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Complaint Investigation

Elm Manor Nursing And Rehabilitation Center

August 27, 2024 · Canandaigua, NY · 210 North Main Street
Citations 1
CMS Rating 1/5
Beds 46
Provider ID 335255
Healthcare Facility
Elm Manor Nursing And Rehabilitation Center
Canandaigua, NY  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)  ·  8 pages
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Elm Manor Nursing and Rehabilitation Center in Canandaigua, NY — inspection on August 27, 2024.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF677
Minimal harm or AM. The staff to resident ratio from 9:00 AM to 10:26 AM was approximately one Registered Nurse to 40 Some e. For the day shift (7:00 AM to 3:00 PM) on 08/23/2024, there were two Certified Nursing Assistants to affected

During the entrance conference meeting on 08/21/2024 at 9:56 AM, the Administrator stated the current facility census was 38 residents.

Review of daily timecards (used to track the actual hours worked by staff), revealed the following (based on the facility's average daily census of 40 residents):

a.

For the evening shift (3:00 PM to 11:00 PM) on 07/29/2024 and 07/31/2024, there was one Certified Nursing Assistant to provide four scheduled showers, incontinence care, toileting, pass dinner trays, and answer call bells.

The staff to resident ratio was approximately one Certified Nursing Assistant to 40 residents.

b.

For the evening shift (3:00 PM to 11:00 PM) on 08/01/2024, there were two Certified Nursing Assistants from 3:00 PM to 7:00 PM and one Certified Nursing Assistant from 9:45 PM to 11:00 PM to provide four scheduled showers, incontinence care, toileting, pass dinner trays, and answer call lights.

There were no Certified Nursing Assistants in the facility from 7:15 PM to 9:45 PM.

There were two Licensed Practical Nurses from 3:00 PM to 7:00 PM and from 7:45 PM to 11:00 PM to provide all resident care including medications, treatments, personal hygiene, and answer call bells.

The staff to resident ratio from 7:15 PM to 9:45 PM was approximately one Licensed Practical Nurse to 20 residents.

c.

For the day shift (7:00 AM to 3:00 PM) on 08/10/2024, there was one Certified Nursing Assistant from 7:00 AM to 3:00 PM to provide all personal hygiene, grooming, dressing, incontinence care, toileting, to pass breakfast and lunch trays, and answer call bells.

The staff to resident ratio was approximately one Certified Nursing Assistant to 40 residents.

335255

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 335255 B.

Wing 08/27/2024

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

Elm Manor Nursing and Rehabilitation Center 210 N Main Street Canandaigua, NY 14424

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Canandaigua, NY, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Elm Manor Nursing and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.