Health inspection·August 30, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on review of facility investigation, facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility displayed past noncompliance, in that they had failed to ensure each resident the right to be free from neglect, resulting in harm, for one of three resident records reviewed (Resident 1). Findings Include: Review of the facility's policy, titled Abuse Prevention and Prohibition last revised August 2021, read, Homewood Retirement Centers s hall provide a safe person-centered environment that is as homelike as possible and includes a culture and environment that treats each resident with respect and dignity. The policy defines neglect as failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physicial harm, pain, mental anguish, or emotional distress. Neglect refers to failure through in attentiveness, carelessness, or omission to provide timely, consistent, safety, adequate and appropriate services, treatment and care, including but not limited to: nutrition, medication, therapies, and activities of daility living. Activities of Daily Living (ADLs) are defined as activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. Review of the facility's Nurse Aide job description, revised March 23, 2015, summarizes the job as providing the activities of daily living care to residents . The nurse aide essential functions are described as promoting the activity of daily living according to the resident's care plan. Also, Resident lifts and transfers will be done according to the resident's care plan and the Lift Free program. Lift is defined as the procedure used to carry the entire weight of the patient. Review of the facility's lift equipment revealed one type utilized is the Vanderlift. According to documentation, the purpose of the Vanderlift is used to transfer residents from bed to chair, chair to bedside commode and chair to bed. Review of the facility's policy related to the Vanderlift use read At least 2 people must be in attendance when lift is being used. Page 1 of 3 395898 395898 08/30/2023 Homewood Living Plum Creek, Inc 425 Westminster Avenue Hanover, PA 17331

F 0600 Level of Harm - Actual harm Review of Resident 1's physician orders revealed diagnoses that included repeated falls and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Residents Affected - Few Review of Resident 1's interdisciplinary plan of care, revealed an ADL care plan that read require extensive assistance with my bathing, grooming, dressing and eating. Vanderlift with transfers to Broda chair. The care plan continues, Vanderlift with 2 [person] assist . According to the facility documentation of an investigation revealed that on August 22, 2023, Resident 1 had fallen from the lift while being transferred from the bed by Employee 1 (Nurse Aide) without assistance from an additional nursing staff individual. The facility investigation revealed Employee 1 reports feeling rushed because she still had resident cares to do and did not ask for help. She did verbalize that she knows the facility policy requires 2 [person] assist for all mechanical lift transfers. Review of Employee 1's statement revealed she made sure it [lift] was hooked up correctly and when I raised her [Resident 1] up out of the bed and off the bed the top right hook twisted in the strap and came off the lift and she slid out of the sling and down on the floor hitting her head on the carpet and the floor and her right elbow also banged on the floor . According to facility documentation, Resident 1 was transferred to the hospital. Review of the hospital discharge summary revealed Resident 1 was diagnosed with subarachnoid hemorrhage (bleeding around the brain), laceration of scalp, and traumatic complete tear of right rotator cuff (muscles and tendons around the shoulder), post fall. An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 29, 2023, at 9:17 AM, confirmed the reported event and fall of Resident 1, and subsequent hospitalization with injuries post-fall. A follow-up interview with the NHA and DON, at 1:28 PM, revealed an agreement the actions of Employee 1 met the definition of neglect and Employee 1 did not follow the facility's Lift policy and Resident 1's care plan regarding two-staff assistance with transfers. During the abbreviated survey, the NHA and DON provided information and documentation of an immediate action plan put into place after Resident 1's fall with injuries from the Vanderlift on August 22, 2023. On August 22, 2023, the facility began an all staff education on the Vanderlift policy, mandatory two-person transfer. All in-house staff education was completed on August 22, 2023, and additional staff education was completed by August 28, 2023. On August 22, 2023, all lift equipment within and utilized by the facility was inspected for safety by the maintenance staff. On August 22, 2023, the facility began an audit of five transfers to be done weekly. The audits will continue weekly x 4, then biweekly x 2, then monthly x 2. The facility's Maintenance staff will 395898 Page 2 of 3 395898 08/30/2023 Homewood Living Plum Creek, Inc 425 Westminster Avenue Hanover, PA 17331

F 0600 increase inspections of lifts to weekly x 4. The results of the audits will be reviewed as part of the facility's Quality Assurance process. Level of Harm - Actual harm During the abbreviated survey, Resident 1 was observed and her clinical record was reviewed. Residents Affected - Few The facility's audits, education, and an observation of the facility staff use of the Vanderlift were reviewed and no concerns were identified. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services 395898 Page 3 of 3