From 7:15 PM to 9:45 PM, two licensed practical nurses handled all resident care alone — medications, treatments, personal hygiene, and call bells. The staff-to-resident ratio hit one nurse for every 20 residents during the evening shift when residents needed dinner service, scheduled showers, incontinence care, and toileting assistance.
Federal inspectors documented the staffing crisis during a complaint investigation in August. They found the 46-bed facility regularly operated with dangerously low staffing levels that left residents waiting hours for basic care.
On July 29th and July 31st, single certified nursing assistants worked alone during evening shifts. One aide handled four scheduled showers, incontinence care, toileting, dinner service, and call bells for all 40 residents.
The morning of August 15th brought its own crisis. The facility's only registered nurse left at 10:26 AM, leaving the building without any nurse for 38 minutes until 11:04 AM.
Resident #38 described waiting over 30 minutes for bathroom assistance during a night shift on August 14th. "There was only one Certified Nursing Assistant working in the facility," the resident told inspectors. "This happens often."
Another resident complained they "cannot get up when they want to due to staffing challenges." Resident #195 said they waited an hour the previous day for their call bell to be answered, adding the facility was understaffed and "they wait a long time for care."
A family member told inspectors their loved one was "frequently incontinent of urine because staff did not arrive timely to provide toileting assistance." The visitor had repeatedly told staff their relative's hair was dirty and needed a shower.
During a 28-minute observation on August 23rd, inspectors watched a red call light — signifying a resident needed bathroom assistance — remain unanswered above multiple room doors. No staff responded, and none were visible in the hallway.
The staffing shortages disrupted medical care. The facility's wound care physician couldn't complete rounds on August 15th because no nurse was available to assist them.
Licensed Practical Nurse #2 told inspectors they "pre-poured medications to administer to residents" because they frequently had to abandon nursing duties to perform aide tasks due to staffing challenges.
The Licensed Practical Nurse Manager confirmed "there were several shifts during July 2024 that had no Certified Nursing Assistants working." They said nursing leadership and administration were aware of the staffing struggles.
Occupational Therapist #1 said resident care was "often hindered related to staffing shortages." It became difficult to work with residents "when they were soiled and had not received incontinence care."
The facility's staffing plan called for three certified nursing assistants on day shift, three on evening shift, and one overnight. But daily timecards revealed the reality: single aides handling 40 residents, shifts with no aides at all, and nurses forced to abandon their clinical duties.
The Assistant Director of Nursing acknowledged the staff shortages but claimed "the facility always had a nurse in the building." The August 15th timecard contradicted that statement.
The Interim Director of Nursing described their staffing expectations: two nurses and three aides on days, two nurses and two to three aides on evenings, one nurse and two aides overnight. The actual staffing fell far short on multiple documented shifts.
Elm Manor's average daily census was 40 residents in a facility licensed for 46 beds. The administrator reported 38 residents during the inspection's entrance conference.
Federal inspectors cited the facility for failing to provide adequate activities of daily living care for dependent residents. The violation carried a designation of minimal harm or potential for actual harm affecting some residents.
Interviews with residents, families, and staff painted a consistent picture: chronic understaffing that left vulnerable residents waiting extended periods for basic care like toileting, bathing, and responding to emergency call bells.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elm Manor Nursing and Rehabilitation Center from 2024-08-27 including all violations, facility responses, and corrective action plans.
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