Health inspection·February 15, 2024

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument User Manual, clinical record review, and staff interviews, it was determined that the facility failed to complete required Minimum Data Set (MDS) assessments for three of 24 residents reviewed (Residents 9, 27, and 71). Residents Affected - Few Findings include: Review of The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that a discharge assessment must be completed when a resident is admitted to a hospital or other care setting. The manual also indicated that a Death in Facility tracking record must be completed when a resident dies in the facility. Further review revealed that the discharge assessment must be completed within 14 calendar days of discharge and the Death in Facility tracking record must be complete within seven calendar days of the death of the resident. Review of Resident 9's clinical record revealed that she passed away at the facility on November 24, 2023. Review of Resident 27's clinical record revealed that she passed away in the facility on November 12, 2023. Review of Resident 9 and 27's MDS completion and submission records on February 12, 2024, at 2:39 PM, revealed that to date no Death in Facility tracking records had been initiated, completed, or submitted for either Resident. During an interview with the Director of Nursing (DON) on February 14, 2024, at 9:15 AM, she confirmed that MDS assessments should have been completed after Residents 9 and 27 passed away. She also revealed that those submissions would be completed. Review of Resident 71's clinical record revealed that she was transferred out to the hospital on October 9, 2023, and was subsequently admitted . Review of Resident 71's MDS completion and submission records on February 12, 2024, at 2:39 PM, revealed that to date no discharge MDS related to the hospitalization had been initiated, completed, or submitted. During an interview with the DON on February 15, 2024, at 9:37 AM, she confirmed that a discharge (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 5 Event ID: 395898 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 395898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homewood Living Plum Creek, Inc 425 Westminster Avenue Hanover, PA 17331 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)