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 9 of 13 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 10 of 13 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 11 of 13 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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 46880 Residents Affected - Few Based on observations and interviews conducted during the Recertification Survey from 08/21/2024 to 08/27/2024, for one (cart two) of two medication carts reviewed, the facility did not ensure all medications were stored and labeled in accordance with acceptable professional standards. Specifically, four medication cups that contained medications that had been pre-poured (medications that are prepared in advance and stored until the time of adminstration), were in the medication cart drawer uncovered and only labeled with room numbers. This is evidenced by the following:

During observations on 08/26/2024 at 3:50 PM, Licensed Practical Nurse #2 was at medication cart two. The top drawer was open and contained four medication cups each containing multiple pills. The medication cups were labeled with room numbers only. During an immediate interview, Licensed Practical Nurse #2 said they had pre-poured their medications and were not aware that it was not good nursing practice to prepare medications and leave them in the medication cart. Licensed Practical Nurse #2 said they had seen another nurse (name unknown) pre-pour medications in the past. Licensed Practical Nurse #2 said they were only able to identify the medication cups based on the room numbers, so if a resident were to wander into another resident's room, they could mistakenly administer the medications to the wrong resident.

During an interview on 08/27/2024 at 11:34 AM, the Director of Nursing said no one should ever pre-pour medications. Medication administration was covered in orientation and each nurse shadowed a preceptor once they began working on the units. The Director of Nursing said they would expect the nurses to complete the five rights of medication administration (a standard for safe medication practices), lock their medication carts, always think about safety, and never pre-pour medications.

10 NYCRR 415.18(e)(1-4)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 45200

Residents Affected - Some Based on observations, interviews, and record review conducted during a Recertification Survey completed 08/21/2024 through 08/27/2024, for one of one main kitchen, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, a potentially hazardous food item was not properly thawed, and potentially hazardous foods were not held cold at or below 45 degrees Fahrenheit ( F). The findings are:

Review of the facility policy, Elm Manor Nursing and Rehabilitation Center Dietary Policy and Procedure Food Preparation, dated 11/03/2022, included the following: It is the policy of Elm Manor Nursing and Rehabilitation Center that all foods are prepared by acceptable methods to maintain optimal nutritional value, flavor, and appearance. Meals are to be attractively served at the proper temperature and to meet the individual resident's needs.

Observations on 08/22/2024 at 2:29 PM included a chest freezer holding approximately six square crates of pint sized 2% milk located in the kitchen dry storage room. The thermometer in the cooler displayed over 50 degrees Fahrenheit. A pint of this milk was measured with a Super-Fast Thermapen brand thermometer with

a temperature of 54 degrees Fahrenheit. During an interview at that time, the Food Service Director stated that the temperature was okay at 9 AM this morning and voluntarily discarded the milk. The surveyor then calibrated the Thermapen using crushed ice and water and it displayed at 32 degrees Fahrenheit.

Observations on 08/26/2024 at 1:00 PM included an approximately 8 by 12 by 6-inch deep pan with water and two bags of precooked chicken patties in the sink in the main kitchen. During an interview at this time,

the Food Service Director stated they had the cold water running to defrost the chicken but someone else in

the kitchen must have turned it off while plating or cleaning up. The Food Service Director stated the chicken was only there for about 45 minutes and then turned on the cold water.

During an interview on 08/27/2024 at 10:32 AM, the Registered Dietician stated they do test trays once a month and sometimes temperatures are not always what they should be. The Registered Dietician stated that they believed the last time a test tray was done the milk was a little warm and they tested the fridge to make sure it was staying at the proper temperature. The Registered Dietician stated it looked like the knob got hit sometimes in the milk cooler.

10 NYCRR: 415.14(h)

10 NYCRR: Subparts 14-1.31(c), 14-1.40(a), 14-1.86(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 335255