Homeland Center

also put the bed as low as it would go. I put her in bed at about 2 PM.Review of a second witness statement by Employee 1, dated December 16, 2025, revealed Employee 1 stated, On 12/15/25 at 2pm I put the resident to bed. I kept her body alarm that was on her chair on the lift pad as she was transferred so that it remained on her.

Both floor alarms were down, I did fail to put the second fall mat down on the side her closet is on.

Once in bed, I lowered her bed down as low as it would go. I left around 3:30 to get my food and saw her in bed. I returned maybe 5-10 minutes later and continued to my set assigned for 2nd shift.Review of witness statements from Employee 4 (CNA), Employee 5 (Licensed Practical Nurse [LPN]), and Employee 6 (Registered Nurse [RN]) revealed that when they responded to Resident 1's room after the fall, Resident 1's bed was observed in an elevated position, the fall mattresses were propped against the wall, and fall mat alarms were in place but not connected.

During an interview with the Nursing Home Administrator (NHA) on December 29, 2025 at approximately 1:00 PM, he revealed that Employee 1 was an agency CNA and had completed orientation to the facility and training on November 25, 2025.

Following the facility's investigation, it was determined that Employee 1 failed to follow Resident 1's plan of care, which resulted in Resident 1 falling from her bed and sustaining a left hip fracture and facial laceration.

The facility notified Employee 1's agency and placed Employee 1 on the do not return list.

The NHA revealed that he expected staff to follow residents' plans of care and that an all staff in-service was completed to review the importance of following care plans.Review of education documentation dated December 17 - 23, 2025, revealed that nurse aides and licensed staff were educated on the importance of alarms functioning, mat placement, and following care plans.

During an interview with Employee 2 (Assistant Director of Nursing [ADON]) on December 29, 2025 at approximately 1:05 PM, Employee 2 confirmed she had received training on the importance of alarms functioning, mat placement, and following care plans.During an interview with Employee 3 (RN) on December 29, 2025 at approximately 1:15 PM, Employee 3 confirmed she had received training on the importance of alarms functioning, mat placement, and following care plans.The facility initiated weekly care plan compliance audits on December 15, 2025.

Audits continue and results are reviewed at the weekly Quality Assurance and Performance Improvement Committee meetings.Review of facility documentation revealed that on December 23, 2025, the facility had completed audits and education for staff to ensure compliance with following the care plan.

During the abbreviated survey, audits and staff education were reviewed.

Staff interviews, resident interviews, resident record review, and observations revealed no concerns with following resident care plans. 28 Pa.

Code 201.14(a) Responsibility of licensee28 Pa.

Code 201.18(b)(1)(e)(1) Management28 Pa.

Code 211.10(c)(d) Resident care policies28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services

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