Cycle 1
Health 2024-08-27 · Fire 2024-08-27
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Canandaigua, NY
Elm Manor Nursing and Rehabilitation Center
1-star overall rating with 2-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
210 North Main Street, Canandaigua, NY
(585) 394-3883
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
46
Certified beds
Average residents
41
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1977-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.61
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.75
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.50
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
2.67
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
86%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
84%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,897
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
4.45
Performance 6.51% · Measure score 4.45 · Achievement 4.45 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Baseline 52.94% · Performance 86.36% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.23 hours · Performance 3.02 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.89% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 12.2% · Lower 95% interval 7.67% |
| Discharge to community | 38.27% |
50.57%
12.3 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 25.58% · Lower 95% interval 26.34% |
| Medicare spending per beneficiary | 1.36 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 113 · Denominator 113 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 113 |
| Discharge self-care score | 63.77% |
53.69%
10.1 pts better
|
Numerator 44 · Denominator 69 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 46 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 2.65% |
2.29%
0.4 pts worse
|
Numerator 3 · Denominator 113 · Adjusted rate 3.07% |
| Healthcare-associated infections requiring hospitalization | 6.51% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 3.57% · Lower 95% interval 3.42% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 82 · Denominator 82 |
| Staff flu vaccination coverage | 24.27% |
42%
17.7 pts worse
|
Numerator 25 · Denominator 103 |
| Discharge function score | 65.22% |
56.45%
8.8 pts better
|
Numerator 45 · Denominator 69 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 80 · Denominator 80 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.69% |
25.2%
20.5 pts worse
|
Numerator 3 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.6% |
91.2%
4.6 pts worse
|
93.4%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.2% · Q2 79.2% · Q3 82.6% · Q4 100.0% · 4Q avg 86.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.1% |
95.3%
13.2 pts worse
|
95.5%
13.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.0%
3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 31.5% |
18.5%
13 pts worse
|
11.4%
20.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 45.5% · Q3 22.7% · Q4 34.8% · 4Q avg 31.5% |
| Percentage of long-stay residents who lose too much weight | 9.6% |
6.1%
3.5 pts worse
|
5.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 17.4% · Q3 4.8% · Q4 0.0% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.2% |
13.5%
8.3 pts better
|
19.6%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 4.2% · Q3 0.0% · Q4 4.3% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.6% |
14.8%
12.2 pts better
|
16.7%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.6% |
15.1%
5.5 pts better
|
16.3%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.6% |
15.5%
0.1 pts worse
|
14.9%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 25.0% · Q3 9.1% · Q4 0.0% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.6%
0.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.4%
1.4 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.7% |
20.8%
9.1 pts better
|
19.8%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 11.7% · Q3 7.9% · Q4 7.9% · 4Q avg 11.7% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
6.9%
0.9 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 17.1% · Q3 5.7% · Q4 0.0% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 46.9% |
76.7%
29.8 pts worse
|
81.7%
34.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 32.0% · Q3 44.0% · Q4 76.3% · 4Q avg 46.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
9.7%
3.4 pts worse
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 13.5% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.2%
0.4 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 2.6% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 40.6% |
78.8%
38.2 pts worse
|
79.7%
39.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 40.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.2% |
20.6%
2.6 pts worse
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 25.0% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-24 · Fire 2022-10-24
9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2020-11-02 · Fire 2020-11-02
5 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-08-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-08-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-08-27
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-08-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-15
F · Potential for more than minimal harm
2022-10-24
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-10-24
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-10-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-10-24
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-10-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-10-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-10-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-10-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-10-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-10-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-10-24
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-01-18
E · Potential for more than minimal harm
2020-11-02
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2020-11-28
E · Potential for more than minimal harm
2020-11-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-11-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-08-27
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-08-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-08-27
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-08-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-08-27
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-08-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-08-27
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-10-15
F · Potential for more than minimal harm
2022-10-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-10-24
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-10-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-10-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-10-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-10-24
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-10-24
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-10-24
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-18
D · Potential for more than minimal harm
2020-11-02
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2020-11-28
D · Potential for more than minimal harm
2020-11-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-11-28
D · Potential for more than minimal harm
2020-11-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-11-28
D · Potential for more than minimal harm
2020-11-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-11-28
D · Potential for more than minimal harm
2020-11-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-11-28
Penalties and ownership
What sits behind the stars
Ownership
Mayer, Giorgio
5% Or Greater Direct Ownership Interest · Individual
Grinspan, Aryeh
5% Or Greater Direct Ownership Interest · Individual
Mayer, Abraham
5% Or Greater Direct Ownership Interest · Individual
Mackenzie, Martin
Operational/Managerial Control · Individual
Mensah, Seth
Operational/Managerial Control · Individual
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