Harrison Springs Health Campus

In the surveyor’s words

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

• Actual harm, isolatedF686Feb 8, 2022

  Based on observation, record review, and interview, the facility failed to ensure services were provided to ensure thorough assessments were performed to accurately identify pressure injuries, effective interventions to prevent the development of pressure injuries were implemented for 2 of 4 residents reviewed for pressure injuries. (Resident 32 and Resident 10) This deficient practice resulted in Resident 32 experiencing a full thickness wound, initially identified as a stage three pressure injury, on the right thumb Findings include: 1. During an observation of wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's hand was contracted and lying on his chest. There was a pillowcase under the resident's hand on the resident's chest. […]

• No harm, potential for more than minimal, widespreadF812Jan 25, 2023

  Based on observation, record review, and interview, the facility failed to ensure the kitchen, dry storage room and equipment were clean and in good repair for 3 of 3 kitchen observations. This deficient practice had the potential to affect 52 of 52 residents that received food from the kitchen. Findings included: 1. During the initial tour of the kitchen on 1/19/23 between 9:20 a.m. and 9:45 a.m., while accompanied by Cook 10, the following concerns were observed: - Ice machine - around the top where the door connected to the machine, there was a moderate build-up of lime scale which dripped down both sides and in the front. - The shelf under the steam table had black and brown food particles and dirt on it and heavy rust on the metal wires. […]

• No harm, potential for more than minimal, patternF585Apr 21, 2026

  Based on record review and interview, the facility failed to ensure Resident Council Minutes were recorded monthly for 11 of 13 months and failed to ensure Resident Council Minutes for follow-up responses to grievances were documented for 13 of 13 months reviewed. This had the potential to affect all 52 of 52 residents residing in the facility. Findings include:During an interview, on 4/15/26 at 10:06 a.m., Activity Aide 3 indicated the Resident Council President 18 had the Resident Council Minutes. She found the binder with the Minutes for the last meeting on 4/14/26. During the review of the 4/14/26 Resident Council Minutes, on 4/15/26 at 10:17 a.m., the following concerns were voiced: The menus changed from the printed menu. Residents wanted more assistance with wheelchair transfers. […]

• No harm, potential for more than minimal, patternF684Apr 21, 2026

  Based on record review and interview, the facility failed to hold blood sugar and blood pressure medications when vital signs were out of the physician-ordered set parameters. This deficient practice affected 5 of 8 residents reviewed for medications with set parameters that were to be held based on the vital sign results (Residents 20, 22, 53, 6, and 52)1.The physician's order for Resident 20, dated 12/4/24, indicated the physician or Nurse Practitioner (NP) was to be notified of a systolic blood pressure (SBP-the top number in a blood pressure reading, measuring the maximum pressure in your arteries when your heart muscle contracts and pumps blood) greater than 165 milliliters of mercury (mmHg) or diastolic blood pressure (DBP-the bottom number in a reading, measuring the pressure in… […]

• No harm, potential for more than minimal, patternF741Nov 6, 2025

  Based on record review and interview, the facility failed to ensure staff were available for one to one supervision related to residents with behaviors requiring one to one supervision for 3 of 4 residents reviewed for sufficient staff for behavior Health Needs. (Residents B, C, and D)Findings Include:1.The record for Resident B was reviewed on 11/6/25 at 10:00 a.m. The diagnoses included, but were not limited to, wedge compression fracture of the first lumbar vertebra, urinary tract infection altered mental status, and dementia. The Minimum Data Set (MDS) assessment, dated 9/9/25, indicated the resident was moderately cognitively intact. The physician order indicated the following: - Buspirone 30 (mg) milligram tablet, given twice a day related to anxiety. […]