Hopkins Center

Inspectors wroteBased on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure the results of the most recent surveys were posted in a place readily accessible to residents, family members, and legal representatives in one of one area reviewed (main lobby). Findings Include: Review of facility survey history revealed a full health survey was conducted on August 7, 2025, and various abbreviated surveys in response to complaints were conducted in 2025 and 2026. A tour was taken of the facility on July 14, 2026, at 10:00 a.m. Observation in the facility lobby area revealed the Department of Health Survey binder was located on the wall. The Department of Health survey binder was reviewed, and the last printed document was from the year 2024. Interview held with Employee E1 the Nursing Home Administrator on July 14, 2026, at 11:50 a.m. [...]

Inspectors wroteBased on observations, review of clinical records, review of facility policy and interview with staff, it was determined that the facility failed to protect resident's privacy related to clinical information for two of nineteen residents observed (Resident R10 and Resident R78). Findings Include: Review facility policy on Patient's Privacy Rights With the most recent review date of July 17, 2026, revealed that under section policy #4 information security and health records access control access to physical and electronic health records is restricted to personal directly involve in patient scare or organization operations authorize disclosures medical and personal information will only be shared with a patient or individuals that have explicitly authorized. Under section PURPOSE: [...]

Inspectors wroteBased on review of facility policy, observations and interviews with residents and staff, it was determined that the facility failed to provide a safe, clean and homelike environment for two of two nursing units observed (Second floor and Third floor units). Findings Include: Review of the facility policy titled, Safe and Homelike Environment last revised on November 24, 2025, reveals the resident has the right to a safe, clean, comfortable, and homelike environment that de-emphasizes the institutional character of the setting. Further review of the facility policy revealed, Process- The Center must provide 1.1 A safe, clean, comfortable, and homelike environment, allowing the patient to use his/her personal belongings to the extent possible.1.1.3.3 Open and close bedroom and bathroom doors, easily access areas of the room and bath, and operate room lighting. [...]

Inspectors wroteBased on review of clinical records, and interview with staff, it was determined that the facility failed to ensure that MDS (minimum data set- a federally required resident assessment completed at a specific interval) was completed accurately for one of nineteen residents reviewed).

Inspectors wroteBased on review of facility records, review of clinical record, review of facility policy and interview with staff and residents, it was determined that the facility did not ensure that a comprehensive person-centered care plan related to smoking was completed for one of nineteen residents reviewed (Resident R66).

Inspectors wroteBased on review of facility policy, observations, and resident and staff interview it was determined the facility did not ensure an environment free of accidents and hazards related to medications found bedside for two of two units reviewed (Second floor and Third Floor). Findings Include: Review of facility policy titled, Medication Storage dated January 2026 states, Policy- Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective administration. The medication supply shall be accessible only to a licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. A tour was taken of the second-floor nursing unit on July 14, 2026, at 9:30 a.m. Observation on July 14, 2026, at 9:41 a.m. [...]

Inspectors wroteBased on observation, review of clinical records, review of facility policy and interview with staff and residents, it was determined that the facility failed to provide oxygen to a resident according to physician orders for one of four residents observed (Resident R78).

Inspectors wroteBased on review of clinical records, facility documentation and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for one of nineteen residents reviewed (Resident R22).

Inspectors wroteBased on review of employee personnel records and staff interview it was determined that the facility failed to complete annual performance review at least every 12 months for two of six nurse aides reviewed (Employee E16 and Employee E18). Findings Include: Review of the facility performance reviews revealed two of the nurse aides were not completed timely. Review of facility documentation provided revealed that nurse aide Employee E16 was hired on November 19, 2017. Review of documentation provided by the facility Employee Performance Appraisal Form revealed nurse aide, Employee E16, most recent performance review was dated March 22, 2025. The facility was unable to provide a performance appraisal form for the year 2026. Review of facility documentation provided revealed that nurse aide Employee E18 was hired on November 4, 2020. [...]

