Harrison Pavilion Care Center

In the surveyor’s words

From the most serious findings on record at Harrison Pavilion Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF740Dec 21, 2021

  Based on interviews with facility staff, the Medical Director, and Non-Physician Practitioners (NPPs), medical record review, review of the pre-admission screening form, review of hospital records, review of Emergency Medical Services (EMS) run report, review of the coroner ' s report, review of facility e-mails, review of the facility timeline investigation, review of the police report, and review of facility policies, the facility failed to provide adequate behavioral health services for one resident (#231) with a known history of [CONDITION(S)], paranoia, delusions, and who had a recent hospitalization for suicide ideations. […]

• Actual harm, patternF692Dec 21, 2021

  Based on observation, record review, staff and resident interview, and review of facility policy, the facility failed to provide each resident with a therapeutic diet as ordered by the physician, and planned by the Registered Dietitian, and/or receive interventions per the plan of care to ensure the resident maintained acceptable parameters of nutritional status including body weight. This resulted in actual harm for three residents (#22, #40, #74) who experienced avoidable, unplanned significant to severe weight loss and/or failed to maintain their weight or improve weight status per the plan of care. Additionally, the facility failed to provide a therapeutic diet as ordered by the physician for one resident (#05) out of eight residents reviewed for Nutrition. […]

• Actual harm, isolatedF686Nov 26, 2025

  Based on record review, observations, staff interviews, policy review, and review of the guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to adequately assess Resident #09's skin, failed to timely identify the resident's pressure ulcer (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), until it had reached an advanced stage and failed to timely implement provider ordered interventions to prevent the development of pressure ulcers and/or aid in the healing of existing pressure ulcers. […]

• Actual harm, isolatedF689Jul 7, 2022

  The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on medical record review, review of the hospital record, resident and staff interview, policy review, and review of a [MEDICATION(S)] Plus Medical Encyclopedia document, the facility failed to ensure a resident was free from an avoidable fall during incontinence care. This resulted in Actual Harm when Resident #15 fell out of bed during incontinence care and sustained an acute displaced fracture of the proximal right femur requiring surgical intervention, when State tested Nursing Assistant (STNA) #50 rolled Resident #15 away from her and Resident #15 rolled out of the raised bed onto the floor. […]

• No harm, potential for more than minimal, widespreadF761Sep 11, 2025

  Based on observation, staff interview, and review of the facility policy, the facility failed to ensure medications were stored appropriately and failed to discard expired medications. This had the potential to affect 35 facility-identified residents who receive medications from medication cart number two/back east, from medication cart short front, and from medication cart short back hall. The facility also failed to discard expired medications and supplies stored in the medication room. This had the potential to affect all of the residents residing in the facility. The facility census was 79 residents.Findings include: Observation on 09/10/25 at 9:33 A.M. […]