Homeland Center
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation.
FORM CMS-2567 (02/99) Previous Versions Obsolete
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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If continuation sheet
HOMELAND CENTER in HARRISBURG, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HARRISBURG, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HOMELAND CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.