Inspectors wroteBased on observation, review of clinical records, review of facility policy and interview with staff it was determined that the facility failed to ensure that controlled substances were securely stored for two of two units observed (second and third floor units).

Inspectors wroteBased on observation, review of clinical records, review of facility policy and interview with staff, it was determined that the facility did not maintain an effective infection control program related to EBP (enhanced barrier precaution) for one of nineteen residents observed (Resident R66).

Inspectors wroteBased on observation, review of the facility policy and staff and resident interview, it was determined that the facility failed to ensure that call bells were available and operable for resident use for one of 19 residents observed (Residents R57).

Inspectors wroteBased on observation, review of posted daily nurse staffing data, and staff interview, it was determined that the facility did not ensure to accurately post information regarding daily nurse staffing data as required. Findings Include: Observation on July 14, 2026, at 11:45 a.m. revealed the nurse staffing was posted on the front desk in the lobby area. Review of the nurse staffing posting revealed it was dated July 7, 2026. Interview on July 14, 2026, at 11:45 a.m. with the front desk receptionist, Employee E20, revealed the staffing coordinator, Employee E21, has been out of work and that may be why the staffing is not up to date. Interview on July 14, 2026, at 11:50 a.m. with the Nursing Home Administrator, Employee E1, confirmed that nurse staffing was only posted at the front lobby and it was posted for July 7, 2026. [...]

Inspectors wroteBased on review of facility documentation and staff interviews, it was determined that the facility failed to include active involvement from direct care staff and input from residents or resident representatives in the facility assessment process. Findings Include: Review of the facility assessment revealed the only assessment contributors as; The Medical Director, Director of Nursing, Nursing Home Administrator, and one Representative from a Governing Body. Further review of the facility assessment revealed there was no direct care staff, residents, or resident representative input in the facility assessment process. [...]

Inspectors wroteReview of the facility ' s policy titled Abuse Prohibition revised October 2022 defines abuse as the willful infliction of injury resulting in physical harm injury or mental anguish. The same policy states anyone who witnesses an incident . injuries of unknown origin will report the incident to his/her supervisor immediately . the supervisor will report the suspected abuse immediately to the Administrator. Review of Resident R1's clincial record revealed the resident diagnoses of chronic obstructive pulmonary disease (lung disease), vascular dementia (a type of dementia caused by damage to the blood vessels in the brain leading to cognitive decline) and documented as severely cognitively impaired. Review of facility documentation and investigation dated October 6, 2025, revealed Licensed Practical Nurse (LPN), Employee E3 noticed a bruise on Resident R1 ' s hand. [...]

Inspectors wroteBased on resident council interview, staff interviews, review of facility policy and reviews of the established mealtime schedule, it was determined that the facility failed to ensure a nourishing snack was provided when 14 hours are between a substantial evening meal and breakfast on the three of three nursing units. (First, Second, and Third Floors).

Inspectors wroteBased on a review of facility policies, staff interviews, and observations, it was determined that the facility failed to maintain personal privacy for one of 18 residents reviewed (Resident R80).

Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to maintain the facility in a clean, safe, comfortable and homelike condition in one of two nursing floors (2nd floor nursing unit).

Inspectors wroteBased on review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan for two of 18 residents reviewed (Resident R42 and R2).

Inspectors wroteBased on the observations, interview with staff, it was determined that the facility failed to administer medications according to professional standards of practice three of three medication administrations observed. (Residents R59, R39 and R50)Findings Include:According National Library of Medicine (Operated by the United States federal government, a biomedical library and a national resource for health professionals, scientists, and the public) five rights of medication use: the right patient, the right drug, the right time, the right dose, and the right route-all of which are generally regarded as a standard for safe medication practices. Observation of the Medication Administration by Employee E13, Licensed Practical Nurse for Resident R59 on August 6, 2025, at 9:00 a.m. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interview, it was revealed that the facility failed to modify protein needs and implement interventions consistent with the resident's assessed needs and current professional standards of practice of nutritional status as it relates to pressure ulcer prevention for one of 18 residents reviewed (Resident R82).

