Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 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.
Unsafe and Poorly Maintained Environment on Floors 2 and 3: Surveyors observed peeling paint, damaged walls, broken or missing handrails, damaged furniture, debris, flies, damaged ceiling and floor tiles, missing closet doors, loose fixtures, and uncovered electrical outlets with exposed wires on Floors 2 and 3. Additional damage was noted in dining areas, resident rooms, hallways, and on med carts, showing the environment was not maintained in a safe, clean, and comfortable condition.
A resident with CVA, respiratory failure, and dysphagia was ordered hospice after a change in condition, but the MDS assessments did not reflect hospice status. The DON later confirmed the MDS was inaccurate and that the resident was receiving hospice services.
Care Plans Did Not Address Urinary Incontinence: The facility failed to develop and implement comprehensive care plans for two residents with occasional urinary incontinence. Both residents had MDS CAA summaries identifying urinary incontinence as a care plan issue, but there was no documented evidence that interventions were included in the care plans. The DON confirmed the care areas were not addressed.
Failure to maintain pressure ulcer offloading for ear wounds. A resident with anoxic brain injury, respiratory failure, and diabetes was non-verbal, dependent for ADLs, and had pressure sores and risk for additional sores. A physician ordered a supportive neck pillow to keep the ears floating, and the care plan called for the pillow with turning and repositioning. Surveyors observed the resident multiple times in bed without the neck pillow in place, including times when the ear was in direct contact with the bed pillow. The DON confirmed the pillow should have been in place.
A resident with spinal stenosis, nutritional deficiency, and chronic inflammatory demyelinating polyneuritis reported damaged teeth after a hospital stay. A dentist later noted the teeth needed removal by an oral surgeon, but there was no documentation that the facility scheduled the oral surgery appointment, and the DON confirmed the missed dental services.
Failure to Notify Ombudsman of Resident Transfers: The facility did not document that written discharge or transfer notices were sent to the State LTC Ombudsman for six residents who were transferred to the hospital after significant changes in condition. The DON confirmed that the notices were not sent.
Failure to Post Current Nurse Staffing Information: Surveyors observed that the staffing information posted in the lobby was outdated and not current for the shift. The DON later confirmed that the correct staffing information should have been posted.
Improper Disposal of Trash and Refuse: During an observation of the dumpster area, the dumpster side door was open, multiple pieces of plastic and paper debris were found in the grassy area beside it, and two dumpster lids were lying on the ground next to the dumpster.
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.
Unsafe and Poorly Maintained Environment on Floors 2 and 3
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment on two of three nursing units, Floors 2 and 3. Observations on September 9, 2025, from 9:45 a.m. through 1:00 p.m. and on September 10, 2025, from 10:00 a.m. through 1:00 p.m. identified peeling paint on the wall under the fire extinguisher in the hallway by room [ROOM NUMBER], peeling paint and a dried brown liquid on the floor in front of the closets in room [ROOM NUMBER], and a marred hallway wall between rooms [ROOM NUMBERS]. A bedside tray table in room [ROOM NUMBER] was missing a drawer, another drawer was crooked, and a metal drawer track was on the floor. A bed curtain in room [ROOM NUMBER] was off its track, debris was on the floor in room [ROOM NUMBER], and marks were observed on the walls in the second-floor dining room. The handrail across from the second-floor nursing station was missing a piece, and the handrail next to the elevator was loose. Flies were observed in rooms 208 and 224 and at the second-floor nursing station. On the third floor, damage was observed to the wall behind bed A and to ceiling tiles in the bathroom of room [ROOM NUMBER]. The radiator cover was damaged, and a sliding closet door was off the tracks in room [ROOM NUMBER]. The entrance door and a floor tile were damaged in room [ROOM NUMBER], a sliding closet door was missing in room [ROOM NUMBER], and the wall across from bed A was damaged. Floor tiles in the bathroom in 325 were damaged, and there was an uncovered electrical outlet with wires exposed on the wall behind bed A in room [ROOM NUMBER]. An electrical outlet to the left of the television in the third-floor dining room had no cover. Ceiling tiles, the radiator under the television, and the piano in the third-floor dining room were damaged. Wheelchair bumper rails in the hallway between rooms 314 and the shower room, and between rooms [ROOM NUMBERS], were damaged. A red substance was observed on the back of the 3rd floor High side med cart, and the sharp's container cabinets on both 3rd floor med carts had broken vents on the sides.
Inaccurate MDS Assessment for Resident Receiving Hospice
Penalty
Summary
Resident 7 had diagnoses including cerebrovascular accident, respiratory failure, and dysphagia. After a change in condition on May 21, 2025, the physician ordered hospice services for the resident. However, the MDS assessments dated May 21 and August 21, 2025 did not indicate that the resident was receiving hospice services, making the assessments inaccurate in reflecting the resident's current status. During an interview on September 12, 2025, at 1:10 p.m., the DON confirmed that Resident 7's MDS assessments were inaccurate and that the resident was receiving hospice services.
