Elkins Crest Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkins Park, Pennsylvania.
- Location
- 265 E. Township Line Road, Elkins Park, Pennsylvania 19027
- CMS Provider Number
- 395711
- Inspections on file
- 24
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Elkins Crest Health & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to follow its abuse reporting policy when a resident with hemiplegia, stroke, dementia, cognitive impairment, and dependence on staff for transfers and personal care was found by a CNA to have bruising on the right arm and hip. An RN documented two faded purple bruises on the resident’s right hip and right upper arm, and the resident could not recall how the bruises occurred, making it an injury of unknown origin. Despite policy requiring immediate reporting of such incidents to the Administrator, DON, and State Survey Agency, the incident was not reported to the State Survey Agency, as confirmed by the DON.
A resident identified as an elopement risk managed to break a window safety device and use bed sheets to climb out of a third-story window, resulting in serious injuries. The resident, who had vascular dementia and anxiety, was last seen in the dining room before being found outside the building. The facility's failure to adequately monitor the resident and secure the environment led to this unauthorized departure.
The facility failed to maintain sanitary conditions for food storage in the main kitchen and two nursing unit pantries. Observations revealed undated and improperly stored food items, including expired pepperoni, undated hamburgers, and opened bags of buns with insects. These issues were found in both the walk-in freezer and refrigerator, as well as in the dry storage area and unit pantries.
A facility failed to complete a Minimum Data Set (MDS) assessment for a significant change in condition for a resident who experienced a decline in overall status and began hospice services. The Director of Nursing confirmed that the required assessment was not conducted.
A facility failed to complete a quarterly MDS assessment for a resident within the required timeframe. The RAI User's Manual mandates that quarterly assessments be completed no more than 92 days after the ARD of the most recent assessment, with a completion date no later than 14 days after the ARD. A review showed that a resident's quarterly MDS assessment was completed in February, but the next assessment was not done until August, exceeding the mandated timeframe. The DON acknowledged the delay during an interview.
Two residents were not instructed to rinse their mouths after using inhalers, as per manufacturer's guidelines, leading to a medication error rate of 6.67%, exceeding the acceptable threshold in the facility.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to follow its abuse policy requiring immediate reporting of all incidents and allegations of abuse, including injuries of unknown source, to the Administrator, Director of Nursing, and the State Survey Agency. The policy, last reviewed August 1, 2025, mandated such reporting, but this did not occur for one resident. The resident involved had diagnoses including hemiplegia, stroke, and dementia, was cognitively impaired, required staff assistance with toileting and personal hygiene, and was dependent on staff for transfers. On November 28, 2025, at 1:19 p.m., a nurse aide observed bruising to the resident’s right arm and right hip, and an RN assessed two faded purple bruises on the right hip and right upper arm, with the resident unable to recall how the bruises occurred, making this an injury of unknown origin. There was no documentation showing that this injury of unknown source was reported to the State Survey Agency as required by facility policy and applicable regulations. In an interview, the Director of Nursing confirmed that the facility did not report the incident to the State Survey Agency, resulting in a failure to timely report suspected abuse, neglect, or injury of unknown origin for this resident.
Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to provide necessary supervision to prevent an elopement incident involving a resident identified as at risk for elopement. The resident, who had been admitted with diagnoses including vascular dementia and anxiety, was identified as a potential elopement risk upon admission. The care plan included interventions such as placing a Wanderguard on the resident's wrist and housing the resident on the third floor. Despite these measures, the resident was able to break a window safety device and use bed sheets to climb out of a third-story window, resulting in a fall and serious injuries including a dislocated knee, subarachnoid hemorrhage, and a vertebrae fracture. The incident occurred when the resident was last seen in the dining room and was later found outside the building with personal belongings scattered around. The facility's investigation revealed that the resident had broken the chain device on the window and used bed sheets and hospital gowns to climb out. This indicates a failure in monitoring the resident's whereabouts and ensuring the security of the environment, which led to the resident's unauthorized departure and subsequent harm.
Food Storage Sanitation Deficiencies
Penalty
Summary
The facility was found to have failed in maintaining sanitary conditions for food storage in the main kitchen and two of the three nursing unit pantries. During an observation of the kitchen, several issues were noted in the walk-in freezer, including an opened box of chicken leg quarters with ice accumulation, an undated opened bag of hamburgers, and two undated opened packages of mixed vegetables. Additionally, pepperoni wrapped in plastic wrap was found with a use-by date that had already passed. In the walk-in refrigerator, an opened bag of shredded cheese was found without a date, and miniature butter cups were observed on the floor beneath the shelves. In the dry storage area, taco shells were removed from their original packaging and not dated, and several bags of hot dog buns and dinner rolls were either past their use-by date or opened and undated. A box of sprinkles was also found with an expired use-by date. Further observations in the first and second-floor unit pantries revealed additional deficiencies. In the first-floor pantry freezer, a package of sausage, egg, and cheese croissant was found without a name or date, along with an unknown item wrapped in aluminum foil. The second-floor pantry freezer contained an unlabeled clear food storage bag of vegetables and an unknown item inside a black bag, both without names or dates. Additionally, an opened bottle of soda was found in the refrigerator without a name or date. These findings indicate a lack of adherence to proper food storage protocols, as required by CFR 483.60 and 28 Pa. Code 201.18(b)(3).
Failure to Complete MDS Assessment for Significant Change
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) assessment for a significant change in condition for one of the 28 sampled residents. Resident 39 experienced a decline in overall status, leading to the initiation of hospice services on April 9, 2024. However, the required MDS assessment to document this significant change in the resident's condition was not completed. This deficiency was confirmed during an interview with the Director of Nursing on October 8, 2024, who acknowledged that the significant change in status MDS assessment had not been conducted.
Failure to Timely Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment for one of the 28 sampled residents, identified as Resident 119, within the required timeframe. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, quarterly assessments must be completed no more than 92 days after the Assessment Reference Date (ARD) of the most recent assessment, with a completion date no later than 14 calendar days after the ARD. A review of Resident 119's clinical records revealed that a quarterly MDS assessment was completed on February 18, 2024, but no subsequent assessment was completed until August 16, 2024, exceeding the mandated timeframe. During an interview on October 8, 2024, the Director of Nursing acknowledged that the MDS quarterly assessment for Resident 119 had not been completed in a timely manner as required by the RAI manual. This oversight indicates a failure to adhere to the established guidelines for resident assessments, resulting in a deficiency noted by the surveyors.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during a medication administration observation. On October 6, 2024, two medication errors were identified out of 30 opportunities, resulting in a 6.67% error rate. Resident 28, diagnosed with chronic obstructive pulmonary disease, was observed not being instructed to rinse her mouth after using a fluticasone furoate-vilanterol inhaler, contrary to the manufacturer's instructions. Similarly, Resident 47, with diagnoses including asthma and shortness of breath, was not directed to rinse her mouth after using a fluticasone furoate inhaler, as per the manufacturer's guidelines. These oversights contributed to the facility's failure to comply with the required medication error rate.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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