Pennsylvania Department of Health
ELKINS CREST HEALTH & REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ELKINS CREST HEALTH & REHABILITATION CENTER
Inspection Results For:

There are 234 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


ELKINS CREST HEALTH & REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed August 7, 2026, it was determined that Elkins Crest Health and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.\~
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Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

�483.60(i) Food safety requirements.
The facility must -

�483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

�483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:
Based on facility policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department.

Findings include:

Review of the facility's policy entitled, "Storage of Refrigerated Food Policy," dated July 30, 2026, revealed that foods that were to be prepared and not placed into service were to be covered, labeled, and dated with use by dates. Staff were to check the refrigerator/freezer/dry storage routinely for food items that were expired and they were to be discarded by the use by date.

Observations during the tour of the dietary department on August 4, 2026, at 10:45 a.m., revealed the following:

In the walk-in refrigerator, there were three containers of fruit salad with best by dates of August 1, 2026, and a container of prepared peppers with a preparation date of July 30, 2026, with no use by date.

The following was observed on the cook's table:

The lids on bottles of spices were left open as follows:

Two containers of ground nutmeg, which was also not labeled with a use by date.
One container of celery seeds, which also had a use by date of December 19, 2025.
One container of rubbed sage, which was also not labeled with a use by date.
One container of ground oregano, which was also not labeled with a use by date.
One container of whole basil, which was also not labeled with a use by date.
One container of whole thyme, which was also not labeled with a use by date.
One container of dill weed, which also had a use by date of August 21, 2025.

An opened container of distilled vinegar had no use by date.
There were two open boxes of corn starch with no open date or use by date.

Small black insects were observed flying throughout the kitchen, including the closed dry storage area.

Observation of the emergency eyewash station in the kitchen area revealed the left outlet had no spray cap or dustcover and the right shower head appeared to have white colored flecks embedded in the sprayer holes. In an interview on August 7, 2026, at 1:07 p.m., the Maintenance Director stated that the maintenance department was responsible for checking the eyewash station for functionality and providing maintenance to the equipment.

28 Pa. Code 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 09/08/2026

Step 1: In the walk-in refrigerator, there were three containers of fruit salad with best by dates of August 1, 2026, and a container of prepared peppers with a preparation date of July 30, 2026, with no use by date. Items were discarded.

Two containers of ground nutmeg, one container of celery seeds, one container of sage, one container of ground oregano, one container of whole basil, one container of whole thyme, one container dill weed, one container of distilled vinegar, two boxes of corn starch were discarded at time of survey.

Eyewash station fixed.

Pest control contacted to schedule more frequent visits through summer months. Bananas removed from dry storage that caused accumulation of small black insects.

Step 2: to identify like areas, an audit of the kitchen was completed and areas out of compliance were corrected

Step 3: to prevent recurrence, NHA/designee kitchen staff was educated on kitchen sanitation and cleaning schedule policy, and food storage policy. Maintenance educated on maintenance of eye wash station upkeeping and monitoring of pest control concerns.

Step 4: to maintain compliance, NHA/designee to complete audit of kitchen weekly x 4 then monthly x 2 and correct identified areas/ report areas that need to be fixed to maintenance director. Results will be reviewed and revised as needed during monthly QAPI meeting.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

�483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
�483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

�483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

�483.10(i)(3) Clean bed and bath linens that are in good condition;

�483.10(i)(4) Private closet space in each resident room, as specified in �483.90 (e)(2)(iv);

�483.10(i)(5) Adequate and comfortable lighting levels in all areas;

�483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81�F; and

�483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:
Based on observation and staff interview, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents on two of three nursing units. (Second and Third Floor Nursing Units)

Findings include:

Observations in resident rooms throughout the facility from August 4, 2026, at 11:05 a.m. through August 6, 2026, at 3:00 p.m. revealed the following:

In room 205, there was no privacy curtain for bed one. The curtain for bed two had brown stains. There was a long-handled tool with a metal scraper at the bottom, leaning against a resident's dresser, that was identified by the Housekeeping Director, as a floor scraper used to remove waxy residue from the floor. Additionally, the blind cords were tangled making the blinds non-adjustable, and the pillow on bed two had a large brown stain.

