Elm Manor Nursing And Rehabilitation Center

F-F677- Activities of Daily Living Care for Dependent Residents.

The Facility Assessment, dated 02/20/2024, included the facility was licensed to provide care for 46 residents and had an average daily census of 40 residents. The staffing plan for a 28-bed unit was one Registered Nurse (Director of Nursing), one Licensed Practical Nurse Manager, two Licensed Practical Nurses for day shift, two Licensed Practical Nurses for evening shift, one Licensed Practical Nurse for night shift, three Certified Nursing Assistants for day shift, three Certified Nursing Assistants for evening shift, and one Certified Nursing Assistant for night shift.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 335255 Department of Health & Human Services Printed: 09/11/2025 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 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

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 0725 d. For the day shift (7:00 AM to 3:00 PM) on 8/15/2024, there was one Registered Nurse from 9:00 AM to 10:26 AM to provide medications and treatments. There was no nurse in the building from 10:26 AM to 11:04 Level of Harm - Minimal harm or AM. The staff to resident ratio from 9:00 AM to 10:26 AM was approximately one Registered Nurse to 40 potential for actual harm residents.

Residents Affected - Some e. For the day shift (7:00 AM to 3:00 PM) on 08/23/2024, there were two Certified Nursing Assistants to provide four scheduled showers, personal hygiene, grooming, dressing, incontinence care, toileting, pass breakfast and lunch trays, and answer call bells. The staff to resident ratio was approximately one Certified Nursing Assistant to 20 residents.

During a continuous observations on 08/23/2024 from 9:16 AM to 9:44 AM (28 minutes), a red call light (signifying resident needs assistant in the bathroom) was on above resident rooms [ROOM NUMBERS]. No staff member responded to the call bell during this time, and no staff were visible in the hallway.

Interviews conducted with residents and visitors included complaints of lack of assistance with activities of daily living (e.g., meals, showers, personal hygiene, toileting) particularly on weekends, evenings, and night shifts. These included, but were not limited to the following:

1. During an interview on 08/21/2024 at 9:57 AM, Resident #17 stated they cannot get up when they want to due to staffing challenges.

2. During an interview on 08/22/2024 at 11:56 AM, a visitor stated their loved one was frequently incontinent of urine because staff did not arrive timely to provide toileting assistance. The family member stated they had told staff their loved one's hair was dirty and needed a shower.

3. During an interview on 08/21/2024 at 11:47 AM, Resident #195 stated the facility was understaffed and

they wait a long time for care. On the day prior, Resident #195 stated they waited an hour for their call bell to be answered.

4. During an interview on 08/21/2024 at 1:47 PM, Resident #38 stated during the night shift on 08/14/2024,

they needed to use the rest room. There was only one Certified Nursing Assistant working in the facility and

it took over 30 minutes to get assistance. Resident #38 stated this happens often.

During an interview on 08/22/2024 at 11:34 AM, the Wound Care Physician stated they were unable to complete wound care rounds on 08/15/2024 as there was no nurse available on the unit to assist them.

During an interview on 08/26/2024 at 3:50 PM, Licensed Practical Nurse #2 stated they pre-poured medications to administer to residents because often times they would have to transition from their role as a Licensed Practical Nurse and take on Certified Nursing Assistant duties due to staffing challenges.

During an interview on 08/26/2024 at 12:33 PM, Licensed Practical Nurse Manager #1 stated there were several shifts during July 2024 that had no Certified Nursing Assistants working. Licensed Practical Nurse Manager #1 stated Nursing Leadership and Administration were aware of staffing struggles.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 335255 Department of Health & Human Services Printed: 09/11/2025 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 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

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 0725 During an interview on 08/26/2024 at 3:49 PM, the Assistant Director of Nursing stated they were aware of staff shortages at the facility. There were times when no Certified Nursing Assistants were scheduled, but the Level of Harm - Minimal harm or facility always had a nurse in the building. potential for actual harm

During an interview on 08/27/2024 at 10:22 AM, Occupational Therapist #1 stated resident care was often Residents Affected - Some hindered related to staffing shortages. It was difficult to work with residents when they were soiled and had not received incontinence care.

During an interview on 08/27/2024 at 12:18 PM, the Interim Director of Nursing stated they were responsible for overseeing nursing staff, and staff scheduling was based on the facility census and resident acuity (a measurement of the level of care residents requires based on their care needs). Their expectation was to have two nurses and three Certified Nursing Assistants on day shift, two nurses and two to three Certified Nursing Assistants on evening shift, and one nurse and two Certified Nursing Assistants on night shift.

10 NYCRR 415.13 (a)(1)(i-iii)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 335255