Inspection visit
Inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment
for residents on three of three nursing units. (Nursing Units One, Two, Three)
Findings include:
Observations during the environmental tour of Unit One on September 20, 2023, at various times, revealed
a bottom dresser drawer without a handle in room [ROOM NUMBER]-2, a broken nightstand top drawer in
room [ROOM NUMBER]-1, and a broken bottom dresser drawer handle in room [ROOM NUMBER]-1.
Observations during the environmental tour of Unit Two on September 19, 20, and 21, 2023, at various
times throughout the day, revealed that the arm and base of the overbed tables in resident rooms 203, 204,
210, 211, 215, and 217 were covered in a dark dried substance. In room [ROOM NUMBER]-1, there was a
celing tile with a large water stain with black spots and white residue surrounding the tile. In room [ROOM
NUMBER]-2, the wall paper was off the wall. In room [ROOM NUMBER]-2, the outlet cover was broken
behind the head of the bed. In room [ROOM NUMBER]-2, the baseboard cover was broken off the heating
unit.
Observations during the environmental tour of Unit Three on September 19 and 20, 2023, at various times
throughout the day, revealed room [ROOM NUMBER] had a marred walledand a piece of wall molding was
missing. On the side of 306-1, there was a piece of wall trim that was dangling by the headboard and on the
side of 306-2, there were several holes in the wall where the wall trim had been. The arm and base of the
overbed tables were covered in a dark, dried substance. The wall paper behind bed 1 and 2 in room
[ROOM NUMBER] was off the wall. In room [ROOM NUMBER]-2, the baseboard cover was broken off the
heating unit and the dresser was missing handles. In room [ROOM NUMBER], the bottom dresser drawer
was broken. In room [ROOM NUMBER], the wall trim behind bed 2 was missing. In room [ROOM
NUMBER], the wall paper was off the wall. In room [ROOM NUMBER], the headboard was detached from
the bed frame and there were large water stained ceiling tiles above the bed. In room [ROOM NUMBER],
the armoire closet was missing a bottom drawer and there were large water stained ceiling tiles above the
bed.
28 Pa. Code 201.18(b)(1) Management.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
395711
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395711
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Elkins Crest Health & Rehabilitation Center
265 E. Township Line Road
Elkins Park, PA 19027
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, observation and staff interview, it was determined that the facility failed to complete
an accurate Minimum Data Set (MDS) assessment for three of 29 sampled residents. (Residents 22, 80,
105)
Residents Affected - Few
Findings include:
Clinical record review revealed that Resident 22 had diagnoses that included dementia and heart disease.
Review of Resident 22's MDS assessment dated [DATE], indicated Resident 22 was on hospice. There was
no documentation in the clinical record that indicated Resident 22 was on hospice services. In an interview
on September 22, 2023, at 10:45 a.m., the Director of Nursing confirmed that MDS assessment had been
inaccurately coded and that Resident 22 was not on hospice at that time.
Clinical record review revealed that Resident 80 had diagnoses that included diabetes and dependence of
renal dialysis. Section B of the MDS assessment dated [DATE], indicated that the resident had the ability to
see in adequate light. In an interview on September 19, 2023, at 10:00 a.m., Resident 80 stated she is blind
and can only see shadows. In an interview on September 21, 2023, at 2:00 p.m., the Director of Nursing
confirmed the resident had severely impaired vision and that the MDS assessment had been inaccurately
coded.