In room 207, the closet door was hanging off the track and the clock displayed the wrong time. The privacy curtains between beds one, two, and three had brown stains. The blinds were covered with dust and dirt, and the ceiling paint was peeling by the window. In the bathroom, there was chipped paint on the right side of the toilet and the rubber baseboard was caved in, creating a hole.

In room 208, there was a large stain on the ceiling and an empty cup and crumpled paper under the side-table near bed two. The tray table used by the resident in bed three was peeling.

In room 214, the privacy curtains were stained between beds one and two.

In room 216, the dresser near bed two had a broken middle drawer. The privacy curtains between beds one and two were soiled with brown stains.

In room 217, the metal legs of the tray table were rusted and there was no closet door for bed two.

In room 219, the privacy curtain between beds one and two had brown stains.

In room 223, the clock displayed the wrong time. There were black marks on the wall across from the bed. There were brown spots under both sides of the bed. The privacy curtains between beds one and two had brown stains.

In room 317, the wall behind bed two was marred with several areas of chipped paint. There was a brown substance splattered on the wall between the two televisions.

In room 318, the wall behind bed two was marred and paint was missing in two areas.

In room 323, the ceiling tile above bed two was bowed and not flush with the rest of the ceiling.

28 Pa. Code 201.18(e)(2.1) Management.

Plan of Correction - To be completed: 09/08/2026

Step 1: areas in tag cleaned/fixed/ pending order/parts arrival for replacement
Room 205 - tool removed, privacy curtain placed, pillow replaced, cords to curtain untangled.
Room 207 � closet door fixed/ placed back on track, blinds cleaned, room painted, rubber base board replaced.
Room 208 � brown spot on ceiling fixed, trash removed from under table, old peeling bed side table replaced.
Room 216 � middle drawer fixed
Room 217 � bed side table replaced, closet door replaced
All privacy curtains in house were cleaned.
All room clocks checked for accuracy. All clocks with correct times were updated.
Room 223 � walls painted to correct black marks, floors stripped to removed brown spots on both sides of the bed
317 � walls painted to correct chipped paint, brown spot cleaned on wall between two televisions
318 � walls painted
323 � ceiling tiles replaced
Step 2: to identify areas effected, house audit completed to identify any areas in need of improvement. Identified areas will be addressed on a plan for completion.
Step 3: to prevent recurrence, NHA/designee, will educate housekeeping on general environmental cleaning and disinfection policy. NHA/designee educated Maintenance on ensuring a safe, sanitary, and comfortable environment.
Step 4: to maintain ongoing compliance, NHA/ designee will complete environmental audit which includes cited areas and identify areas that need further intervention weekly x 4 and monthly x 2. NHA/designee will audit environmental repair plan weekly x4 and monthly x 2. Results will be reviewed and revised as needed during monthly QAPI meeting.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

�483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

�483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

�483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

�483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

�483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

�483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide feeding assistance in a manner that maintained dignity for four of 29 sampled residents. (Residents 28, 33, 59, 96)

Findings include:

Clinical record review revealed that Resident 28 had diagnoses that included cognitive communication deficit, down syndrome, need for assistance with personal care, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated June 17, 2026, revealed the resident had severe cognitive impairment and the care plan revealed the resident needed assistance with feeding at mealtimes. On August 4, 2026, at 12:38 p.m., Resident 28 was observed in the dining room with other residents. Registered Nurse (RN) 1 was observed feeding lunch to the resident while standing.

Clinical record review revealed that Resident 33 had diagnoses that included a history of traumatic brain injury, unspecified severe protein-calorie malnutrition, and contractures of the left and right hands. Review of the MDS assessment dated July 14, 2026, revealed the resident had moderate cognitive impairment and was dependent on staff for eating meals. On August 5, 2026, at 12:46 p.m., Resident 33 was observed in the dining room with other residents. Licensed Practical Nurse (LPN) 1 was observed feeding lunch to the resident while standing.

