Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Ellen Memorial Rehabilitation and Healthcare Cente

HONESDALE, PA · 128 certified beds · Last Life Safety survey January 10, 2025

CMS Certification Number 395357 · first certified September 1976

Ownership

Independently operated (no chain recorded by CMS) · For profit - Corporation

  • Ownership changed June 1, 2019 (change of ownership)to ELLEN MEMORIAL HEALTH CARE CENTER from ELLEN MEMORIAL HEALTH CARE CENTER
10
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
3
Tags cited more than once
Across separate surveys
6
Inspection & testing records
Of the citations on file

Position within PA

10 citations — more than 47% of the 656 certified nursing homes in PA. Compared within PA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 4 citations; the earlier surveys in the window averaged 3. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (November 2025 to January 2026), and past the point by which nine in ten PA facilities have been surveyed. This facility’s last Life Safety survey was January 2025. Facilities in PA are typically surveyed 10–12 months after the last one (median 11), measured over 1,113 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 10 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.

This facility10PA median10National median11
Citations on file over three years, compared
MeasureCitations
This facility10
Median facility in PA10
Median facility nationally11

Survey history

Citations at each Life Safety survey
32023-0332024-0342025-01
Citations at each Life Safety survey
Survey dateCitations
March 17, 20233
March 15, 20243
January 10, 20254

Most-cited tags

Most-cited tags at this facility
K-03532K-03212K-03632K-07121K-03251K-03551K-01331
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0353Inspect, test, and maintain automatic sprinkler systems.22025-01-10
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.22025-01-10
K-0363Install corridor and hallway doors that block smoke.22025-01-10
K-0712Have simulated fire drills held at unexpected times.12025-01-10
K-0325Have properly installed hallway dispensers for alcohol-based hand rub.12023-03-17
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.12024-03-15
K-0133Install a two-hour-resistant firewall separation.12023-03-17

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 8
  • Construction Deficiencies 1
  • Miscellaneous Deficiencies 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies8
Construction Deficiencies1
Miscellaneous Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

January 10, 2025 — 4 citations

Citations issued on January 10, 2025
TagWhat the surveyor checksStatus
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (March 11, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (March 11, 2025)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (March 11, 2025)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (March 11, 2025)

March 15, 2024 — 3 citations

Citations issued on March 15, 2024
TagWhat the surveyor checksStatus
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (April 23, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (April 23, 2024)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (April 23, 2024)

March 17, 2023 — 3 citations

Citations issued on March 17, 2023
TagWhat the surveyor checksStatus
K-0133Install a two-hour-resistant firewall separation.Deficient, Provider has date of correction (April 13, 2023)
K-0325Have properly installed hallway dispensers for alcohol-based hand rub.Deficient, Provider has date of correction (April 13, 2023)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (April 13, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.