Clinical record review revealed that Resident 105 had diagnoses that included traumatic hemorrhage of the
cerebrum (stroke), tracheostomy (surgical airway), and seizures. Review of Resident 105's MDS
assessment dated [DATE], indicated that Resident 105 did not utilize any type of restraint. On September
27, 2022, a physician ordered for staff to apply a left hand mitt restraint. Observations on September 19,
20, and 21, 2023 at various times, revealed Resident 105 wearing the a left hand mitt restraint, which was
not identified on the MDS assessment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395711
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395711
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Elkins Crest Health & Rehabilitation Center
265 E. Township Line Road
Elkins Park, PA 19027
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and staff interview, it was determined that the facility failed to develop a care plan and
provide specialized services in accordance with the Pre-admission Screening and Resident Review
(PASARR) evaluation for two of 29 sampled residents. (Residents 67, 77)
Findings include:
Clinical record review revealed that Resident 67 was admitted on [DATE], with diagnoses that included
anxiety, mood disorder, major depressive disorder, violent behavior, and psychosis (a severe mental
condition in which thought and emotions are affected that contact is lost with external reality). Review of the
Minimum Data Set (MDS) assessment dated [DATE], identified the resident was oriented and required
extensive assistance from staff. Review of the record revealed that Resident 67 had a PASARR Level 1
(federally required assessment to help ensure that all individuals with serious mental disorders and/or
intellectual disabilities are not inappropriately placed in nursing homes for long term care) completed on
August 5, 2020. According to that assessment, Resident 67 had a positive screen for serious mental illness
that identified a need for specialized services such as training, service coordination, advocacy services,
peer counseling, support groups, community integration activities, equipment, assessments, and
transportation to help people function as independently as possible. Review of the clinical record revealed a
lack of documentation to support that specialized services were included in the care plan or provided to
Resident 67.
Clinical record review revealed that Resident 77 was admitted on [DATE], with diagnoses that included
schizophrenia, major depressive disorder, and schizoaffective disorder (a person who experience psychotic
symptoms such as, hallucinations and delusions). Review of the MDS assessment dated [DATE], identified
the resident was oriented and required assistance from staff. Review of the record revealed that Resident
77 had a PASARR Level 1 completed on August 3, 2018. According to that assessment, Resident 77 had a
positive screen for serious mental illness that identified a need for specialized services. Review of the
clinical record revealed a lack of documentation to support that specialized services were included in the
care plan or provided to Resident 77.
In an interview on September 21, 2023, at 2:00 p.m., the Administrator confirmed that no specialized
services were provided for Residents 67 and 77.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395711
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395711
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Elkins Crest Health & Rehabilitation Center
265 E. Township Line Road
Elkins Park, PA 19027
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on policy review and observation, it was determined that the facility failed to properly store food and
maintain sanitary conditions in the dietary department.
Residents Affected - Many
Findings include:
Review of the facility's policy entitled, Storage of Dry Food Policy, last reviewed March 2, 2023, revealed
food was to be stored in a manner to avoid contamination, optimize food safety, and protect food quality and
that foods were to be marked with a date when they were opened.
Review of the facility's policy entitled, Use-By Guide-Quick Reference, last reviewed March 2, 2023,
revealed foods should not be kept longer than seven days from the date marked on the product and the
use-by date marked on the container.
Observation during the tour of the kitchen on September 19, 2023, at 10:03 a.m., revealed the following:
In the walk-in cooler, there was a container of diced tomatoes, an opened bag of lettuce, and a bag of
tortillas that were not dated. There were two opened large jars of french dressing and mayonnaise with food
debris on the outside of both containers. There were two large containers of sour cream with a use-by date
of August 31, 2023, and one container of ricotta cheese with a use-by date of September 10, 2023. There
was a cooked pork loin dated September 11, 2023. There were two vents with an accumulation of dust.
In the freezer, there was a bag of opened sausage patties and a bag of tortillas that were not dated.
In the bulk food storage area there were three large bins of flour, sugar, and thickener that were not dated.
The top of the lid to the flour bin was covered with food debris. The bottom of the scoop holder had a
accumulation of food debris.
CFR 483.60(i) Food Safety Requirement
Previously cited 10/04/22.
28 Pa. Code 201.14(a) Responsibility of licensee.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395711
If continuation sheet
Page 4 of 4
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the September 22, 2023 survey of ELKINS CREST HEALTH & REHABILITATION CENTER?
This was a inspection survey of ELKINS CREST HEALTH & REHABILITATION CENTER on September 22, 2023. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ELKINS CREST HEALTH & REHABILITATION CENTER on September 22, 2023?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.