Clinical record review revealed that Resident 59 had diagnoses that included moderate intellectual disabilities and dysphagia. Review of the MDS assessment dated July 1, 2026, revealed the resident had moderate cognitive impairment and required set-up assistance for meals. The care plan indicated that staff was to provide assistance for eating meals. On August 4, 2026, at 12:42 p.m., Resident 59 was observed in the dining room with other residents. RN 1 was observed feeding lunch to the resident while standing.

Clinical record review revealed that Resident 96 had diagnoses that included cognitive communication deficit, ventilator associated pneumonia, and unspecified convulsions. Review of the MDS assessment dated May 25, 2026, revealed the resident had severe cognitive impairment and required set-up assistance for meals. Review of the care plan revealed that the resident required encouragement during meals. On August 4, 2026, at 12:48 p.m., Resident 96 was observed in the dining room with other residents. Rather than encouraging the resident to eat after set-up, RN 1 was observed feeding lunch to the resident while standing.

In an interview on August 7, 2026, at 9:50 a.m., the Director of Nursing confirmed that staff were to sit with residents when assisting them to eat.

28 Pa. Code 201.18(e)(1) Management.

28 Pa. Code 201.29(a) Resident rights.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 09/08/2026

Step 1: one to one education provided to staff identified in tag. There were no ill effects noted for R 28, R 33, R 59, R96 and plans of care are being followed.
Step 2: To identify like residents affected, residents who need assists with feeding were identified for monitoring to ensure residents have feeding assistance provided in a dignified manner.
Step 3 : to prevent recurrence, DON/designee educated nursing staff on providing feeding assistance in a manner that maintains dignity while feeding residents.
Step 4: To maintain ongoing compliance, DON/designee to complete 2 dining room audits at mealtimes x 4 weeks then monthly x 2. Results will be reviewed and revised as needed during monthly QAPI meeting.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:

�483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by �483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Observations:

Based on facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to assess a resident's ability to self-administer medications for one of 29 sampled residents. (Resident 4)

Findings include:

Review of the facility policy entitled, "Self-Administration of Medications," last reviewed July 30, 2026, revealed that a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Staff should ensure that the physician's order for self-administration listed the specific medication(s) the resident may self-administer. The facility would provide a locked medication storage compartment and key to the resident. Staff should document the self-administration of medications on the resident's Medication Administration Record according to the medication administration schedule and should document the self-administration and self-storage of medications in the resident's care plan.

Clinical record review revealed that Resident 4 had diagnoses that included a traumatic amputation at knee level of the lower right leg, diabetes, allergies due to pollen, and shortness of breath. Review of the Minimum Data Set (MDS) assessment, dated May 18, 2026, revealed that Resident 4 had no cognitive impairment. Observations on August 4, 2026, at 1:20 p.m., August 5, 2026, at 8:30 a.m. and 11:33 a.m., and on August 6, 2026, at 9:55 a.m., revealed that there was one bottle of fluticasone nasal spray (a medication used to treat symptoms caused by allergies), and one Breyna inhaler (budesonide and formoterol; a steroid and muscle relaxing lung agent) unsecured on the bedside table in the resident's room. In an interview on August 4, 2026, at 1:20 p.m., Resident 4 stated that he self-administered the medications twice a day.

There was no documentation to indicate that the facility had assessed Resident 4 for the ability to self-administer the fluticasone nasal spray, or Breyna inhaler. The medications were not secured in his room.

In an interview on August 7, 2026, at 9:44 a.m., the Director of Nursing confirmed that Resident 4 was not assessed to self-administer the medications.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 09/08/2026

Step 1: Meds removed from bed side, self- administration assessment completed on R 4
Step 2: to identify like residents, A house room audit was completed to ensure no meds were left at the bedside.
Step 3:To prevent this from reoccurring, DON/designee educated Licensed nurses on self-administration policy
Step 4: for ongoing monitoring for compliance, Unit Manager/designee will complete room audits will be completed weekly x 4 and monthly x 2 to ensure no meds are left at the bedside. Results will be reviewed and revised as needed during monthly QAPI meeting.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

�483.21(b) Comprehensive Care Plans
�483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to include the resident or resident's responsible party in the comprehensive care planning process and failed to review resident care plans with the required interdisciplinary team for five of 29 sampled residents. (Residents 4, 8, 11, 15, 89)

Findings include:

Clinical record review revealed that a Minimum Data set (MDS) assessment was completed on May 2, 2026, and May 18, 2026, for Resident 4. There was a lack of evidence that the facility conducted the required care plan reviews, that were to involve the resident or resident representative and interdisciplinary team, after completion of the MDS assessment.

