Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elk Crossing during CMS and state inspections, most recent first.
Unsafe food handling and inadequate facial hair restraints were observed during meal prep and service. A dietary employee and another staff member were seen working in the kitchen without beard guards covering visible facial hair, one staff member prepared a sandwich with bare hands, and another touched meal service items without washing hands. The facility policy required safe food handling, beard nets when facial hair is visible, and handwashing after contact with the face, hair, or other potentially contaminated surfaces.
Two residents with urinary catheters were observed with catheter bags hanging under a wheelchair or bed and touching the floor. One resident had a suprapubic catheter, severe cognitive impairment, and staff-dependent catheter care, while the other had an order for catheter care every shift and as needed. An LPN and the DON stated catheter bags in contact with the floor were an infection control concern.
Failure to Report Abuse Allegation to State Agency: A resident with intact cognition reported that an aide slapped her during shower assistance, and staff initiated an internal investigation but did not report the allegation to the OSDH. The DON later acknowledged the report should have been sent to the state, while a CNA said the resident accused them of slapping her during care and a family member said the resident had a history of making false accusations.
A resident with urinary retention and an order for a urinary catheter to gravity had no catheter documented on the baseline care plan within 48 hours of admission. The resident was later observed in a wheelchair with the catheter bag hanging under the wheelchair and lying on the floor, and CNAs stated the catheter was present on admission. The DON stated the catheter should have been included on the baseline care plan.
The facility failed to ensure proper food service sanitation and storage requirements were followed. Observations included a burned-out oven hood light, residue in the dish wash area, split gaskets on coolers and freezers, and improperly stored ready-to-eat foods. The CDM confirmed the issues and stated that maintenance concerns were reported to the maintenance department.
The facility failed to ensure accurate resident assessments. A resident with hyperlipidemia and a non-ruptured cerebral aneurysm had a quarterly assessment incorrectly documenting anticoagulant use. The DON confirmed the resident received aspirin and clopidogrel bisulfate, which were misclassified as anticoagulants instead of antiplatelets.
Unsafe Food Handling and Inadequate Facial Hair Restraints
Penalty
Summary
Food was not prepared and served in a sanitary manner during two meal preparation and service observations. On 04/20/26 at 10:50 a.m., a dietary employee and another staff member were observed in the kitchen without beard guards covering visible facial hair; the dietary employee was scrubbing the sink and walls in the dish room while the other staff member was setting up dishes and preparing the lunch meal. Later that day at 12:08 p.m., one staff member was observed preparing a sandwich with bare hands, and another staff member was observed touching the ice scoop, cups, lids, straws, and plates while serving resident meals without washing hands; that same staff member was wearing a beard guard but did not have a hair restraint over the mustache. The facility policy stated that all staff will use safe food handling practices, beard nets are required when facial hair is visible, and employees will wash their hands just before work and any time after touching their face, hair, or other potentially contaminated surfaces. The dietary manager stated staff were supposed to wear guards and avoid touching food with ungloved hands, and the registered dietician stated facial hair restraints and food handling were discussed often with dietary staff.
Urinary Catheter Bags Contacted the Floor
Penalty
Summary
The facility failed to ensure infection control practices were followed for residents with urinary catheters for 2 of 2 sampled residents reviewed. Resident #1 had a suprapubic catheter, was dependent on staff for catheter maintenance, and had severely impaired cognition with a BIMS score of six. During observation, Resident #1’s urinary catheter bag was seen hanging under the wheelchair and dragging on the floor, and later hanging from the bed frame and touching the floor. A physician’s order showed the suprapubic catheter was to be changed every month, and an LPN stated the catheter bag should not touch the floor because of infection control concerns. Resident #13 was observed in a wheelchair with the urinary catheter bag hanging under the wheelchair and lying on the floor. A physician’s order showed urinary catheter care was to be provided every shift and as needed, and the resident’s face sheet showed admission with a diagnosis of urinary retention. An LPN stated the catheter bag lying on the floor was an infection control issue, and the DON also stated urinary catheter bags in contact with the floor were an infection control concern.
