Inspection visit
Inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 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
on two of three nursing units. (Floors 2 and 3)Findings include:Findings include: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. revealed the following: Peeling paint was observed on the wall under the fire extinguisher in the
hallway by room [ROOM NUMBER].Peeling paint and a dried brown liquid were observed on the floor in
front of the closets in room [ROOM NUMBER].The hallway wall between rooms [ROOM NUMBERS] was
marred.A bedside tray table in room [ROOM NUMBER] was missing a drawer, another drawer was
crooked, and a metal drawer track was observed on the floor. A bed curtain in room [ROOM NUMBER] was
off its track. Debris was observed on the floor in room [ROOM NUMBER].Marks were observed on the walls
in the second-floor dining room.The handrail in the hallway across from the second-floor nursing station
was missing a piece.The handrail next to the elevator was loose.Flies were observed in rooms 208, 224,
and at the second-floor nursing station. There was damage to the wall behind the A bed and ceiling tiles
were damaged 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].The wall across
from bed A was damaged. Floor tiles in the bathroom in 325 were damaged. 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.The sharp's
container cabinets on both 3rd floor med carts had broken vents on the sides.28 Pa. Code 201.14(a)
Responsibility of licensee.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 8
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
09/12/2025
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 0628
Level of Harm - Potential for
minimal harm
Residents Affected - Many
Provide the required documentation or notification related to the resident's needs, appeal rights, or
bed-hold policies.
Based on clinical record review and staff interview, it was determined that the facility failed to notify the
State Ombudsman's office in writing of the transfer from the facility for six of six sampled residents who
were transferred to the hospital. (Residents 2, 4, 6, 15, 16, 155)Findings include:
Clinical record review revealed that Resident 2 was transferred to the hospital on May 12, 2025, after a
significant change in condition. 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.
Clinical record review revealed that Resident 4 was transferred to the hospital on June 17, 2025, and on
August 11, 2025, after significant changes in condition. 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.
Clinical record review revealed that Resident 6 was transferred to the hospital on October 23, 2024, after a
significant change in condition. 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.
Clinical record review revealed that Resident 15 was transferred to the hospital on June 14, 2025, and on
June 27, 2025, after significant changes in condition. 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.
Clinical record review revealed that Resident 16 was transferred to the hospital on April 2, 2025, after a
significant change in condition. 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.
Clinical record review revealed that Resident 155 was transferred to the hospital on July 8, 2025, after a
significant change in condition. 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.
In an interview on September 12, 2025, at 9:45 a.m., the Director of Nursing confirmed that the written
copies of the discharge or transfer notices were not sent to the Office of the State Long Term Care
Ombudsman.
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 2 of 8
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
09/12/2025
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
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that
the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of one of
33 sampled residents. (Resident 7)Findings include:Clinical record review revealed that Resident 7 had
diagnoses that included cerebrovascular accident (stroke), respiratory failure, and dysphagia (difficulty
swallowing). After a change in condition on May 21, 2025, the physician ordered the resident to begin
receiving hospice services. The MDS assessments, dated May 21 and August 21, 2025, did not indicate
that Resident 7 received hospice services. In an interview on September 12, 2025, at 1:10 p.m., the
Director of Nursing confirmed that Residents 7's MDS assessments were inaccurate and the resident was
receiving hospice services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395711
If continuation sheet
Page 3 of 8
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
09/12/2025
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**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 and implement
a comprehensive care plan that addressed an individual resident's needs as identified in the
comprehensive assessment for two of 33 sampled residents. (Residents 75 and 76)Findings include:
Clinical record review revealed that Resident 75 had diagnoses that included senile degeneration of the
brain, major depression, and difficulty in walking. According to the Minimum Data Set (MDS) assessment
dated [DATE], the resident was occasionally incontinent of urine. The MDS Care Area Assessment (CAA)
summary, dated February 13, 2025, indicated that the resident's urinary incontinence was to be addressed
in the care plan. There was no documented evidence that interventions to address Resident 75's urinary
incontinence were addressed in the care plan. Clinical record review revealed that Resident 76 had
diagnoses that included dementia, muscle weakness, and difficulty in walking. According to the MDS
assessment dated [DATE], the resident was occasionally incontinent of urine. The MDS CAA summary,
dated January 2, 2025, revealed the resident's urinary incontinence was to be addressed in the care plan.
There was no documented evidence that interventions to address Resident 76's urinary incontinence were
addressed in the care plan. In an interview on September 12, 2025, at 10:10 a.m., the Director of Nursing
confirmed the identified care areas were not addressed in the care plans. 28 Pa. Code 211.12(d)(1)(5)
Nursing services.
