Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was
determined that the facility failed to ensure the right to receive services with reasonable accommodation of
resident needs for one of 22 residents reviewed (Resident 4), and failed to ensure that resident needs were
accommodated regarding call bell accessibility for one of 22 residents reviewed (Residents 87).
Residents Affected - Few
Findings include:
Review of facility policy, titled Call Lights- Answering, last reviewed April 18, 2024, read, in part, Purpose:
To identify and respond to the residents needs. Procedure: call bell will be answered timely. When leaving
the room, check to see that the call signal will be within the resident's reach.
Review of Resident 4's clinical record revealed diagnoses that included dementia (a chronic disorder of the
mental processes caused by brain disease, marked by memory disorders, personality changes, and
impaired reasoning), major depressive disorder (a mood disorder that causes a persistent feeling of
sadness and loss of interest in things), and anxiety disorder (a persistent feeling of worry, nervousness, or
unease).
Observation of Resident 4's room on January 21, 2025, at 1:06 PM, revealed her call light was on above
her room.
Interview with Resident 4 on January 21, 2025, at 1:10 PM, revealed she needed to use the rest room.
Observation in the hallway on January 21, 2025, at 1:14 PM, the surveyor observed Employee 1
(Registered Nurse) enter residents 4's room to administer a medication. The surveyor heard Resident 4 tell
Employee 1 she needed to use the restroom, Employee 1 replied, I will let them know. Employee 1 turned
off Resident 4's call light and exited the room.
Observation on January 21, 2025, at 1:21 PM, the surveyor observed Employee 2 (Nurse Aide) walk past
Resident 4's room and Employee 1 in the hallway. Employee 1 did not notify Employee 2 that Resident 4
needed to use the rest room.
During an interview with Employee 1 on January 21, 2025, at 1:28 PM, the surveyor inquired if she was
going to notify nurse aide staff that Resident 4 needed to use the restroom and if she had turned off
Resident 4's call bell. Employee 1 replied that she did notify a nurse aide and turned off Resident 4's call
bell.
(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 6
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
01/23/2025
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)
F 0558
Level of Harm - Minimal harm
or potential for actual harm
Observation on January 21, 2025, at 1:28 PM, Employee 1 called Employee 3 (Nurse Aide) to ask for
assistance for Resident 4.
Observation on January 21, 2025, at 1:29 PM, revealed Employee 3 was entering Resident 4's room to
provide assistance.
Residents Affected - Few
Interview with the Director of Nursing (DON) on January 23, 2025, at 10:18 AM, revealed Employee 1
notified Employee 3 that Resident 4 needed assistance after she left the room via their communication
devices, but Employee 3 was busy with an emergent situation for another resident, so she was unable to
assist Resident 4 at that time and was delayed in assisting her.
During a follow-up interview with the DON on January 23, 2025, at 1:11 PM, the surveyor revealed the
concern with Employee 1 turning off Resident 4's call bell before her needs were met and lack of prompt
response until surveyor inquiry. No further information was provided.
Review of Resident 87's clinical record revealed diagnoses that included macular degeneration (a vision
impairment resulting from deterioration of the central part of retina, a thin layer at the back of the eye on the
inner side), age related nuclear cataract (hardening and cloudy eye lens leading to vision changes), and
hypertension (high blood pressure).
Observation in Resident 87's room on January 21, 2025, at 10:32 AM, revealed she was in her bed eating
breakfast and her call bell was out of reach, laying on her recliner.
Review of Resident 87's care plan revealed a focus area of, I have had falls related to poor safety
awareness, with a start date of January 17, 2025, with an intervention for please keep my frequently used
items within reach, with a start date of January 17, 2025.
Interview with the DON on January 23, 2025, at 1:09 PM, revealed she would expect Resident 87's call bell
to be in reach.
28 Pa code 201.29(a) Resident Rights
28 Pa Code 211.12(d)(1) Nursing Services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395898
If continuation sheet
Page 2 of 6
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
01/23/2025
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)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that
the resident assessment accurately reflected the resident's status for one of 25 residents reviewed
(Resident 49).
