailable because they had not been reordered or had not arrived from the pharmacy, and that nurses documented refusals or notes when medications were unavailable because the electronic record did not provide an option for unavailable medications. The Medical Director stated that providers should have been notified when medications were missed or significantly late and that residents should not consistently receive medications late or not at all.
Failure to Assess and Monitor Self-Administration of Insulin
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined whether a resident’s right to self-administer medications was clinically appropriate. The resident had diagnoses including diabetes, kidney and pancreas transplant, and end-stage kidney disease, and was documented as cognitively intact and using insulin. The resident’s care plan did not include self-administration of medications, self-supplied insulin, or use of a continuous glucose monitoring system, and the facility could not provide documented evidence that the resident had been assessed to safely self-administer insulin or keep medications at the bedside. The resident had orders for Humalog before meals for self-directed diabetic monitoring and insulin administration using their own continuous glucose monitor and home-dosing of insulin, as well as insulin glargine at bedtime for supervised self-administration with nursing to record blood glucose readings and the amount administered by the patient. Review of the MAR showed multiple occasions when blood glucose monitoring or insulin administration were not documented, and many entries were charted as refusals. There was no documented evidence of the amount of Humalog the resident gave themselves for each scheduled dose. Staff interviews confirmed they were unaware the resident was managing their own insulin with personal supplies, did not regularly verify the amount administered, and were not consistently tracking blood glucose readings or insulin administration.
Incomplete Care Plans for Insulin, Catheter, and Incontinence Needs
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans with measurable goals, timeframes, and interventions for three residents. Resident #1 had diagnoses including diabetes, a kidney transplant, and end-stage kidney disease, was cognitively intact, and was receiving Humalog insulin before meals and insulin glargine at bedtime, but the care plan only addressed diabetes in general and did not include interventions for glucose monitoring or insulin management. Resident #8 had diagnoses including benign prostatic hyperplasia, chronic kidney disease, and an indwelling urinary catheter, was cognitively intact, and had a care plan reviewed on 04/30/2026 that did not include goals or interventions related to the catheter; the Kardex also did not include the indwelling urinary catheter as of 05/05/2026. Resident #10 had diagnoses including dementia, muscle weakness, and pressure ulcers, and the Minimum Data Set showed severe cognitive impairment, substantial assistance needed with toileting hygiene, and frequent urine and bowel incontinence. The resident’s care plan included extensive assistance with toileting, but it did not include goals or interventions for frequent incontinence care. During interviews, the Regional Director of Nursing stated care plans should include incontinence care with checking and changing every two hours and as needed, and that insulin should be included in the care plan; the Regional Director of Nursing also stated a urinary catheter should be included in the care plan so proper catheter care and monitoring are done. The Administrator stated the QAPI committee was unaware of issues regarding care plans.
Missed sacral wound care and prolonged uncovered pressure ulcer
Penalty
Summary
Resident #10, who had dementia, myoclonus, and an unstageable pressure ulcer of the sacral region, had a physician order for daily wound care that included soaking gauze with Vashe wound cleanser, packing the sacral wound, and applying a dressing. The resident’s care plan identified the sacral pressure ulcer and risk for further skin breakdown related to immobility and incontinence, with interventions to monitor that the dressing remained intact and report loose dressings to nursing staff. The April 2026 treatment record showed the ordered wound treatment was not documented as completed on multiple dates, and there was no progress note explanation for the missed treatments. Wound assessments during the month documented the sacral wound as healing without signs of infection. During observation, an LPN completed a dressing change to the sacral wound on 04/30/2026. The next morning, the resident was observed in bed calling out for assistance while incontinent of urine and stool, with no dressing covering the sacral wound and no wound packing visible. The CNA notified the LPN that the wound was uncovered, but the LPN stated they were in the middle of a medication pass and would address it later. The wound remained uncovered during later observations, including while the resident was receiving physical therapy in bed. When the Wound Care Physician, DON, and Regional DON entered the room for wound rounds, the resident was still incontinent and had no dressing or packing in place; the physician then cleaned and repacked the wound and applied a new dressing. The Wound Care Physician stated the brief should have been changed when soiled and the wound should have had a dressing covering it. An LPN later stated that when only one nurse was assigned to day shift, not all treatments could be completed, and that there had been occasions when they found Resident #10 without a dressing in place.
