Ellen Memorial Rehabilitation And Healthcare Cente

During a telephone interview conducted by the surveyor on March 31, 2026, at 12:11 PM Employee 1, Nurse Aide, confirmed she was aware of Resident CR1's transfer and ambulation status at the time of the fall.

Employee 1 stated that Resident CR1 told her that Employee 2, Nurse Aide, instructed the resident that she had to prove herself by ambulating to the bathroom.

Employee 1 stated that she knew the resident's transfer status required assistance of two staff members with use of a stand-up lift for transfers and ambulation with a roller walker and assistance of two staff members.

Employee 1 stated the resident was transferred and ambulated without the required level of assistance, resulting in a fall with injury requiring surgical intervention.

Employee 1 stated she was suspended and sent home immediately following the incident and her employment was terminated on March 16, 2026.

During a telephone interview conducted by the surveyor on March 31, 2026, at 12:30 PM Employee 2, Nurse Aide, stated that on March 13, 2026, at 4:00 PM, she entered Resident CR1's room at the start of her shift to encourage the resident to request staff assistance when ready to use the bathroom.

Employee 2 denied pressuring the resident or encouraging the resident to ambulate or toilet independently.

Employee 2 stated she was suspended and sent home at the time of the incident.

Employee 2 stated that following completion of the facility's investigation, she returned to work on March 16, 2026.

Review of Employee 1's personnel file revealed the employee completed training, including abuse and neglect prevention, safe bed mobility procedures, safe transfer and lift techniques, and documentation requirements within the electronic health record, with attestation signed March 11, 2026.

During an interview on March 31, 2026, at 1:00 PM, the Nursing Home Administrator confirmed the facility investigation determined Employee 1 did not follow Resident CR1's care plan requiring assistance of two staff members for ambulation and transfers.

The Nursing Home Administrator confirmed Employee 1 was removed from the schedule pending investigation and employment was terminated March 16, 2026.

The facility implemented corrective actions immediately following the incident.

The resident was assessed and transferred for medical evaluation.

Employees 1 and 2, Nurse Aides, were suspended pending investigation.

The facility reviewed all resident records to verify transfer and ambulation requirements were accurately reflected in care plans and Kardex reports.

Nursing staff received re-education regarding adherence to individualized care plans and neglect prevention requirements. To sustain compliance, nursing administration implemented observational audits to ensure staff compliance with transfer requirements.

Audits were conducted three times weekly for four weeks, weekly for four weeks, and monthly thereafter.

Audit results were reviewed through the Quality Assurance Performance Improvement (QAPI, a program that monitors and improves quality of care and services) committee to determine ongoing compliance needs.

The facility achieved substantial compliance on March 16, 2026.

This deficiency is cited as past noncompliance. 28 Pa.

Code 201.14 (a) Responsibility of licensee.28 Pa.

Code 201.18 (e)(1) Management.28 Pa.

Code 201.29 (a) Resident rights.28 Pa.

Code 211.10 (c) Resident care policies.28 Pa.

Code 211.12 (d)(5) Nursing services.