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Inspection visit

Health inspection

HOPKINS CENTERCMS #3953421 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, interviews with resident and staff and review of facility documentation, revealed the facility failed to provide a safe, functional, and comfortable environment for residents for two of eleven resident rooms reviewed (Resident R4 and R7) Findings Include: Review of facility policy titled, Center Operations Policies and Procedures with a revision date of February 1, 2023. The policy states, The resident/patient has the right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely. Patients have the right to reside and receive services in the center with reasonable accommodation of individual needs and preferences, expect when the health or safety of the individual or other patients would be endangered. Further review of the policy under process states, 1.6 Comfortable and safe temperature levels. Facilities initially certified before October 1, 1990 must maintain a temperature range of 71 to 81 degrees Fahrenheit. Review of facility Center Emergency Preparedness Plan dated 2024/2025 states under Loss of Utilities, a. Notify HVAC Company and report problem: b. Monitor room temperatures. When the temperature of any resident/patient area reaches 81 degrees Fahrenheit for four (4) consecutive hours: i. Open doors ii. Operate fans iii. Notify the Administrator or designee and the Medical Director iv. Make arrangements for transfer of residents/patients to other areas of the center, or other facilities, if necessary, v. Monitor residents'/patients' temperatures every four (4) hours. Observation of Resident R4's room On July 1, 2025 at 10:47 a.m. revealed the resident was in her room seated in her geri-chair next to her bed. The room had lots of sunlight and felt hot and humid. The room have a large portable air conditioning unit that was connected through the ceiling with tubing. While observing in the room the Director of Maintenance, Employee E3 entered the resident's room to check on the air conditioning unit. When asked what was done when they found out the temperatures were too high, and Employee E3 stated that they offered the residents tabletop fans, took temperature every hour (Rooms 302, 308, 311, 316, 320, and 325), attempted to fix the air conditioning units, and then called for portable air conditioning units to be rented. He stated that the Regional Director of Maintenance usually helps with servicing all units, but he has been out for two weeks due to family emergencies. When asked if there is a air conditioning servicing company, he stated no that I know of, my Regional will usually come in and help troubleshoot the individual room air conditioning units and the central air conditioning unit. Central air conditioning logs were requested and the last one provided was from the year 2016. Employee E2, The Director of Nursing confirmed at 3:54 p.m. that all air conditioning services are provided in house. (continued on next page) 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 3 Event ID: 395342 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 395342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopkins Center 8100 Washington Lane Wyncote, PA 19095 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Director of Maintenance, Employee E3 on July 1 2025 at 11:10 a.m. was asked to provide proof of temperature checks in the rooms identified since June 2025. The Director of Maintenance, Employee E3 revealed he has been completing hourly logs related to the resident rooms identified where the heat was high, and the air conditioning units were not working. The Director of Maintenance, Employee E3 was asked to provide the ongoing logs coming from June 1, 2025 through present day. Employee E3 stated that he has only been working at the facility for a month and was unable to tell how to pull up temperature logs prior to June 30, 2025 on their electronic tracking system. Employee E3 stated that when I got here about a month ago there were about two or three months worth of backed up electronic maintenance requests that were incomplete. Review of facility documentation of room temperature for Sunday, June 29, 2025 revealed, Water full was running down onto room [ROOM NUMBER]-have to empty water. room [ROOM NUMBER]- Unit leaking water on 204- have to install white unit-take down ceiling tile in 204. Interview with Employee E4 revealed that last Sunday June 29, 2025 he got a call from the Director of Maintenance Employee E3 that he needed to come in because there was a leak from one of the portable air conditioning units. Employee E3 stated he came in around 9:00 a.m. to empty the bins of water. He stated that he also checked the room temperatures for the six identified rooms. He stated he was at the facility for a couple hours probably till around 11:00 a.m. when he left. When asked if he came to the facility on Saturday June 28, 2025 he stated that he did not. Interview held with the Director of