Food Served at Unsafe and Unappetizing Temperatures
Penalty
Summary
Food and drink were not provided at a safe and appetizing temperature during the lunch meal service. Resident #9 stated that the food was typically cold, did not taste good, and that buns became soggy because vegetables were placed on the same plate. During observation of the tray line, meal trays were placed and covered on an open cart with no insulating doors, and cold food and drink items were pre-portioned and pre-poured on the trays. The last cart left the kitchen at 12:41 PM and residents were served lunch at 12:50 PM. A test tray was evaluated with the Regional Food Service Director and Dietary Aide #1, and temperatures were taken with the surveyor's digital thermometer. The test tray showed the hamburger at 131.5 degrees Fahrenheit and described as lukewarm and not palatable, sweet potatoes at 126.1 degrees Fahrenheit and described as cold, hard, bland, and not palatable, milk at 53.6 degrees Fahrenheit and lukewarm, and juice at 54.7 degrees Fahrenheit and lukewarm. In the hallway and outside the dining room, meal carts held collected trays with several plates that appeared untouched, with only small bites taken from the burgers and sweet potatoes. The Regional Food Service Director stated the kitchen had been short staffed, that they had been coming to the facility periodically for the previous year, that many residents did not eat lunch, and that tray line took longer than it should have. Resident #9 later stated they could not eat the hamburger because it was cold and tough, did not like the lunch, did not eat it, and were not offered anything else to eat.
Food Service Sanitation and Hand Hygiene Lapses
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During tray line while lunch meals were being prepared, a liquid substance drained from the kitchen sink plumbing onto the floor. Dietary Aide #2 placed towels on the floor to clean up the liquid, removed the wet towels, and put on a new pair of gloves without washing hands. The aide then continued handling trays, meal tickets, cutting hamburgers, and placing them on residents’ trays. The facility’s hand hygiene policy required handwashing or alcohol-based hand rub before handling food and after removing gloves, and the Infection Preventionist stated staff should wash hands and change gloves when going from dirty to clean and before touching food. Additional observations showed food service equipment and related items were not maintained in a sanitary manner. An ice scoop was observed resting inside a cooler of ice, and later the ice machine had dried white debris around the grate with a cleaning log showing the last documented cleaning as 02/25/2026. The dumbwaiter used for transporting clean laundry and meal trays was observed dirty with dark debris and scattered hair, and clean resident clothing was transported uncovered while uncovered used meal trays were sent down in the same dumbwaiter. The dumbwaiter cleaning log had multiple blank entries, and staff interviews indicated uncertainty about who was responsible for cleaning the dumbwaiter, ice machine, and ice scoop.
QAPI Committee Lacked Documented Infection Preventionist Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance Committee with the required members and to document that the Infection Preventionist attended the Quality Assurance and Performance Improvement meetings on a regular quarterly basis. The report states that the committee was required to include, at a minimum, the DON, the Medical Director or designee, at least three other staff members, one in a leadership role, and the Infection Preventionist, but the facility could not provide documented evidence that the Infection Preventionist was present at the QAPI meetings quarterly. The facility’s QAPI policies described a data-driven program to monitor clinical care, resident safety, regulatory compliance, and operational performance, and identified infection prevention as an area reviewed annually. The facility assessment stated that the infection prevention and control program was headed by a certified Infection Preventionist, and that infection prevention education covered hand hygiene, isolation, standard universal precautions, PPE, and environmental cleaning. Review of quarterly QAPI attendance records from 05/30/2025 to 02/25/2026 showed no documented evidence that the Infection Preventionist attended the meetings, and during interview the Regional Administrator and Administrator stated they knew the regulation and did not know why the Infection Preventionist had not attended the meetings at least quarterly.