Residents Affected - Few
Findings Include:
Review of Resident 49's clinical record revealed diagnoses that included cerebral infarction (occurs when
blood flow to the brain is interrupted, causing brain tissue to die) and gastro-esophageal reflux disease (a
chronic condition where stomach contents flow back up into the esophagus, causing irritation and various
symptoms).
Review of Resident 49's quarterly MDS (Minimum Data Set is part of federally mandated process for
clinical assessment of all Medicare and Medicaid certified nursing homes) dated November 8, 2024,
revealed in Section I6100. Post Traumatic Stress Disorder (PTSD), that Resident 49 has been treated for
PTSD in the previous 7 days while a resident.
Review of Resident 49's electronic medical record failed to reveal any treatment for PTSD.
Review of Resident 49's care plan failed to reveal any care plan for PTSD.
Interview with the Director of Nursing on January 22, 2025, at 9:58 AM, revealed that Resident 49's MDS
completed on November 8, 2024, was marked in error and that Resident 49 does not have any history of
PTSD and an MDS correction will be completed.
28 Pa Code 211.12 (d)(3)(5) Nursing Services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395898
If continuation sheet
Page 3 of 6
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
01/23/2025
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)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, clinical record review, and resident and staff interviews, it was determined that the
facility failed to implement resident-directed care and treatment consistent with the resident's physician
orders and care plan for one of 22 residents reviewed (Resident 41).
Residents Affected - Few
Findings include:
Review of Resident 41's clinical record revealed diagnoses that included congestive heart failure (CHF- a
chronic condition in which the heart doesn't pump blood as well as it should), localized edema (swelling
caused due to excess fluid accumulation), and muscle weakness.
Interview with Resident 41 on January 21, 2025, at 10:17 AM, revealed he has had issues with fluid
retention in his legs.
Review of Resident 41's physician orders revealed an order for Tubi grips to bilateral lower extremities
(BLE), on AM off HS (evening)- twice a day for edema, with a start date of September 20, 2024.
Review of Resident 41's care plan revealed a focus area of, I require limited to extensive assistance with
my bathing, grooming, dressing, supervision, and set up with mobility and eating related to CHF and
unsteady gait, with an intervention for Tubi grips on AM off HS to BLE, with a start date of October 31,
2024.
Observation of Resident 41 on January 21, 2025, at 12:18 PM, revealed he was in bed eating lunch, he
had edema to his lower extremities, and his Tubi grips were not in place.
Observation of Resident 41 on January 22, 2025, at 10:15 AM, revealed he was in his wheelchair, he had
edema to his lower extremities, and his Tubi grips were not in place.
Interview with Resident 41 on January 22, 2025, at 12:20 PM, revealed he has not worn Tubi grips to his
legs in over a month since he has had a lot off weight loss and his edema has improved.
Review of Resident 41's TAR (Treatment Administration Record- documentation for treatments/medication
administered or monitored) revealed his physician order for Tubi grips was signed off that they were in place
on January 21 and 22, 2025.
During an interview with the Director of Nursing on January 23, 2025, at 10:33 AM, she revealed Resident
41 used to have a lot of edema but it has really gone down, so they changed his physician order on
January 22, 2025, to be as needed. She further revealed she would expect the order not to be signed that
the Tubi grips were in place when they were not.
28 Pa Code 211.12(d)(1)(3)(5) Nursing Services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395898
If continuation sheet
Page 4 of 6
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
01/23/2025
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility
failed to ensure PRN (as needed) orders for anti-psychotic drugs are limited to 14 days for one of five
residents reviewed for unnecessary medications (Resident 4).
Findings include:
Review of facility policy, titled Antipsychotic Medication Use, last reviewed April 18, 2024, read, in part,
Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time
and are subject to gradual dose reduction and re-review. PRN orders for antipsychotic medications will not
be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the
appropriateness of that medication and document the rationale for continued use. The duration of the PRN
order will be indicated in the order.