Clinical record review revealed that an MDS assessment was completed on February 24, 2026, for Resident 8. MDS assessments were completed on April 24, 2026, and June 10, 2026. There was a lack of evidence that the facility conducted the required care plan reviews, that were to involve the resident or resident representative and interdisciplinary team, after completion of the MDS assessments.

Clinical record review revealed that an MDS assessment was completed on April 19, 2026, for Resident 11. There was a lack of evidence that the facility conducted the required care plan review, that was to involve the resident or resident representative and interdisciplinary team, after completion of the MDS assessment.

Clinical record review revealed that MDS assessments were completed on January 8, 2026, April 2, 2026, and May 26, 2026, for Resident 15. There was a lack of evidence that the facility conducted the required care plan reviews, that were to involve the resident or resident representative and interdisciplinary team, after completion of the MDS assessments.

Clinical record review revealed that MDS assessments were completed on March 15, 2026, and June 15, 2026, for Resident 89. There was a lack of evidence that the facility conducted the required care plan reviews, that were to involve the resident or resident representative and interdisciplinary team, after completion of the MDS assessments.

During an interview on August 7, 2026, at 10:48 a.m., the Director of Nursing confirmed that there was no evidence that care conferences were held timely with the residents, resident representatives, and required interdisciplinary team members.

28 Pa. Code 201.29(a) Resident rights.

Plan of Correction - To be completed: 09/08/2026

Step 1: R 4, 8, 11, 15, 89 will have the resident or resident responsible party in the comprehensive care plan process, and care plans have been reviewed and updated as needed with the required interdisciplinary team members present.
Step 2: To identify others with potential to be affected, Residents and Responsible parties will be included in the comprehensive care plan process, and resident care plans will be reviewed with the required interdisciplinary team. CP's will be updated moving forward per care conference schedule.
Step 3. To prevent recurrence, DON/designee educated on ensuring the resident and responsible party are involved in the care plan process, and resident care plans have the required interdisciplinary team members in attendance.
Step 4: To maintain ongoing compliance, DON/designee will audit the care conference schedule to ensure the interdisciplinary team was in attendance, resident and responsible party and care plans updated weekly x 4 then monthly x 2 to ensure reviews and updates are completed timely. Results will be reviewed and revised as needed during monthly QAPI meeting.

483.25 REQUIREMENT Quality of Care:

� 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to follow physician's orders for one of 29 sampled residents. (Resident 51)

Findings include:

Clinical record review revealed that Resident 51 had diagnoses that included hypertension, vascular insufficiency (condition where leg veins fail to send blood back to the heart efficiently), peripheral vascular disease (a slow disease of the blood vessels outside the heart and brain that involves narrowed, blocked, or damaged vessels), and localized swelling in both legs. A physician's order dated April 11, 2025, directed staff to apply anti-embolism stockings to both legs while out of bed in the morning and remove them at bedtime. Review of the comprehensive care plan revealed that the resident was at risk for an altered cardiovascular system. Multiple observations on August 4, 5, and 6, 2026, between 9:30 a.m. and 2:00 p.m., revealed Resident 51 was out of bed in a wheelchair and the anti-embolism stockings were not applied.

In an interview on August 7, 2026, at 11:21 a.m., the Director of Nursing confirmed that the anti-embolism stockings should have been applied at the times of the observations.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 09/08/2026

Step 1:R 51 has been evaluated and ted stockings are being applied per order to resident.
Step 2: to identify like residents, an audit was completed to identify residents who had orders to ted stockings to ensure orders were completed as followed.
Step 3: To prevent this from reoccurring, DON/designee will educate nursing staff on following doctors orders.
Step 4: for ongoing monitoring, DON/designee audits will be completed on 5 random residents weekly x4 and monthly x2 to ensure orders are being implemented/ followed. Results will be reviewed and revised as needed during monthly QAPI meeting.

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