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🔎 Elm Manor Nursing And Rehabilitation Center

Inspection Results


Inspection Overview

Elm Manor Nursing And Rehabilitation Center has been cited for a total of 36 deficiencies since we began saving each survey.

In New York, the average facility has **24.69 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: E

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2024-08-27
Correction Date: 2024-10-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-08-27
Correction Date: 2024-10-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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 locked, compartments for controlled drugs.

Survey Date: 2024-08-27
Correction Date: 2024-10-15
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-08-27
Correction Date: 2024-10-15
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Survey Date: 2024-08-27
Correction Date: 2024-10-15
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2024-08-27
Correction Date: 2024-10-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2024-08-27
Correction Date: 2024-10-15
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2023-02-01
Correction Date: 2023-03-30
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Survey Date: 2023-02-01
Correction Date: 2023-03-30
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Allow residents to self-administer drugs if determined clinically appropriate.

Survey Date: 2022-10-24
Correction Date: 2023-01-18
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2022-10-24
Correction Date: 2023-01-18
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2022-10-24
Correction Date: 2023-01-18
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Survey Date: 2022-10-24
Correction Date: 2023-01-18
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-10-24
Correction Date: 2023-01-18
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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 locked, compartments for controlled drugs.

Survey Date: 2022-10-24
Correction Date: 2023-01-18
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2022-10-24
Correction Date: 2023-01-18
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-10-24
Correction Date: 2023-01-18
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-10-24
Correction Date: 2023-01-18
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2021-09-16
Correction Date: 2021-11-15
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Survey Date: 2020-11-02
Correction Date: 2020-11-28
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2020-11-02
Correction Date: 2020-11-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2020-11-02
Correction Date: 2020-11-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2020-11-02
Correction Date: 2020-11-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2020-11-02
Correction Date: 2020-11-28
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2020-10-14
Correction Date: 2020-12-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2019-04-12
Correction Date: 2019-06-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: B

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Survey Date: 2019-04-12
Correction Date: 2019-06-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2019-04-12
Correction Date: 2019-06-11
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2019-04-12
Correction Date: 2019-06-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2019-04-12
Correction Date: 2019-06-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2019-04-12
Correction Date: 2019-06-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Survey Date: 2019-04-12
Correction Date: 2019-07-19
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: B

Post nurse staffing information every day.

Survey Date: 2019-04-12
Correction Date: 2019-07-19
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2019-04-12
Correction Date: 2019-06-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-04-12
Correction Date: 2019-06-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Survey Date: 2019-04-12
Correction Date: 2019-07-19
Category: Administration Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**