Inspectors wroteBased on the observations, and staff interviews, it was determined that the facility did not provide pharmacy services according to professional standards of practice for one of four residents reviewed. (Resident R50) Findings Include:Review of drug information for Fish oil revealed that Omega-3-acid ethyl [NAME] capsules are a prescription medicine used along with a low fat and low cholesterol diet to lower very high triglyceride (fat) levels in adults. Take omega-3-acid ethyl [NAME] capsules whole. Do not break open, crush, dissolve, or chew omega-3-acid ethyl [NAME] capsules before swallowing. If you cannot swallow omega-3-acid ethyl [NAME] capsules whole, tell your healthcare provider. You may need a different medicine. Review of physician order for Resident R50 dated March 8. 2024 revealed an order for Omega-3 Fatty Acids Capsule 1000 MG, give one capsule by mouth one time a day. [...]

Inspectors wroteBased on observations, review of clinical records, professional standards of practice and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for three of four residents observed during medication administration (Resident R50, Resident R59 and R39).

Inspectors wroteBased on review of clinical record, facility policy, observations, and interviews with staff, it was determined that the facility failed to exercise proper infection control techniques for one of two nursing units observed (Second Floor Nursing Unit) and two of four medication administration pass observed. (Resident R39 and Resident R59)

Inspectors wroteBased 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. [...]

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were revised in a timely manner related to discharge planning for one of six records reviewed (Resident R2).

Inspectors wroteBased on review of facility policy, facility documents, clinical records, and interview with staff; it was determined the facility failed to develop a comprehensive care plan and interventions to address Resident R75 diagnosis of alcohol dependency. This failure resulted in actual harm to Resident R75 who was observed with signs/symptoms of intoxication, transferred to hospital, and diagnosed with alcohol intoxication which required intravenous therapy for one of 38 residents reviewed. (Resident R75)

Inspectors wroteBased on the review of facility documentation, clinical records, hospital records, and interviews with resident and staff, it was determined the facility failed to provide appropriate staff supervision and failed to complete a thorough assessment of the resident environment for Resident R75 with a diagnosis of alcohol dependency. This failure resulted in actual harm to Resident R75 who was found with symptoms of intoxication, transferred to the hospital, diagnosed with alcohol intoxication with a blood alcohol level of 276 mg/dL and required intravenous therapy for one of 38 residents reviewed. (Resident R75)

Inspectors wroteBased on review of personnel records and interviews with staff, it was determined that the facility failed to complete annual performance reviews for nurse aide staff as required for five of five nurse aide personnel files reviewed (Employees E5, E6, E21, E22 and E23).

Inspectors wroteBased on review of clinical records, observations, review of facility policy and interview with staff, it was determined that the facility failed to implement special contact precautions, enhanced barrier precautions and practice infection control practices related to residents reported to be under precautions for care for four of eight residents reviewed. (Resident R15, Resident R7, Resident 69 amd Resident 75)

Inspectors wroteBased on review of documentation and staff interview, it was determined the facility failed to ensure residents were provided a Notification of Medicare Non-coverage (NOMNC) and an Advanced Beneficiary Notice of Non-coverage (ABN) for three of three residents reviewed (Resident 91, Resident 151, Resident 152).

Inspectors wroteBased on observation, review of the facility policy and staff and resident interview, it was determined that the facility failed to ensure that call bells were available and operable for resident use for two of 38 residents observed residents. (Residents R63 and R39)

Inspectors wroteBased on observations and review of facility provided documentation, it was determined facility did not ensure to provide a sanitary, comfortable environment for residents for four out of 11 rooms observed on third floor unit (Room# 300, 302, 304, 305)

Inspectors wroteBased on review of facility policies, clinical record, facility documentation, and interviews with residents and staff, it was determined the facility failed to prevent resident neglect by not following safe resident care guidelines which resulted in harm to Resident R1 who sustained fractures of the left humerus, the spine, and contusion to the right shin for one of seven residents reviewed (Resident R1).

