Elm Manor Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Elm Manor Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF725May 20, 2026

  Based on interviews and record review, the facility failed to ensure sufficient nursing staff were available to provide nursing services necessary to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents for three (3) of three (3) sampled residents reviewed (Residents #1, #8, and #13), and additional residents identified through facility-generated medication administration audit reports. Specifically, the facility failed to consistently meet staffing levels identified in its Facility Assessment, staffing records reflected repeated discrepancies regarding licensed nursing coverage, and residents experienced delayed medication administration during periods of inadequate staffing.The findings include:The facility policy Staffing, dated… […]

• No harm, potential for more than minimal, widespreadF727May 20, 2026

  Based on interviews and record review, the facility failed to use the services of a registered nurse for at least eight (8) consecutive hours per day, seven (7) days per week. Specifically, the facility was unable to provide documented evidence of registered nurse coverage within a 24-hour period on three (3) separate days, and (8) hours or more of registered nurse coverage on two (2) separate days during the five (5) months reviewed. The findings include: Review of Employee Paired Punches (direct care staff time punches provided by the facility) from 12/01/2025 to 05/05/2026 revealed that there was no registered nurse within a 24-hour period on 12/15/2025, 12/16/2025, and 12/18/2025. […]

• No harm, potential for more than minimal, widespreadF835May 20, 2026

  Based on observations, interviews, and record review, the facility failed to ensure it was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to ensure administrative systems, including staffing oversight, medication administration monitoring, and quality assurance processes, were implemented and functioning to identify and correct deficient practices, resulting in a pattern of noncompliance across multiple areas of care, including but not limited to sufficient nursing staffing, medication administration, food service, resident rights, accident hazards, and activities of daily living (basic tasks for… […]

• No harm, potential for more than minimal, widespreadF812Oct 24, 2022

  Based on observations, interviews and record review conducted during the Recertification Survey completed on 10/24/22, it was determined that for one of one main kitchen, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were food and non-food contact surfaces not maintained in clean and sanitary condition, sections of flooring in disrepair, improper thawing of a potentially hazardous food, pests were present, a thermometer in use was not accurate, equipment was not properly air dried, a food preparation sink lacked an indirect drain, food was stored directly underneath an unprotected sewer line, and there was lack of sufficient support personnel to safely and effectively carry out the… […]

• No harm, potential for more than minimal, patternF550May 20, 2026

  Based on observations, interviews, and record review, the facility failed to ensure residents and/or their representatives received information necessary to make informed decisions regarding Medicare coverage enrollment and plan changes and failed to ensure residents were treated with dignity and respect for five (5) of fourteen (14) residents reviewed (Residents #6, #8, #10, #12, and #14). Specifically, under Issue One (1) for three (3) of three (3) residents reviewed (Residents #6, #8, and #10), the facility obtained authorizations permitting the Administrator to act regarding Medicare Part D enrollment and plan changes and failed to ensure residents and/or their representatives received information regarding plan options, financial implications, reenrollment rights, and coverage… […]