Health inspection·December 29, 2025

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that a comprehensive, person-centered care plan was implemented, which resulted in actual harm as evidenced by a fracture of the left hip and laceration for one of three residents reviewed (Resident 1).Findings Include:Review of facility policy, titled MDS Assessment Completion and Care Planning, last revised October 2024, read in part, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially when changes are made.Review of Resident 1's clinical record revealed diagnoses that included dementia (a decline in mental ability that interferes with daily life) and osteoporosis (bone disease causing bones to become weak, porous, and brittle).Review of Resident 1's fall care plan revealed the interventions for, tab alarm at all times in bed and chair, bilateral floor mattresses/alarming floor mats, low bed, can roll onto mattress beside bed at times which was last revised on August 15, 2025.Review of Resident 1's Kardex (quick reference tool utilized to identify a resident's care needs/preferences and assistance needed) revealed section titled, Safety, which stated, tab alarm at all times in bed and chair, bilateral floor mattresses/alarming floor mats, low bed, can roll onto mattress beside bed at times.Review of facility incident report dated December 15, 2025, revealed Resident 1 sustained an unwitnessed fall from bed at 4:15 PM. Review of the incident description revealed, resident rolled out of bed to floor. Bed was not in low position and mats were not on floor. Resident sustained a 4-5 cm laceration to left forehead.Review of Resident 1's interdisciplinary progress notes revealed that an assessment conducted by the Registered Nurse revealed Resident 1 sustained a 4.5-5 cm laceration to left forehead, bleeding noted from the laceration. The physician was notified and an order to send Resident 1 to the emergency room for evaluation and treatment was obtained.Review of Resident 1's hospital summary dated December 15, 2025, at 5:41 PM, revealed that the Resident was initially treated in the emergency department and was subsequently admitted to the hospital for an orthopedic consult and monitoring.Review of the emergency room physician's notes revealed Resident 1's 2 cm facial laceration was repaired with staples. X-ray results revealed Resident 1 suffered a mildly displaced fracture of the proximal left femoral metaphysis (hip fracture). Resident 1 was deemed not appropriate for surgical intervention due to multiple health factors.Review of a witness statement by Employee 1 (Certified Nurse Assistant assigned to Resident 1 at the time of the fall), dated December 15, 2025, revealed Employee 1 stated, in part, .I did put her to bed. I did place floor alarms on both sides. I (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 2 Event ID: 395475 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 395475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Homeland Center 1901 North Fifth Street Harrisburg, PA 17102 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)