Ellen Memorial Rehab: Fall Injury After Unsafe Transfer - PA

That sequence of events at Ellen Memorial Rehabilitation and Healthcare Center, documented in a complaint inspection completed March 31, 2026, forms the basis of a federal deficiency finding against the facility, cited as actual harm.

The resident, identified in inspection records only as Resident CR1, had a care plan that was unambiguous. Transfers and ambulation required the assistance of two staff members, with a stand-up lift for transfers and a roller walker with two-person support for walking. That requirement was not a suggestion buried in paperwork. It was the standard of care for this specific person, documented and assigned.

What happened on March 13, 2026, began at the start of an afternoon shift, when a nurse aide identified in the report as Employee 2 entered the resident's room. By Employee 2's own account, she asked the resident, "Hey do we plan on using the toilet today? I would like you to try since you were incontinent yesterday." The resident said she would, but not right then. Employee 2 said she accepted that, told the resident to let staff know when she was ready, and left to answer call bells.

Employee 1, another nurse aide, tells a different story about what the resident was told. According to Employee 1, Resident CR1 told her directly that Employee 2 had instructed her she needed to prove herself by ambulating to the bathroom. Employee 1 confirmed this account during a telephone interview with the surveyor on March 31, 2026.

Whatever was said, the result was the same. Resident CR1 was moving toward the bathroom with a walker and without the two-person assistance her care plan required. Employee 1 was there, and she knew it was wrong. She confirmed to surveyors that she was fully aware of the resident's transfer status at the time, that the care plan required two staff members and a stand-up lift, and that neither requirement was being met.

Employee 1 documented that she told the resident, "That is not the way you transfer anymore." The resident insisted on using the walker anyway. Employee 1 let her continue.

The resident was ambulating with the walker when she turned to sit on the toilet and began to fall. Employee 1 leaned into the resident's body, trying to guide her to the floor safely. The resident landed sitting on her left foot. Employee 1 was pinned beneath her and could not move, and called out for help.

The nursing home administrator confirmed to surveyors that the facility's own investigation concluded Employee 1 did not follow the care plan. Employee 1 was suspended immediately following the incident and terminated on March 16, 2026. Employee 2 was also suspended pending investigation, but returned to work on March 16 after the facility completed its review.

The two aides' accounts of what happened before the fall remain in direct conflict. Employee 2 denied pressuring the resident or encouraging her to ambulate or toilet independently. Employee 1 said the resident told her otherwise. The resident's own account does not appear in the inspection narrative.

What is documented is that Employee 1 completed training on safe transfer and lift techniques, abuse and neglect prevention, and safe bed mobility procedures. She signed an attestation confirming that training on March 11, 2026, two days before the fall.

The facility's response after the incident was extensive, at least on paper. Resident CR1 was assessed and transferred for medical evaluation. All resident records were reviewed to confirm transfer and ambulation requirements were accurately reflected in care plans. Nursing staff received re-education on individualized care plans and neglect prevention. Observational audits were implemented three times weekly for four weeks, then weekly for four weeks, then monthly. Results went to the facility's Quality Assurance Performance Improvement committee.

The deficiency was cited as past noncompliance, with the facility deemed to have achieved substantial compliance on March 16, 2026, three days after the fall.

That designation matters in regulatory terms. It means the violation had ended by the time surveyors arrived. It does not change what the inspection found: that a resident whose care plan required two people and a mechanical lift to move safely was walking to a bathroom alone, fell, and required surgery.

The gap between Employee 2's account and what Resident CR1 reportedly told Employee 1 is the part of this case that the facility's investigation did not fully resolve, at least not in any way that appears in the public record. Employee 2 came back to work. Employee 1, who was present during the fall and who acknowledged knowing the resident was being transferred without required assistance, was terminated.

Whether the resident understood the risk she was taking, or whether she was made to feel that refusing was not an option, is not something the inspection report addresses. What it does address is that the system meant to prevent exactly this kind of harm, the care plan, the two-person requirement, the stand-up lift, was bypassed entirely, and a resident ended up on a bathroom floor with her foot beneath her, waiting for someone to come.

The violation is cited under Pennsylvania nursing home regulations governing resident rights, nursing services, resident care policies, and management responsibility.

Resident CR1's surgical outcome is not described further in the inspection record.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Ellen Memorial Rehabilitation and Healthcare Cente from 2026-03-31 including all violations, facility responses, and corrective action plans.

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