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