Failure to Report Abuse Allegation to State Agency
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported to the OSDH for one resident who reported that an aide had slapped her. The resident had a BIMS score of 15 indicating intact cognition on a significant change assessment, and a care plan later noted impaired thought processes related to metabolic encephalopathy. An internal investigation dated 03/30/26 stated the allegation was not considered a credible allegation of abuse because of lack of specificity, absence of physical findings, and inconsistency with observed care and staff interaction, so it was not reported to state authorities. During interview, the resident stated that about a month earlier a nurse aide had slapped her while assisting with a shower and identified the person as one of the traveling nurses. The DON stated an immediate investigation was initiated and the allegation was not substantiated, but also acknowledged the abuse allegation was not reported to the OSDH. CNA #3 stated a hospice aide was assisting with the shower, that they entered the room to help with oxygen tubing, and that the resident yelled that they had been slapped; CNA #3 reported the allegation to the DON immediately. A family member stated the facility called them about the allegation the same day it occurred and that they observed the resident daily for a week for bruising, but believed the resident had made up the allegation when she did not get her way.
Failure to Include Urinary Catheter in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan for a urinary catheter for Resident #13 within 48 hours of admission. Resident #13 was admitted with a diagnosis of urinary retention and had a physician order dated 04/16/26 for a urinary catheter to gravity with catheter care every shift and as needed. The baseline care plan dated 04/15/26 did not include documentation of the urinary catheter, although it did show the resident required two or more staff assistance with toileting. On 04/22/26, the resident was observed in a wheelchair with the catheter bag hanging under the wheelchair and lying on the floor. CNA #1 and CNA #2 stated the resident had the urinary catheter when admitted to the facility, and the DON stated the catheter should have been included on the baseline care plan.
Failure to Ensure Proper Food Service Sanitation and Storage
Penalty
Summary
The facility failed to ensure proper food service sanitation and storage requirements were followed. During a tour of the kitchen, several deficiencies were observed, including a burned-out oven hood light, an accumulation of black and brown residue on the floor and wall in the dish wash area, an unsecured metal backsplash in the dish wash area, and a split gasket on the walk-in freezer door. Additionally, two plastic storage bags of ready-to-eat hot dogs with open dates of April 7th and April 8th, and a plastic storage bag of ready-to-eat turkey with a discard date of April 20th were found in the walk-in cooler. The CDM confirmed that the hot dogs were to be held for seven days once opened and that the turkey should have been discarded. Further observations included a split gasket on the Delfield one-door reach-in cooler in the long-term care serving and dining area, and a split gasket on the ice cream freezer in the skilled serving and dining area. The CDM stated that food service areas were cleaned daily and maintenance concerns were reported to the maintenance department. However, a blanket was observed on the floor around the garbage disposal drain due to plumbing issues causing water to flood the floor. The CDM was made aware of the cleaning and maintenance concerns.
Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to ensure resident assessments were accurate for one of 18 sampled residents. Resident #59, who had diagnoses including hyperlipidemia and a non-ruptured cerebral aneurysm, had a quarterly assessment dated 04/03/24 that incorrectly documented the resident had received an anticoagulant during the last seven days or since admission/entry or reentry if less than seven days. However, there was no documentation supporting that the resident had received an anticoagulant during this period. On 04/23/24, the Director of Nursing (DON) was informed of the discrepancy and stated that the resident had received aspirin and clopidogrel bisulfate, which were incorrectly coded as anticoagulants instead of antiplatelets.
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Illustrative
What surveyors actually found near you
We read the 19 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Duncan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wilkins Health & Rehabilitation Community | 2.3 mi | ★★★★★ | 0 | 0 |
| Meridian Nursing Home | 7.9 mi | ★★★★★ | 0 | 0 |
| Gregston Nursing Home, Inc. | 8.2 mi | ★★★★★ | 9 | 0 |
| Marlow Nursing & Rehab | 8.2 mi | ★★★★★ | 10 | 0 |
| Temple Manor Nursing Home | 23.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.