Elm Manor Nursing And Rehabilitation Center
Elm Manor Nursing and Rehabilitation Center in Canandaigua, NY — inspection on August 27, 2024.
Found 8 citations. 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
Review of interdisciplinary progress notes, dated 08/05/2024, revealed Resident #191 was assessed by Social Services and Dietary departments as a new admission and was doing well.
In a nursing progress note, dated 08/06/2024 at 2:44 PM, Assistant Director of Nursing documented that Resident #191 had left the facility.
There was no other documentation in the resident's medical record regarding the Resident #191's health status, current condition, medical notification, and/or input regarding why the resident was transferred/discharged out of the facility or to where.
During an interview on 08/27/2024 at 12:38 PM, the Assistant Director of Nursing said that Resident #191 left the faciity on [DATE] by ambulance, but there was no documentation to support the resident's transfer.
During an interview on 08/27/2024 at 2:27 PM, the Administrator said they did not know much about Resident #191's transfer, but that the resident was in the facility less than 24 hours.
Additionally, the Administrator said they were not aware there was no documentation in the resident's electronic health record to show why the resident was transferred to the hospital. 10 NYCRR 415.3(i)(1)(ii)(a)(b)
335255 08/27/2024
Elm Manor Nursing and Rehabilitation Center 210 North Main Street Canandaigua, NY 14424
During an interview on 08/26/2024 at 9:48 AM, the Social Worker said they were not trained on how to complete Baseline Care Plans and they did not know what a Baseline Care Plan was.
During an interview on 08/26/2024 at 11:49 AM, the Administrator stated the Social Worker should complete Baseline Care Plans upon admission in the residents' electronic health record, print them, present them to the resident and/or their representative to be signed, and provide them with a copy.
The Administrator said they thought the Social Worker had been following their process for Baseline Care Plans until recently. 10 NYCRR 415.11
335255 08/27/2024
Elm Manor Nursing and Rehabilitation Center 210 North Main Street Canandaigua, NY 14424
Review of progress notes from
inch below their ears, and down their neck.
During observations on 08/26/2024 at 11:39 AM, Resident #26's hair was long.
During an interview at that time, Resident #26 stated they had not received a shower or shave and they would like a haircut.
During observations on 08/27/2024 at 11:04 AM, Resident #26 was wearing the same clothes from the previous day and the front of their shirt had dried food stains.
During an interview at that time, Resident #26 stated they could not remember the last time they received assistance with a shower, hair washing, or shave, and they would like a haircut.
Review of the unit shower schedule (list of scheduled shower day/shift for all residents residing on the unit) revealed Resident #26 was scheduled for a shower on Monday evenings (Resident would have been scheduled for the evening shift on 08/26/2024).
During an interview on 08/21/2024 at 11:22 AM, Certified Nursing Assistant #2 stated the facility did not have a hairdresser at the facility to provide haircuts.
During an interview on 08/26/2024 at 11:49 AM, Certified Nursing Assistant #1 stated they report to the nurse when a resident's shower was completed. If a resident refused assistance with a shower, they would reapproach the resident at a later time and report the refusal to the nurse so it could be documented in the electronic medical record.
Certified Nursing Assistant #1 stated sometimes showers were not given due to staff shortages.
During an interview on 08/26/2024 at 12:47 PM, the Licensed Practical Nurse Manager stated they expected that shower days included hair washing, shaving, and nail care.
The Certified Nursing Assistants should document in the electronic health record what care was performed on the resident's shower day and notify the nurse so skin checks could be completed.
Licensed Practical Nurse Manager stated the Certified Nursing Assistant should notify the nurse if a resident refused so the resident could be reapproached at a later time and the nurse could document the refusal of care.
During electronic medical record reviewed at that time, the Licensed Practical Nurse Manager stated there was no documentation since 05/04/2024 for Resident #5 and no documentation since 07/01/2024 for Resident #26 that indicated either resident had received or refused a shower.
During an interview on 08/26/2024 at 3:49 PM, the Assistant Director of Nursing stated it was their expectation that all activities of daily living were completed and documented in the electronic medical record. If staff were unable to provide care or the resident refused, the nurse should be notified so they could reapproach the resident.
The Assistant Director of Nursing stated there was no hairdresser employed by the facility. 10 NYCRR 415.12(a)(3)
335255 08/27/2024
Elm Manor Nursing and Rehabilitation Center 210 North Main Street Canandaigua, NY 14424
During an interview on 08/26/2024 at 3:41 PM, the Nurse Manager stated the suction machine should have clean tubing and a canister ready to use.
The packaging could be kept over the tubing to keep it clean, but the equipment should be ready to use.
The Nurse Manager stated there are currently five residents (#1, #12, #30, #194, and #295) in the facility that are on aspiration precautions.
During an interview on 08/27/2024 at 10:45 AM, the Nurse Manager stated one would waste valuable time putting the tubing on the suction machine in an emergency. 10 NYCRR: 415.12(h)(1)
335255 08/27/2024
Elm Manor Nursing and Rehabilitation Center 210 North Main Street Canandaigua, NY 14424
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)
335255 08/27/2024
Elm Manor Nursing and Rehabilitation Center 210 North Main Street Canandaigua, NY 14424
Based on observations and interviews conducted during the Recertification Survey from 08/21/2024
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)
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)
335255 08/27/2024
Elm Manor Nursing and Rehabilitation Center 210 North Main Street Canandaigua, NY 14424
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
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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.