Inspectors wroteBased on staff and resident's responsible party interview and review of clinical records, it was determined that the facility failed to ensure that advanced notice was provided to the resident and his emergency contact of care plan meetings and failed to ensure that care plan meetings were held in a timely manner for 3 out of 3 residents reviewed (Resident R1, R2 and R3).

Inspectors wroteBased on observations, staff interviews and review of facility documentation, it was determined that the facility failed to ensure that an effective pest control program and a pest free environment.

Inspectors wroteBased on staff and resident's emergency contact interviews, review of faciltiy policy and review of clinical records, it was determined that the facility failed to ensure that documented room change notifications to the resident and emergency contact were provided for 1 out of 7 residents reviewed (Resident R1).

Inspectors wroteBased on staff interviews, review of facility policy and review of the clinical record, it was determined that the facility failed to develop and implement an effective discharge planning process for 1 out of 2 residents reviewed for this care area (Resident R1).

Inspectors wroteBased on review of facility policy, review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to conduct a thorough investigation related to an allegation of mental abuse for one of six residents reviewed (Resident R1)

Inspectors wroteBased on observations, interview with staff and residents and review of facility documentation, it was determined that the facility failed to provide a functional heating unit for one of eight rooms observed. (room [ROOM NUMBER])

Inspectors wroteBased on observations, staff interviews and review of facility documentation, it was determined that the facility failed to ensure that an effective pest control program and a pest free envioronment.

Inspectors wroteBased on observations, clinical record review and interviews with staff, it was determined that the facility failed to develop a comprehensive person-centered care plan related to intravenous (IV) therapy for one of three residents reviewed (Resident R1).

Inspectors wroteBased on observations, clinical record review, review of facility policies and interviews with staff, it was determined that the facility failed to administer intravenous (IV) medications in accordance with professional standards of practice for one of three residents reviewed related to IV therapy (Resident R1).

Inspectors wroteBased on review of review of personnel files, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that nursing staff had the specific competencies and skills sets necessary to care for residents' needs related to medication administration and infusion therapy, which resulted in a significant medication error for Resident R1, for two of two personnel files reviewed (Employees E3 and E4).

Inspectors wroteBased on review of facility policies, facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents remained free from significant medication errors for one of five residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and interview with staff, it was determined that the facility failed to maintain proper infection control practices related to hand hygiene and wound care for one of 8 residents reviewed (Resident R8).

Inspectors wroteBased on review of facility policies and documentation, clinical record review and interviews with staff, it was determined that the facility failed to adequately supervise a resident who was at risk for elopement, and failed to secure windows on the unit, for one of five residents reviewed (Resident R1). This failure resulted in an Immediate Jeopardy situation as Resident R1 exited the building through a second-floor window and sustained serious injuries, including a laceration to his head requiring sutures and multiple facial fractures.

Inspectors wroteBased on clinical record reviews, review of facility policies and documentation and interviews with staff, it was determined that the facility failed to ensure that a resident remained free from neglect, which resulted in actual harm with serious injuries, including a laceration requiring sutures and multiple facial fractures to Resident R1, for one of five residents reviewed.

Inspectors wroteBased on review of facility policies and documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a licensed nurse and a nurse aide maintained professional standards of quality of care for one of five residents reviewed (Resident R1). This failure resulted in Resident R1 eloping from the building through a second floor window due to lack of supervision and sustaining serious injuries.

Inspectors wroteBased on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively mange the facility related to the elopement of one resident (Resident R1) who sustained serious injuries and resulted in a Immediate Jeopardy situation.

Inspectors wroteBased on observation, clinical record review, facility documentation and staff interview, the facility failed to ensure Resident R19's care plan was updated to include one-to-one supervision with all meals after Resident R19 sustained a choking incident. This failure resulted in actual harm to Resident R19 who experienced a second choking incident, falling to the floor, requiring suctioning and was subsequently transferred to the hospital sustaining a laceration to the left eye which required stitches for one of 21 residents reviewed (Resident R19). Also, the facility failed to revise a resident's care plan related to hospice services for one of 21 residents reviewed. (Resident R88)