Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elm Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to develop Baseline Care Plans within 48 hours of admission for several residents, as required by policy. Interviews revealed that the Social Worker responsible was not trained on completing these plans, leading to a lack of documentation and provision of care plan summaries to residents or their representatives.
The facility did not ensure suction machines were ready for immediate use in emergencies, as observed during a survey. Suction machines lacked necessary tubing and reservoirs, posing a risk to residents on aspiration precautions. The Nurse Manager confirmed the equipment should be ready to use, highlighting a lapse in preparedness.
The facility experienced significant staffing shortages, resulting in inadequate care for residents. On multiple occasions, the staff-to-resident ratio was insufficient, leading to delays in essential care such as showers, toileting, and meal assistance. Residents and visitors reported long wait times for assistance, and staff interviews confirmed the challenges in maintaining adequate care levels. The Interim Director of Nursing acknowledged the staffing issues, which were not consistently aligned with the facility's expected staffing levels.
During a survey at Elm Manor Nursing and Rehabilitation Center, deficiencies were found in food storage and preparation. Milk was stored at over 50°F, exceeding safe temperatures, and chicken patties were improperly thawed without running water. The Food Service Director and Registered Dietician acknowledged these issues, noting occasional temperature discrepancies in test trays.
A resident with multiple health conditions was transferred from the facility without proper documentation or justification. Initial assessments showed the resident was alert and doing well, but a nursing note later indicated the resident left by ambulance without any documented reason or details about the transfer. Interviews revealed that staff were unaware of the lack of documentation, violating facility policy.
Two residents in the facility did not receive necessary assistance with personal hygiene and grooming, leading to deficiencies in care. One resident, with Alzheimer's and other conditions, had no documented showers or hair washing for months, despite a physician's order. Another resident, with osteoarthritis and dementia, also lacked documented hygiene care, expressing a need for a haircut and shower. Staff interviews revealed issues with documentation and care follow-up, exacerbated by staff shortages.
A survey identified a deficiency in medication management practices when an LPN was found with pre-poured medication cups labeled only with room numbers, contrary to professional standards. The DON confirmed that pre-pouring is against policy and emphasized adherence to the five rights of medication administration.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to ensure that Baseline Care Plans were developed within 48 hours of admission for six residents reviewed during the Recertification Survey. Specifically, there was no evidence of Baseline Care Plans being completed for five residents, and for one resident, although a Baseline Care Plan was developed, there was no documentation that a summary was provided to the resident or their representative. This deficiency was identified through interviews and record reviews conducted during the survey. The facility's policy, revised in December 2016, mandates that a Baseline Care Plan be developed within 48 hours of admission to address the resident's immediate needs. However, interviews revealed that the Social Worker responsible for completing these plans was not trained and unaware of the requirements. The Administrator believed the Social Worker was following the process but discovered otherwise during the survey. The lack of training and oversight contributed to the failure in meeting regulatory requirements for Baseline Care Plans.
Suction Machines Not Prepared for Emergency Use
Penalty
Summary
The facility failed to ensure that suction machines were prepared for immediate use in case of an aspiration emergency, posing a potential hazard to residents at risk for aspiration. During the recertification survey, it was observed on multiple occasions that suction machines on the crash cart next to the nurse's station were not fully assembled. Specifically, neither the Medline Vac-Assist nor the Invacare suction machines had tubing or a reservoir attached to catch fluids. On one occasion, the Medline device had the reservoir in place, but the Invacare did not, and neither had tubing attached. Additionally, a Medline suction machine near a resident room was found without the reservoir or tubing attached. Interviews with the Nurse Manager confirmed that the suction machines should have clean tubing and a canister ready for use, with the packaging kept over the tubing to maintain cleanliness. The Nurse Manager acknowledged that there were five residents in the facility on aspiration precautions and stated that valuable time would be wasted attaching tubing in an emergency.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, as evidenced by multiple instances of inadequate staffing during various shifts. On several occasions, the staff-to-resident ratio was significantly below the required levels, leading to delays in providing essential care such as showers, incontinence care, toileting, and meal assistance. For example, on certain evening shifts, only one Certified Nursing Assistant (CNA) was available to care for approximately 40 residents, resulting in unmet care needs and prolonged wait times for residents requiring assistance. Interviews with residents and visitors highlighted the impact of staffing shortages on resident care. Residents reported long wait times for assistance with activities of daily living, such as getting up, toileting, and personal hygiene. One resident mentioned waiting an hour for their call bell to be answered, while another described frequent delays in receiving help during the night shift. A visitor expressed concerns about their loved one's hygiene and incontinence issues due to the lack of timely staff response. Staff interviews further confirmed the staffing challenges, with Licensed Practical Nurses (LPNs) and other staff members acknowledging the frequent understaffing and its effect on resident care. The Wound Care Physician noted an inability to complete rounds due to the absence of a nurse to assist, and an LPN admitted to pre-pouring medications to manage dual responsibilities as a nurse and CNA. The Interim Director of Nursing acknowledged the staffing issues and stated that scheduling was based on facility census and resident acuity, yet the expected staffing levels were not consistently met.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
During a Recertification Survey conducted from August 21 to August 27, 2024, at Elm Manor Nursing and Rehabilitation Center, deficiencies were identified in the facility's food storage, preparation, and service practices. Specifically, a potentially hazardous food item was not properly thawed, and potentially hazardous foods were not maintained at the required cold temperature of 45 degrees Fahrenheit or below. Observations on August 22, 2024, revealed that a chest freezer in the kitchen dry storage room was holding milk at a temperature exceeding 50 degrees Fahrenheit, with a specific measurement of 54 degrees Fahrenheit. The Food Service Director acknowledged the issue and discarded the milk, noting that the temperature was acceptable earlier that morning. Further observations on August 26, 2024, identified improper thawing practices, with precooked chicken patties left in a sink without running cold water. The Food Service Director admitted that the water had been turned off, possibly during plating or cleaning, and was only off for about 45 minutes before being turned back on. Additionally, the Registered Dietician noted that monthly test trays sometimes revealed temperature discrepancies, and previous tests indicated that milk was occasionally warm due to the milk cooler's knob being inadvertently adjusted. These findings indicate a failure to adhere to professional standards for food service safety, as outlined in the facility's dietary policy.