Maintenance Employee E3 at 11:15 a.m. revealed he was unsure who was responsible for checking the air room temperatures on second shift or on overnight shift. Employee E3 stated that he did not come in on Saturday June 28 or Sunday June 29. Temperatures were checked in all six identified rooms and two of the rooms had temperatures that were over 81 degrees. Employee E3 stated that when he goes into the resident room he takes the temperature in three different places within the room. Air temperatures taken at three different spots within Resident R4's room on July 1, 2025 at 11:17 a m revealed the following air temperatures 84.4 degrees Fahrenheit (F), 94.3 degrees (F), and 98.4 degrees (F). At 11: 24 a m on July 1, 2025, Resident R7 air room temperatures were- 88.3 degrees (F), 84.5 degrees (F), and 81.9 degrees (F). Review of the facility air temperature logs provided by the Director of Maintenance, Employee E3 revealed the following: June 25, 2025 there were temperature logs provided for six different times (10:15 a.m., 11:30 a.m.,12:45 p.m., 1:45 p.m., 3:00 p.m., 4:00 p.m.) For June 25, 2025 there were resident rooms that were recorded at being over 81 degrees Fahrenheit: room [ROOM NUMBER]- 10:15 a.m.- 83.3 degrees, 12:45 p.m.- 84.4 degrees, 1:45 p.m.-83.3 degrees, 3:00 p.m.-83.6 degrees, 4:00 p.m.-84.1 degrees room [ROOM NUMBER]- 10:15 a.m.-83.2 degrees, 12:45 p.m.-84.4 degrees, 12:45p.m.-86.5 degrees, 1:45 p.m.- 85.1 degrees, 3:00 p.m.- 86 degrees, 4:00 p.m.-86.7 degrees room [ROOM NUMBER]: 10:15 a.m.- 86.4 degrees 11:30 a.m.- 89.2 degrees 12:45 p.m.-88.5 degrees, 1:45 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395342 If continuation sheet Page 2 of 3 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 395342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopkins Center 8100 Washington Lane Wyncote, PA 19095 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 0921 p.m.-87.3 degrees, 3:00 p.m.-87.9 degrees, 4:00 p.m.-85.1 degrees Level of Harm - Minimal harm or potential for actual harm For June 26, 2025 there were temperature logs provided for one time 3:40 p.m. and the documentation notes (also empty water). Residents Affected - Some For June 27, 2025 there were temperature logs provided for two times 7:30 a.m. and 8:30 a.m. For the 7:30 a.m. room temperatures the following rooms were above 81 degrees- 302-81.3 degrees, 308-82.5 degrees, 311-85.6 degrees, 316-87.3 degrees. For the 8:30 a.m. room temperatures the following rooms were above 81 degrees- 302-84.6 degrees, 308-82.1 degrees, 311-85.1 degrees, 316-87.4 degrees. For June 28, 2025 (Saturday) there were no logs provided. An interview was held with Employee E1, the Nursing Home Administrator and Employee E2, the Director of Nursing at 1:03 p.m. When asked when concerns were identified with the air conditioning units, Employee E1, Nursing Home Administrator stated, right around when the heat wave started, staff noticed some air conditioning units weren't turning on.According to the facility documentation provided the air conditioning units were ordered on June 25, 2025, the same day the units were found to not be working. Continued interview with Employee E1, the Nursing Home Administrator revealed, Maintenance is supposed to be responsible for monitoring the temperatures, but I just come to find out they haven't been doing that. When Employee E1, the Nursing Home Administrator was asked if he was overseeing the process and if he saw any of the temperatures logs he stated, no I haven't seen them. When asked if the residents in the identified rooms were given an option for a room change Employee E1, the Nursing Home Administator stated, yes they were or their representatives were. When asked if this was documented anywhere, Employee E1 stated, honestly, I couldn't tell you if it was or not. The facility was unable to provide documentation that room changes were offered. Interview conducted on July 1, 2025 at 1:10 p.m. with the Employee E5, the Regional Maintenance Director revealed that when the temperatures are at an unsafe level the facility policy is to check the temperature of the rooms identified every four hours including all shifts. 28 Pa. Code 202.28(b)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395342 If continuation sheet Page 3 of 3

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Citations

1 citation 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.

  • 0921GeneralS&S Epotential for harm

    F921 - Other Environmental Conditions

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

FAQ · About this visit

Common questions about this visit

What happened during the July 1, 2025 survey of HOPKINS CENTER?

This was a inspection survey of HOPKINS CENTER on July 1, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at HOPKINS CENTER on July 1, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public."

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.

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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.