Review of Resident 4's clinical record revealed diagnoses that included dementia (a chronic disorder of the
mental processes caused by brain disease, marked by memory disorders, personality changes, and
impaired reasoning), major depressive disorder (a mood disorder that causes a persistent feeling of
sadness and loss of interest in things), and anxiety disorder (a persistent feeling of worry, nervousness, or
unease).
Review of Resident 26's physician orders on January 21, 2025, revealed an order for Seroquel
(antipsychotic medication) 25 mg tablet -12.5 mg by mouth twice daily as needed for hallucinations, with a
start date of December 31, 2024, and no stop date.
During an interview with the Director of Nursing (DON) on January 23, 2025, at 10:14 AM, she revealed
Resident 4 was assessed by the practitioner on January 13, 2025, with a noted plan to continue
medications as recommended by psych services, and that her next appointment with them was in February.
The surveyor revealed the concern with the lack of a 14 day stop date on the PRN Seroquel order and lack
of a new order past 14 days.
Follow-up interview with the DON on January 23, 2025, at 1:06 PM, she revealed she would expect the
facility to comply with the regulation for a stop date of 14 days for PRN antipsychotic medications without
exception.
28 Pa code 211.9(a)(1) Pharmacy services
28 Pa code 211.12(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395898
If continuation sheet
Page 5 of 6
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
01/23/2025
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on facility policy review, observations, clinical record review, and staff interview, it was determined
that the facility failed to implement infection control practices to help prevent the development and
transmission of infectious diseases for two of two residents on droplet precautions (Resident 46 and 68).
Residents Affected - Some
Findings include:
Review of facility policy, titled Infection Control Policy, last reviewed April 18, 2024, read, in part, Purpose:
The objectives of our infection control policies and procedures are to: Prevent and control the spread of
communicable/contagious diseases. Establish guidelines to follow in the implementation of
transmission-based precautions. It shall be the responsibility of the Administrator and Director of Nursing
(DON) through the Quality Improvement committee, to assure that infection control policies and procedures
are implemented and followed.
Review of facility document, titled Droplet Precautions, posted outside of Resident 46 and 68's rooms,
revealed Everyone must clean their hands before entering & leaving room. Make sure their eyes nose and
mouth are fully covered before room entry. Remove face protection before room exit.
Review of Resident 46's clinical record revealed diagnoses that included influenza (a disease caused by
virus infecting the respiratory tract), congestive heart failure (a chronic condition in which the heart doesn't
pump blood as well as it should), and chronic kidney disease (a condition characterized by a gradual loss of
kidney function).
Observation on January 21, 2025, at 12:16 PM, revealed Employee 4 (Nurse Aide) was bringing Resident
46's lunch tray into her room, he did not put on eye protection prior to room entry.
Review of Resident 68's clinical record revealed diagnoses that included influenza, congestive heart failure,
and muscle weakness.
Observation on January 22, 2025, at 12:24 PM, revealed Employee 5 (Nurse Aide) was bringing Resident
68's lunch tray into his room. After leaving the room, she disposed of her face shield outside of the room in
a trash bin outside of the room.
During an interview with the DON on January 23, 2025, at 10:39 AM, she revealed the disposal bin for
personal protective equipment (PPE) should have been stored inside Resident 68's room, and she would
expect PPE to be worn appropriately by staff.
28 Pa Code 201.18(b)(1) Management.
28 Pa Code 211.12(d)(1)(5) Nursing Services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395898
If continuation sheet
Page 6 of 6
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
5 citations 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.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
FAQ · About this visit
Common questions about this visit
What happened during the January 23, 2025 survey of HOMEWOOD LIVING PLUM CREEK, INC?
This was a inspection survey of HOMEWOOD LIVING PLUM CREEK, INC on January 23, 2025. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HOMEWOOD LIVING PLUM CREEK, INC on January 23, 2025?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
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.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.