Harrison Springs Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Corydon, Indiana.
- Location
- 871 Pacer Drive Nw, Corydon, Indiana 47112
- CMS Provider Number
- 155852
- Inspections on file
- 29
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Harrison Springs Health Campus during CMS and state inspections, most recent first.
Resident Council minutes were not consistently recorded, and grievance follow-up was not documented in the minutes reviewed. Residents raised concerns about menu changes, wheelchair transfer assistance, and delayed staff response when using the toilet, but the available notes lacked monthly documentation and did not show responses to concerns. The Resident Council President and activity staff described monthly meetings, yet the binder contained only a few sets of minutes and several meetings were missing from the record.
Failure to Hold Medications Outside Ordered Vital Sign Parameters The facility administered BP and diabetes medications outside physician-set hold parameters for multiple residents. Metoprolol, midodrine, and insulin were given or managed without following ordered SBP, DBP, pulse, or blood sugar limits, and MD/NP notification was not documented when required. Staff interviews confirmed that medications should be held when vital signs are outside the ordered parameters and the physician notified.
Three residents with behavioral health needs, including exit-seeking and aggression, were not consistently provided with one-on-one supervision by facility staff. Instead, the facility relied on family members or outside agency sitters to supervise these residents, and only provided staff supervision temporarily when family was unavailable. This resulted in a failure to ensure sufficient staff with the necessary competencies and skills to meet the behavioral health needs of these residents.
A resident with a history of amputation and diabetes developed an open surgical wound, but staff failed to document physician notification when the wound dehisced. Nursing staff observed the wound opening and a remaining staple, notified a supervisor, and left a voicemail for the physician's office, but there was no evidence of follow-up or documentation that the physician was informed as required by facility policy.
Resident Council Minutes and Grievance Follow-Up Not Documented
Penalty
Summary
The facility failed to ensure Resident Council Minutes were recorded monthly for 11 of 13 months reviewed and failed to ensure follow-up responses to grievances were documented for 13 of 13 months reviewed. During record review and interviews, the Resident Council binder contained only December 2025 and April 2026 minutes from the period reviewed, with no documented minutes from 2023 and 2024 and no monthly minutes for most of April 2025 through April 2026. The Resident Council policy stated that minutes were to be recorded and maintained for at least 2 years and that actions taken or considerations given to issues were to be reported back at the next meeting. During interviews, Activity Aide 3 stated the Resident Council President had the minutes and that the binder with the most recent meeting minutes was found on 4/14/26. The Resident Council President stated that meetings were held monthly with staff present, but she did not document all of them and felt it was her responsibility, though she let it slide. Activity Aide 4 stated residents had monthly meetings and that two activity aides helped direct the meetings, while the Resident Council President took notes and activities staff also took notes. The President later presented notes from February and March 2026 and stated that sometimes staff made copies of the minutes, but sometimes they were lost in transmission. At the Resident Council meeting observed on 4/17/26, residents voiced concerns that menus changed from the printed menu and that they wanted more assistance with wheelchair transfers. Resident 50 stated staff took 30 to 40 minutes to respond when she was on the bedside toilet or bathroom toilet, and residents were unsure whether the facility responded to their concerns. The minutes reviewed by surveyors did not document grievance follow-up, and the ED stated that a previous Activities Director had not been documenting the Resident Council meetings as she should have. The ED also stated that activity staff would verbalize resident grievances to Administration if they felt they were important and that she would review them and let staff know what follow-up would be completed, but the minutes presented still lacked documentation of follow-up responses.