Event ID:
Facility ID:
395711
If continuation sheet
Page 4 of 8
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
09/12/2025
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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 provide
necessary treatment and services to promote healing and to prevent new pressure sores from developing
for one of two sampled residents with pressure sores. (Resident 4) Findings include: Clinical record review
revealed that Resident 4 had diagnoses that included anoxic brain injury (lack of oxygen to the brain),
respiratory failure, and diabetes. The Minimum Data Set assessment dated [DATE], indicated that the
resident was non-verbal, dependent on staff for activities of daily living, had a pressure sore, and was at
risk for developing additional pressure sores. On July 22, 2025, a physician's order directed staff to keep
the resident's ears floating using a supportive neck pillow every shift. A review of the wound care
physician's note, dated August 21, 2025, indicated the resident had bilateral open ear wounds. The care
plan indicated that the resident had bilateral ear wounds and was at risk for worsening skin problems due to
reduced mobility. Interventions included keeping the resident's ears floating by applying a neck support
pillow with turning and repositioning every two hours. On September 9, 2025, at 11:05 a.m. and on
September 11, 2025, at 11:30 a.m., 12:30 p.m., and 2:25 p.m., the resident was observed lying in bed
without the neck pillow in place. The resident's right ear was in direct contact with the bed pillow. On
September 12, 2025, at 8:48 a.m., the resident was observed lying in bed without the neck pillow in place
with his head facing forward. Bilateral ear wounds were observed. On September 12, 2025, at 10:10 a.m.,
the Director of Nursing confirmed that the neck pillow was supposed to be in place, and that it was not at
the time of the observations. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395711
If continuation sheet
Page 5 of 8
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
09/12/2025
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 0732
Post nurse staffing information every day.
Level of Harm - Potential for
minimal harm
Based on observation and staff interview, it was determined that the facility failed to ensure that current and
accurate nurse staffing information was posted in the facility at the beginning of each shift.Findings include:
Residents Affected - Many
Observations during a tour of the facility conducted on September 9, 2025, at 9:45 a.m., revealed that
staffing information posted in the lobby was dated for September 5, 2025.
In an interview on September 12, 2025, at 10:15 a.m., the Director of Nursing confirmed that the correct
staffing information should have been posted.
28 Pa. Code 201.18(b)(3) Management.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395711
If continuation sheet
Page 6 of 8
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
09/12/2025
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 0790
Provide routine and 24-hour emergency dental care for each resident.
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 and resident and staff interviews, it was determined that the facility failed to provide
routine and emergency dental services for one of 33 sampled residents. (Resident 67)Findings include:
Clinical record review revealed that Resident 67 was admitted on [DATE], and had diagnoses that included
spinal stenosis, nutritional deficiency, and chronic inflammatory demyelinating polyneuritis (an autoimmune
disorder that damages nerve cells).During an interview on September 9, 2025, at 11:00 a.m. Resident 67
stated some of her teeth were damaged while she was hospitalized in October 2024. A dentist had referred
her to an oral surgeon for extractions but no appointment had been made. On May 21, 2025, a dentist
examined the resident and noted that she needed the damaged teeth removed by an oral surgeon. There
was no documentation in the clinical record to support that the facility scheduled an examination with the
oral surgeon to meet the needs of the resident.During an interview on September 12, 2025, at 9:45 a.m.,
the Director of Nursing, confirmed that the facility had failed to provide recommended dental services to
Resident 67.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 28 Pa Code 211.15 Dental services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395711
If continuation sheet
Page 7 of 8
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
09/12/2025
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 0814
Dispose of garbage and refuse properly.
Level of Harm - Potential for
minimal harm
Based on observation, it was determined that the facility failed to dispose of trash and refuse properly.
Findings include: Observation of the dumpster area on September 9, 2025, at 10:30 a.m., revealed the side
door of the dumpster was open. The grassy area adjacent to the dumpster had multiple pieces of plastic
and paper debris. There were two dumpster lids laying on the ground next to the dumpster. 28 Pa Code
201.18(b)(3) Management.
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395711
If continuation sheet
Page 8 of 8
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
10 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.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
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.
F628 - Documentation
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F790 - Dental services
Provide routine and 24-hour emergency dental care for each resident.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
FAQ · About this visit
Common questions about this visit
What happened during the September 12, 2025 survey of ELKINS CREST HEALTH & REHABILITATION CENTER?
This was a inspection survey of ELKINS CREST HEALTH & REHABILITATION CENTER on September 12, 2025. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ELKINS CREST HEALTH & REHABILITATION CENTER on September 12, 2025?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and maintain an Emergency Preparedness Program (EP)."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.