Infection Control Failures During Resident Care and Food Handling
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident reviewed for activities of daily living. Resident #10 had diagnoses including dementia, myoclonus, and an unstageable sacral pressure ulcer. The resident’s MDS dated 03/10/2026 indicated severely impaired cognition and an unstageable pressure ulcer, and the care plan required extensive staff assistance with bathing, toileting, transferring, and dressing. The care plan also identified the need for Enhanced Barrier Precautions related to the resident’s wound. During an observation and interview on 05/01/2026, a CNA put on gloves, cleansed stool and urine from Resident #10, and did not change gloves before washing the resident’s face or body. The CNA also did not remove gloves or perform hand hygiene before touching multiple surfaces in the resident’s room, including the closet, bed controls, call light, and clean gown. The CNA then left the room twice wearing the same gloves and touched hallway surfaces and items, including a closet door, clean sheets, clean towels, and a glove box. When interviewed, the CNA stated the resident’s pressure ulcer did not have a cover or dressing and acknowledged they should have removed gloves, washed hands, and put on new gloves before continuing care and touching surfaces. The CNA also stated they had not been asked to wear a gown for care and only wore one for residents positive for COVID-19, but after seeing the EBP sign stated they should have worn a gown. A separate observation on 04/29/2026 showed a dietary aide responding to liquid draining from kitchen sink plumbing onto the floor during tray line. The aide placed towels on the floor, picked up the wet towels, and put them in a bin, then removed gloves and put on a new pair without washing hands. The aide continued handling trays, meal tickets, cutting hamburgers, and placing them on resident trays. The aide stated they changed gloves after cleaning up the floor but did not know they should wash hands between glove use and did not remember infection control training. The Infection Preventionist stated staff should wear gowns and gloves for close contact care for residents with wounds, remove PPE after care, and perform hand hygiene, and stated staff should wash hands and change gloves when going from dirty to clean and before touching food.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to ensure that Baseline Care Plans were developed within 48 hours of admission for six residents reviewed during the Recertification Survey. Specifically, there was no evidence of Baseline Care Plans being completed for five residents, and for one resident, although a Baseline Care Plan was developed, there was no documentation that a summary was provided to the resident or their representative. This deficiency was identified through interviews and record reviews conducted during the survey. The facility's policy, revised in December 2016, mandates that a Baseline Care Plan be developed within 48 hours of admission to address the resident's immediate needs. However, interviews revealed that the Social Worker responsible for completing these plans was not trained and unaware of the requirements. The Administrator believed the Social Worker was following the process but discovered otherwise during the survey. The lack of training and oversight contributed to the failure in meeting regulatory requirements for Baseline Care Plans.
Suction Machines Not Prepared for Emergency Use
Penalty
Summary
The facility failed to ensure that suction machines were prepared for immediate use in case of an aspiration emergency, posing a potential hazard to residents at risk for aspiration. During the recertification survey, it was observed on multiple occasions that suction machines on the crash cart next to the nurse's station were not fully assembled. Specifically, neither the Medline Vac-Assist nor the Invacare suction machines had tubing or a reservoir attached to catch fluids. On one occasion, the Medline device had the reservoir in place, but the Invacare did not, and neither had tubing attached. Additionally, a Medline suction machine near a resident room was found without the reservoir or tubing attached. Interviews with the Nurse Manager confirmed that the suction machines should have clean tubing and a canister ready for use, with the packaging kept over the tubing to maintain cleanliness. The Nurse Manager acknowledged that there were five residents in the facility on aspiration precautions and stated that valuable time would be wasted attaching tubing in an emergency.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, as evidenced by multiple instances of inadequate staffing during various shifts. On several occasions, the staff-to-resident ratio was significantly below the required levels, leading to delays in providing essential care such as showers, incontinence care, toileting, and meal assistance. For example, on certain evening shifts, only one Certified Nursing Assistant (CNA) was available to care for approximately 40 residents, resulting in unmet care needs and prolonged wait times for residents requiring assistance. Interviews with residents and visitors highlighted the impact of staffing shortages on resident care. Residents reported long wait times for assistance with activities of daily living, such as getting up, toileting, and personal hygiene. One resident mentioned waiting an hour for their call bell to be answered, while another described frequent delays in receiving help during the night shift. A visitor expressed concerns about their loved one's hygiene and incontinence issues due to the lack of timely staff response. Staff interviews further confirmed the staffing challenges, with Licensed Practical Nurses (LPNs) and other staff members acknowledging the frequent understaffing and its effect on resident care. The Wound Care Physician noted an inability to complete rounds due to the absence of a nurse to assist, and an LPN admitted to pre-pouring medications to manage dual responsibilities as a nurse and CNA. The Interim Director of Nursing acknowledged the staffing issues and stated that scheduling was based on facility census and resident acuity, yet the expected staffing levels were not consistently met.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
During a Recertification Survey conducted from August 21 to August 27, 2024, at Elm Manor Nursing and Rehabilitation Center, deficiencies were identified in the facility's food storage, preparation, and service practices. Specifically, a potentially hazardous food item was not properly thawed, and potentially hazardous foods were not maintained at the required cold temperature of 45 degrees Fahrenheit or below. Observations on August 22, 2024, revealed that a chest freezer in the kitchen dry storage room was holding milk at a temperature exceeding 50 degrees Fahrenheit, with a specific measurement of 54 degrees Fahrenheit. The Food Service Director acknowledged the issue and discarded the milk, noting that the temperature was acceptable earlier that morning. Further observations on August 26, 2024, identified improper thawing practices, with precooked chicken patties left in a sink without running cold water. The Food Service Director admitted that the water had been turned off, possibly during plating or cleaning, and was only off for about 45 minutes before being turned back on. Additionally, the Registered Dietician noted that monthly test trays sometimes revealed temperature discrepancies, and previous tests indicated that milk was occasionally warm due to the milk cooler's knob being inadvertently adjusted. These findings indicate a failure to adhere to professional standards for food service safety, as outlined in the facility's dietary policy.
