Cycle 1
Health 2025-01-10 · Fire 2025-01-10
7 health deficiencies
Top issue: Administration (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Honesdale, PA
Ellen Memorial Rehabilitation and Healthcare Cente
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
23 Ellen Memorial Lane, Honesdale, PA
(570) 253-5690
Overall
2 / 5
CMS overall stars
Health inspections
3 / 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
128
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-09-21
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
0.38
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.59
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.53
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
0.94
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.16
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
2.74
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,923
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.69
Baseline 21.57% · Performance 21.11% · Measure score 0.69 · Achievement 0.69 · Improvement 0.50
Healthcare-associated infections
0
Baseline 7.63% · Performance 7.69% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.01
Baseline 46.25% · Performance 39.13% · Measure score 6.01 · Achievement 6.01 · Improvement 2.83
Adjusted total nurse staffing
3.42
Baseline 3.38 hours · Performance 4.05 hours · Measure score 3.42 · Achievement 3.42 · Improvement 2.29
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.5% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 131 · Observed rate 14.5% · Lower 95% interval 9.47% |
| Discharge to community | 39.76% |
50.57%
10.8 pts worse
|
Worse than the National Rate · Eligible stays 96 · Observed rate 33.33% · Lower 95% interval 31.99% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 92.17% |
95.27%
3.1 pts worse
|
Numerator 106 · Denominator 115 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 115 |
| Discharge self-care score | 30.85% |
53.69%
22.8 pts worse
|
Numerator 29 · Denominator 94 |
| Discharge mobility score | 29.79% |
50.94%
21.1 pts worse
|
Numerator 28 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 4.35% |
2.29%
2.1 pts worse
|
Numerator 5 · Denominator 115 · Adjusted rate 3.43% |
| Healthcare-associated infections requiring hospitalization | 7.69% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 94 · Observed rate 8.51% · Lower 95% interval 4.64% |
| Staff COVID-19 vaccination coverage | 1.31% |
8.2%
6.9 pts worse
|
Numerator 2 · Denominator 153 |
| Staff flu vaccination coverage | 20.28% |
42%
21.7 pts worse
|
Numerator 43 · Denominator 212 |
| Discharge function score | 36.17% |
56.45%
20.3 pts worse
|
Numerator 34 · Denominator 94 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.73% |
96.28%
1.5 pts better
|
Numerator 43 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 22.22% |
25.2%
3 pts worse
|
Numerator 14 · Denominator 63 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.2
0.7 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.6% |
86.9%
0.7 pts better
|
93.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.3% · Q2 90.3% · Q3 85.6% · Q4 84.8% · 4Q avg 87.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 42.6% |
93.5%
50.9 pts worse
|
95.5%
52.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 42.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.2%
1.7 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.1% · Q4 1.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 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 who lose too much weight | 8.3% |
6.5%
1.8 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 7.3% · Q3 9.2% · Q4 8.3% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.2% |
19.9%
5.7 pts better
|
19.6%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 15.1% · Q3 13.2% · Q4 15.8% · 4Q avg 14.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
18.7%
7.6 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 11.1% · Q3 8.5% · Q4 11.5% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.2%
0.1 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.7% |
19.6%
8.9 pts better
|
16.3%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 13.9% · Q3 5.9% · Q4 13.0% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
18.3%
5.4 pts better
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 12.3% · Q3 10.3% · Q4 9.5% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 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 | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
26.4%
0.4 pts better
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 36.5% · Q3 16.4% · Q4 27.8% · 4Q avg 26.0% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
5.3%
1 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 2.5% · Q3 4.3% · Q4 5.5% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 45.2% |
68.9%
23.7 pts worse
|
81.7%
36.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 31.3% · Q2 43.2% · Q3 63.4% · Q4 41.9% · 4Q avg 45.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
9.8%
1.2 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 8.7% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 41.7% |
68.7%
27 pts worse
|
79.7%
38 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 41.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.3% |
23.1%
1.8 pts better
|
23.9%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 20.7% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-15 · Fire 2024-03-15
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-17 · Fire 2023-03-17
17 health deficiencies
Top issue: Infection Control (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-10
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 2025-03-11
E · Potential for more than minimal harm
2025-01-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-11
E · Potential for more than minimal harm
2025-01-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-11
C · Minimal harm
2025-01-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-11
E · Potential for more than minimal harm
2024-03-15
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 2024-04-23
E · Potential for more than minimal harm
2024-03-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-23
E · Potential for more than minimal harm
2023-03-17
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-17
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-10
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-04-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-01-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-10
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-02-18
E · Potential for more than minimal harm
2024-03-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-14
E · Potential for more than minimal harm
2024-03-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-05-14
E · Potential for more than minimal harm
2024-03-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-14
E · Potential for more than minimal harm
2024-03-15
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-03-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-03-15
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-05-14
E · Potential for more than minimal harm
2023-10-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-08-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-05
F · Potential for more than minimal harm
2023-03-17
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 2023-04-13
E · Potential for more than minimal harm
2023-03-17
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-17
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-17
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 2023-04-13
E · Potential for more than minimal harm
2023-03-17
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-17
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-17
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-17
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 2023-04-13
D · Potential for more than minimal harm
2023-03-17
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-17
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-17
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-04-13
Penalties and ownership
What sits behind the stars
Ownership
Buckman, Richard
5% Or Greater Direct Ownership Interest · Individual
Galat, Charles
5% Or Greater Direct Ownership Interest · Individual
Buckman, Richard
Corporate Officer · Individual
Lipperini Ramirez, Shira
W-2 Managing Employee · Individual
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#3
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