Harrison's Crossing Health Campus

In the surveyor’s words

From the most serious findings on record at Harrison's Crossing Health Campus, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 6, 2023

  Based on observation, interview and record review, the facility failed to ensure person-centered fall interventions were in place for a resident, (Resident B) who had a history of falls, which resulted in actual harm when he fell out of bed and sustained multiple rib fractures and hospitalization . The facility failed to ensure a resident, (Resident C) who had a history of falls, also received person-centered interventions as outlined in her plan of care for 2 of 3 residents reviewed for falls. Findings include: 1. On 9/6/23 at 11:32 a.m., a comprehensive record review was completed for Resident B. He was a long-term care resident who received Hospice services. […]

• No harm, potential for more than minimal, isolatedF605Apr 21, 2026

  Based on record review and interview, the facility failed to ensure documented physician rationale for a declination of pharmacy recommendations and failed to ensure the physician signed and dated the pharmacy recommendations for 3 of 5 residents reviewed for unnecessary medication (Residents 19, 56, and 8). Findings include: 1. Resident 19's record was reviewed on 4/15/26 at 2:13 p.m. The profile indicated that the resident's diagnoses included, but were not limited to, unspecified dementia (a clinical term for cognitive decline that prevents a definitive diagnosis of a specific type), unspecified severity with anxiety (a diagnosis for significant anxiety, panic, or fear that causes distress or functional impairment but does not fully meet the specific criteria for other, more defined… […]

• No harm, potential for more than minimal, isolatedF690Apr 21, 2026

  Based on interview and record review, the facility failed to assess or provide valid medical justification from the attending physician to determine if continued use or removal of a urinary catheter was clinically warranted for 1 of 1 residents reviewed for catheter use (Resident 41).Findings include:On 4/14/26 at 1:41 p.m., during an interview, Resident 41's husband indicated the resident had an indwelling foley catheter (a thin, flexible catheter used especially to drain urine from the bladder). He indicated the catheter was placed in the hospital and she had no issues with urination prior to being in the hospital and did not know why she still had a catheter. He had requested it be removed. […]

• No harm, potential for more than minimal, isolatedF558Feb 18, 2025

  Based on observation and record review, the facility failed to ensure a resident was treated in a dignified manner during 1 of 1 random meal service observation (Resident 8). Findings include: On 2/14/25 at 10:05 a.m., Resident 8 was observed eating a meal at the nurses' station table with several other residents who were not eating. The resident was observed spilling food over their clothing. Certified Nurse Aide (CNA) 20 was standing next to the resident and talking to him. On 2/14/25 at 10:07 a.m., during an interview, CNA 20 acknowledged the resident should have a clothing protector, but she forgot to put one on because he was in the hall. The employee did not obtain a clothing protector, and the resident continued to spill food over himself. […]

• No harm, potential for more than minimal, isolatedF561Feb 18, 2025

  Based on interview and record review, the facility failed to ensure a resident was provided showers as preferred for 1 of 26 residents reviewed for choices (Resident 2). Findings include: During an interview, on 2/10/25 at 11:34 a.m., Resident 2 indicated it had been almost 2 weeks since she last had a shower. She was scheduled to receive 3 showers a week, on Monday, Wednesday, and Friday. She further indicated the shower in her room was too cold and she was waiting for it to be fixed by the maintenance worker. Resident 2's record was reviewed on 2/12/25 at 11:52 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 11/22/24, indicated the resident was cognitively intact and required two-person physical assist with transfers. […]