Inadequate Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure proper documentation and justification for the transfer or discharge of a resident, identified as Resident #191, during a recertification survey and complaint investigation. Resident #191, who had a recent right above the knee amputation, diabetes, and chronic obstructive pulmonary disease, was admitted to the facility for short-term rehabilitation. Initial assessments indicated that the resident was alert and oriented, and doing well according to the Social Services and Dietary departments. However, a nursing progress note later indicated that the resident had left the facility, but there was no documentation explaining the reason for the transfer or discharge, the resident's health status, or the receiving healthcare institution. Interviews conducted during the investigation revealed that the Assistant Director of Nursing acknowledged the resident left by ambulance, but there was no supporting documentation for the transfer. The facility's Administrator was unaware of the lack of documentation in the resident's electronic health record. This lack of documentation violated the facility's policy, which requires a clear statement of facts supporting the transfer or discharge and documentation of all related activities in the social service notes. The deficiency was identified under 10 NYCRR 415.3(i)(1)(ii)(a)(b).
Deficiency in Resident Hygiene and Grooming Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for two residents, leading to deficiencies in personal hygiene and grooming. Resident #5, diagnosed with Alzheimer's dementia, hypertension, and chronic pain syndrome, required extensive assistance with personal hygiene and bathing. Despite a physician's order specifying a shower day and the importance of bathing to the resident, there was no documented evidence of showers or hair washing from early May to late August. Observations noted the resident's hair was greasy, and a family member expressed concerns about the resident's hygiene. Resident #26, with diagnoses including osteoarthritis, vascular dementia, and hypertension, also required significant assistance with personal hygiene and bathing. The resident's care plan indicated a need for help with showering and grooming, yet there was no documentation of showers or hair washing from early July to late August. Observations revealed the resident's hair was long and unkempt, and the resident expressed a desire for a haircut and a shower. The facility lacked a hairdresser, and staff interviews indicated that showers were sometimes missed due to staff shortages. Interviews with facility staff, including CNAs and the LPN Manager, revealed a lack of documentation and follow-up on residents' refusals of care. The LPN Manager and Assistant Director of Nursing acknowledged the expectation for complete documentation of daily living activities and the need for reapproaching residents who refused care. However, there was no evidence of such documentation or follow-up for the two residents in question, highlighting a deficiency in the facility's care practices.
Deficiency in Medication Management Practices
Penalty
Summary
During a recertification survey conducted from August 21 to August 27, 2024, a deficiency was identified in the medication management practices of the facility. Specifically, on August 26, 2024, at 3:50 PM, an LPN was observed with a medication cart containing four medication cups in the top drawer. These cups were pre-poured with multiple pills and labeled only with room numbers, which is not in accordance with acceptable professional standards. The LPN admitted to pre-pouring medications and was unaware that this practice was not acceptable. The LPN also mentioned having seen another nurse pre-pour medications in the past and relied solely on room numbers to identify the medication cups, posing a risk of administering medications to the wrong resident if a resident were to enter another's room. In an interview on August 27, 2024, the Director of Nursing (DON) confirmed that pre-pouring medications is against the facility's policy and emphasized that medication administration is covered during orientation. The DON stated that nurses are expected to adhere to the five rights of medication administration, keep medication carts locked, prioritize safety, and avoid pre-pouring medications. This deficiency highlights a lapse in adherence to medication management protocols, as observed during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| M.m. Ewing Continuing Care Center | 1.4 mi | — | 0 | 0 |
| Ontario Center For Rehabilitation And Healthcare | 3.7 mi | — | 5 | 0 |
| Clifton Springs Hospital And Clinic Extended Care | 8.7 mi | — | 0 | 0 |
| Crest Manor Living And Rehabilitation Center | 14.4 mi | — | 0 | 0 |
| Wayne Health Care | 14.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.