Inadequate Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure proper documentation and justification for the transfer or discharge of a resident, identified as Resident #191, during a recertification survey and complaint investigation. Resident #191, who had a recent right above the knee amputation, diabetes, and chronic obstructive pulmonary disease, was admitted to the facility for short-term rehabilitation. Initial assessments indicated that the resident was alert and oriented, and doing well according to the Social Services and Dietary departments. However, a nursing progress note later indicated that the resident had left the facility, but there was no documentation explaining the reason for the transfer or discharge, the resident's health status, or the receiving healthcare institution. Interviews conducted during the investigation revealed that the Assistant Director of Nursing acknowledged the resident left by ambulance, but there was no supporting documentation for the transfer. The facility's Administrator was unaware of the lack of documentation in the resident's electronic health record. This lack of documentation violated the facility's policy, which requires a clear statement of facts supporting the transfer or discharge and documentation of all related activities in the social service notes. The deficiency was identified under 10 NYCRR 415.3(i)(1)(ii)(a)(b).
Deficiency in Resident Hygiene and Grooming Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for two residents, leading to deficiencies in personal hygiene and grooming. Resident #5, diagnosed with Alzheimer's dementia, hypertension, and chronic pain syndrome, required extensive assistance with personal hygiene and bathing. Despite a physician's order specifying a shower day and the importance of bathing to the resident, there was no documented evidence of showers or hair washing from early May to late August. Observations noted the resident's hair was greasy, and a family member expressed concerns about the resident's hygiene. Resident #26, with diagnoses including osteoarthritis, vascular dementia, and hypertension, also required significant assistance with personal hygiene and bathing. The resident's care plan indicated a need for help with showering and grooming, yet there was no documentation of showers or hair washing from early July to late August. Observations revealed the resident's hair was long and unkempt, and the resident expressed a desire for a haircut and a shower. The facility lacked a hairdresser, and staff interviews indicated that showers were sometimes missed due to staff shortages. Interviews with facility staff, including CNAs and the LPN Manager, revealed a lack of documentation and follow-up on residents' refusals of care. The LPN Manager and Assistant Director of Nursing acknowledged the expectation for complete documentation of daily living activities and the need for reapproaching residents who refused care. However, there was no evidence of such documentation or follow-up for the two residents in question, highlighting a deficiency in the facility's care practices.
Deficiency in Medication Management Practices
Penalty
Summary
During a recertification survey conducted from August 21 to August 27, 2024, a deficiency was identified in the medication management practices of the facility. Specifically, on August 26, 2024, at 3:50 PM, an LPN was observed with a medication cart containing four medication cups in the top drawer. These cups were pre-poured with multiple pills and labeled only with room numbers, which is not in accordance with acceptable professional standards. The LPN admitted to pre-pouring medications and was unaware that this practice was not acceptable. The LPN also mentioned having seen another nurse pre-pour medications in the past and relied solely on room numbers to identify the medication cups, posing a risk of administering medications to the wrong resident if a resident were to enter another's room. In an interview on August 27, 2024, the Director of Nursing (DON) confirmed that pre-pouring medications is against the facility's policy and emphasized that medication administration is covered during orientation. The DON stated that nurses are expected to adhere to the five rights of medication administration, keep medication carts locked, prioritize safety, and avoid pre-pouring medications. This deficiency highlights a lapse in adherence to medication management protocols, as observed during the survey.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 77 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Canandaigua
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| M.m. Ewing Continuing Care Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Ontario Center For Rehabilitation And Healthcare | 3.7 mi | ★★★★★ | 5 | 0 |
| Clifton Springs Hospital And Clinic Extended Care | 8.7 mi | ★★★★★ | 0 | 0 |
| Crest Manor Living And Rehabilitation Center | 14.4 mi | ★★★★★ | 2 | 0 |
| Wayne Health Care | 14.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.