Care Plans Did Not Address Urinary Incontinence
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed urinary incontinence for two sampled residents. Resident 75 had diagnoses including senile degeneration of the brain, major depression, and difficulty walking, and the MDS assessment indicated the resident was occasionally incontinent of urine. The MDS CAA summary dated February 13, 2025, stated that urinary incontinence was to be addressed in the care plan, but there was no documented evidence that interventions for this need were included in the care plan. Resident 76 had diagnoses including dementia, muscle weakness, and difficulty walking, and the MDS assessment indicated the resident was occasionally incontinent of urine. The MDS CAA summary dated January 2, 2025, also identified urinary incontinence as a care plan issue, but there was no documented evidence that interventions to address it were included in the care plan. The DON confirmed on September 12, 2025, at 10:10 a.m., that the identified care areas were not addressed in the care plans.
Failure to Maintain Pressure Ulcer Offloading for Ear Wounds
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was cited after surveyors found that the facility failed to provide necessary treatment and services to promote healing and prevent new pressure sores for Resident 4. The resident had diagnoses including anoxic brain injury, respiratory failure, and diabetes, and the MDS indicated the resident was non-verbal, dependent on staff for activities of daily living, had a pressure sore, and was at risk for additional pressure sores. A physician ordered staff to keep the resident's ears floating using a supportive neck pillow every shift, and the wound care physician later documented bilateral open ear wounds. The care plan identified bilateral ear wounds and interventions to keep the ears floating with a neck support pillow during turning and repositioning every two hours. However, on multiple observations the resident was lying in bed without the neck pillow in place, including times when the right ear was in direct contact with the bed pillow and another time when the head was facing forward without the pillow. The DON confirmed the neck pillow was supposed to be in place and was not at the time of the observations.
Failure to Provide Recommended Dental Services
Penalty
Summary
The facility failed to provide routine and emergency dental services for one resident. Resident 67, who was admitted with diagnoses including spinal stenosis, nutritional deficiency, and chronic inflammatory demyelinating polyneuritis, reported that some of her teeth were damaged while she was hospitalized in October 2024. The resident stated that a dentist had referred her to an oral surgeon for extractions, but no appointment had been made. Clinical record review showed that on May 21, 2025, a dentist examined the resident and documented that the damaged teeth needed to be removed by an oral surgeon, but there was no documentation that the facility scheduled an oral surgeon examination to meet the resident’s needs. The DON later confirmed that the facility had failed to provide the recommended dental services.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the State Ombudsman’s office in writing of resident transfers from the facility for six sampled residents who were sent to the hospital. Clinical record review showed that Resident 2 was transferred on May 12, 2025, after a significant change in condition, Resident 4 was transferred on June 17, 2025 and again on August 11, 2025 after significant changes in condition, Resident 6 was transferred on October 23, 2024 after a significant change in condition, Resident 15 was transferred on June 14, 2025 and again on June 27, 2025 after significant changes in condition, Resident 16 was transferred on April 2, 2025 after a significant change in condition, and Resident 155 was transferred on July 8, 2025 after a significant change in condition. For each of these residents, there was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman. During an interview on September 12, 2025 at 9:45 a.m., the DON confirmed that the written copies of the discharge or transfer notices were not sent to the Office of the State Long Term Care Ombudsman.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that current and accurate nurse staffing information was posted at the beginning of each shift. During a tour of the facility on September 9, 2025, at 9:45 a.m., surveyors observed that the staffing information posted in the lobby was dated September 5, 2025. In an interview on September 12, 2025, at 10:15 a.m., the DON confirmed that the correct staffing information should have been posted.
Improper Disposal of Trash and Refuse
Penalty
Summary
The facility failed to dispose of trash and refuse properly. During observation of the dumpster area, the side door of the dumpster was open, the grassy area next to the dumpster had multiple pieces of plastic and paper debris, and two dumpster lids were lying on the ground beside the dumpster.
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.
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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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Nursing homes near Elkins Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pennypack Rehab And Care Center | 1.5 mi | ★★★★★ | 6 | 0 |
| Independence Rehab And Nursing | 1.8 mi | ★★★★★ | 44 | 1 |
| Laurel Square Healthcare And Rehabilitation Center | 1.9 mi | ★★★★★ | 3 | 0 |
| Lafayette-redeemer, The | 2 mi | ★★★★★ | 0 | 0 |
| York Nursing And Rehabilitation Center | 2.1 mi | ★★★★★ | 17 | 1 |
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