Failure to Hold Medications Outside Ordered Vital Sign Parameters
Penalty
Summary
The facility failed to hold medications when residents’ vital signs were outside physician-ordered parameters and failed to notify the physician or NP when required. This affected 5 of 8 residents reviewed for medications with set hold parameters: Residents 20, 22, 53, 6, and 52. The report documents multiple instances in which metoprolol, midodrine, and insulin were administered or managed without following the ordered blood pressure, pulse, or blood sugar limits. Resident 20 had diagnoses including paroxysmal atrial fibrillation and portal hypertension, and the care plan addressed cardiovascular distress. The physician ordered metoprolol succinate ER 50 mg daily to be held for SBP less than 105 mmHg or heart rate less than 60 bpm, and blood pressure notification was required for SBP greater than 165 mmHg or DBP greater than 100 mmHg. The MAR showed metoprolol was given on multiple occasions when the pulse was below 60 and when blood pressure readings were below the hold parameters. The record also lacked documentation that the MD or NP was notified of an elevated SBP of 169. Resident 22 had diagnoses including interstitial pulmonary disease, orthostatic hypotension, and atherosclerotic heart disease, with a care plan for cardiovascular distress. The physician ordered metoprolol succinate ER 50 mg twice daily to be held if SBP was less than 100 or DBP was less than 60. The March 2026 MAR showed the medication was administered when DBP was 58 and 57. Resident 53 had diagnoses including acute respiratory failure with hypoxia and diabetes mellitus, with care plans for cardiovascular distress and blood sugar monitoring. The resident had an order for insulin lispro sliding scale with instructions to call the MD if blood sugar was greater than 400, but the MAR showed blood sugar readings of 478 and 461 without MD notification. The resident also had a metoprolol order to hold for SBP less than 105, DBP less than 60, or pulse less than 60, and the medication was administered on several occasions outside those parameters. Resident 6 had diagnoses including atrial fibrillation, aortic valve stenosis, chronic pulmonary edema, hypertensive heart disease, and CHF. The resident had orders for midodrine to be held if SBP was greater than 130 and metoprolol succinate to be held if SBP was less than 100 or pulse was less than 60. The record showed midodrine was held on several dates without a documented blood pressure reading, and metoprolol was administered when SBP was 98 on two occasions. Resident 52 had CHF and chronic pain syndrome, with an order for midodrine 10 mg every 8 hours to be held if SBP was greater than 125; the MAR showed the medication was administered when SBP was 127. Staff interviews confirmed that medications with set parameters were to be held and the physician notified when vital signs were outside ordered limits.
Failure to Provide Sufficient Staff for Behavioral Health Supervision
Penalty
Summary
The facility failed to ensure that sufficient staff with appropriate competencies and skills were available to meet the behavioral health needs of residents requiring one-on-one supervision. For three residents with exit-seeking behaviors and other behavioral health concerns, the facility relied on family members or outside agency sitters to provide necessary supervision, rather than consistently providing this care through facility staff. In several instances, the facility contacted family members to sit with residents or to arrange for private sitters, and when family could not provide supervision, the facility considered alternate placement for the residents. One resident with dementia and a history of exit-seeking was observed wandering without required safety devices and was only provided one-on-one supervision when family or an outside agency sitter was available. Another resident with multiple medical and behavioral diagnoses, including agitation and aggression, required one-on-one supervision due to exit-seeking and aggressive behaviors. The facility communicated to the family that it could not provide ongoing one-on-one care and that the family would need to arrange supervision or consider alternate placement. During periods when family members were unavailable, staff provided one-on-one care only temporarily, and the facility continued to seek alternate placement. A third resident with dementia and a history of falls was admitted and subsequently found outside the facility attempting to leave. The care plan called for one-on-one supervision until alternate placement could be found, but the facility again relied on family to provide this supervision. The facility's approach to residents requiring intensive behavioral supervision was to request family or outside agencies to provide care, and only provided staff supervision for short periods, indicating a lack of sufficient staff to meet these residents' behavioral health needs as required.
Failure to Notify Physician of Surgical Wound Dehiscence
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician was notified and/or follow-up occurred after a resident's surgical wound opened. The resident, who had a history of left toe amputation, an open wound of the left foot, gangrene, orthopedic aftercare, and diabetes, was under a care plan that required monitoring and treatment of a surgical incision. Physician orders specified wound care procedures, and the resident was noted to be cognitively intact and in need of surgical wound care. Documentation showed that the resident experienced worsening pain and drainage from the surgical site, with the physician noting a lack of healing and the need for further surgical intervention. On a subsequent date, nursing staff observed the resident's incision had a small open area and a remaining staple, and while the supervisor was notified and a voicemail was left for the physician's office regarding the staple, there was no documentation that the physician was informed about the wound opening. Interviews with nursing staff revealed uncertainty about when the wound began to open and whether the physician or nurse practitioner was properly notified. One nurse indicated she informed her supervisor about the wound opening and assumed the physician would be notified, but could not confirm if this occurred. Another LPN stated that while a voicemail was left about the staple, there was no evidence of follow-up or documentation regarding the open incision. The facility's policy required documentation of physician notification attempts and responses, but the record lacked evidence that the physician was informed about the surgical wound dehiscence.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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