Pennsylvania Department of Health
ELLEN MEMORIAL REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ELLEN MEMORIAL REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

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ELLEN MEMORIAL REHABILITATION AND HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Complaint Investigation completed on 15, 2026, at Ellen Memorial Rehabilitation and Healthcare Center , it was determined that there were no federal deficiencies, related to the Health portion of the survey process, identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care as they relate to the Health portion of the survey process; however, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 201.14(c) LICENSURE Responsibility of licensee.:

(c) The licensee through the administrator shall report as soon as possible, or, at the latest, within 24 hours to the appropriate Division of Nursing Care Facilities field office serious incidents involving residents as set forth in § 51.3 (relating to notification). For purposes of this subpart, references to patients in § 51.3 include references to residents.

Observations:

Based on clinical record review, review of the Pennsylvania Department of Health Electronic Reporting System (ERS), and staff interviews, it was determined that the facility failed to report a reportable incident involving a resident animal bite-injury caused by a visitor's dog to the Department of Health, Division of Nursing Care Facilities, for one of eight residents reviewed (Resident 3).

Findings include:

A clinical record review revealed that Resident 3 was admitted to the facility on September 3, 2025, with diagnoses that included early onset Alzheimer's dementia (develops before the age of 65 and is a type of brain disorder that slowly destroys a person's memory and thinking skills and characterized by a loss of cognitive functioning such as thinking, remembering, and reasoning that interfere with a person's daily life and activities).

A review of facility investigative documentation dated April 9, 2026, at 12:40PM. revealed Resident 3 reached toward a visitor's muzzled dog to pet the animal. Documentation indicated the dog lunged toward the resident and, despite the muzzle being in place, scratched the resident with its teeth. As a result of the incident, Resident 3 sustained a 0.3 centimeter laceration (a cut or tear in the skin) to the knuckle of the right index finger. Minimal bleeding was observed, and the resident was able to move the finger without difficulty.

The attending physician was notified of the incident and provided orders for Augmentin (an antibiotic medication used to treat bacterial infections) 125 milligrams by mouth twice daily for seven days and for the injury to be cleansed with soap and water daily and as needed. The resident representative was notified of the incident and the physician's orders.

A review of the Pennsylvania Department of Health Electronic Reporting System revealed the facility did not submit a report regarding Resident 3's injury involving a visitor's dog.

During an interview on June 15, 2026, at 12:30 p.m., the Nursing Home Administrator and Director of Nursing confirmed the incident involving Resident 3 and the visitor's dog was not reported to the Department of Health through the Electronic Reporting System as required.

Plan of Correction - To be completed: 07/07/2026

1. The incident with Resident 3 was reported to the Pennsylvania Department of Health Electronic Reporting System and accepted.
2. DON or designee will review incident reports for the last 2 weeks of current residents to ensure any reportable incidents were reported.
3. The DON/NHA will be educated on the requirements for reportable incidents.
4. DON/designee will audit incident reports 3x per week for 4 weeks then once a week for 2 months to evaluate the requirement of reportable incidents. Results of audits will be reviewed by the QAPI Committee

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratios were provided on each shift for three shifts out of 14 shifts reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:10 on the day shift, 1:11 on the evening shift, and 1:15 on the night shift based on the facility's census.

June 13, 2026 - 10.60 nurse aides on the evening shift versus the required 10.91 for a census of 120.

June 13, 2026 - 6.53 nurse aides on the night shift versus the required 8.00 for a census of 120.

June 14, 2026 9.67 nurse aides on the evening shift versus the required 10.82 for a census of 120.

On the above dates mentioned, no additional excess higher-level staff were available to compensate for this deficiency.

An interview with the Nursing Home Administrator (NHA) on June 15, 2026, at 1:30 PM confirmed the facility had not met the required nurse aide to resident ratios on the above dates.

Plan of Correction - To be completed: 07/07/2026

1.The facility cannot retroactively correct nurse aide staffing ratio.
2. Director of Nursing or designee will conduct an initial audit of the
past two weeks schedule to determine if ratio met compliance.
3. Director of Nursing or designee will re-educate the nursing scheduler
on the proper ratio. The facility will hold labor meetings Monday-Friday
to validate ratio is accurate and within compliance. During these
meetings the facility will review upcoming schedules to ensure
adequate staffing. Facility will audit each shift to determine the needs for
the shift to have adequate staffing.
4. Director of Nursing or designee will conduct random audits of facility
ratio weekly for four weeks, then monthly for two months thereafter to
confirm proper ratio hours. Results of audits will be reviewed by the

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse (LPN) ratio to resident ratio was provided on each shift for one shift out of 14 shifts reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide a minimum of one LPN per 25 residents during the day shift.

June 12, 2026 -4.0 licensed practical nurse staff on the day shift versus the required 4.76 for a census of 119.

An interview with the Director of Nursing (DON) on June 15, 2026, at 1:30 PM, confirmed the facility had not met the required licensed practical nurse to resident ratios on the above date.

Plan of Correction - To be completed: 07/07/2026

1.The facility cannot retroactively correct LPN staffing ratio.
2. Director of Nursing or designee will conduct an initial audit of the
past two weeks schedule to determine if ratio met compliance.
3. Director of Nursing or designee will re-educate the nursing scheduler
on the proper ratio. The facility will hold labor meetings Monday-Friday
to validate ratio is accurate and within compliance. During these
meetings the facility will review upcoming schedules to ensure
adequate staffing. Facility will audit each shift to determine the needs for the shift to have adequate staffing.
4. Director of Nursing or designee will conduct random audits of facility
ratio weekly for four weeks, then monthly for two months thereafter to
confirm proper ratio hours. Results of audits will be reviewed by the
Quality Assurance Performance Improvement Committee and
changes will be made as necessary

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 3.20 hours of general nursing care to each resident:

June 13, 2026 2.88 direct care nursing hours per resident.

June 14, 2026 3.00 direct care nursing hours per resident.

The facility's general nursing hours were below minimum required levels on the above dates.

During an interview with the Nursing Home Administrator (NHA) on June 15, 2026, at 1:30 PM, the above information was reviewed and confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 07/07/2026

1. The facility cannot retroactively correct staffing PPD.
2. Director of Nursing or designee will conduct an initial audit of the
past two weeks schedule to determine if PPD met compliance.
3. Director of Nursing or designee will re-educate the nursing scheduler
on the proper PPD. The facility will hold labor meetings Monday-Friday
to validate PPD is accurate and within compliance. During these
meetings the facility will review upcoming schedules to validate
adequate staffing. Facility will audit each shift to determine the needs for
the shift to have adequate staffing.
4. Director of Nursing or designee will conduct random audits of facility
PPD weekly for four weeks, then monthly for two months thereafter to
verify proper PPD hours. Results of audits will be reviewed by the
Quality Assurance Performance Improvement Committee and
changes will be made as necessary

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