Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harrison Pavilion Care Center during CMS and state inspections, most recent first.
A resident at high risk for pressure ulcers was not properly assessed or provided with timely interventions as ordered by providers. Despite clear risk factors and physician orders for preventive care, staff failed to implement and document necessary treatments, resulting in the development of avoidable stage II and stage III pressure ulcers. Staff interviews confirmed delays in care and lack of adherence to protocols, leading to actual harm.
A resident with severe cognitive impairment and multiple mental health diagnoses experienced a significant change in mental status, including confusion and agitation, leading to a physician-ordered transfer to the hospital. Despite facility policy requiring notification, the resident's POA was not informed of the change in condition or the transfer, as confirmed by staff interviews and record review.
A resident with multiple medical conditions and moderate cognitive impairment did not receive several scheduled doses of IV Meropenem for an infected wound due to medication unavailability and an agency nurse's failure to locate the medication. Pharmacy and facility records confirmed the missed doses, and the DON verified that the medication was not administered as required by facility policy.
A staff member served a pureed meal to a resident with dysphagia and severe cognitive impairment using a plate that still had food particles from a previous meal. The plate was only rinsed with water before use, contrary to facility policy requiring proper dishwashing and sanitary practices.
A resident with a stage three pressure ulcer and impaired cognition received wound care from an LPN who did not remove soiled gloves or perform hand hygiene after removing the old dressing, instead wearing the same gloves throughout the procedure. This action was not in accordance with the facility's infection control policy, as confirmed by staff interview and policy review.
Expired medications and supplies were found in the medication room, including multi-vitamin with iron, wound therapy foam kit, and tube feeding bottles past expiration. Multiple med carts also contained loose unidentified pills, tablets out of packaging, and sticky substances in drawers, along with expired hydrogen peroxide and an IV start kit. An LPN confirmed the expired items should have been discarded and the carts cleaned.
Food items were found improperly stored and the kitchen was not maintained in a clean, sanitary manner. A bottle of cleaning spray, a soiled rag, cardboard, and an opened soda were on the clean dish rack; multiple dry goods, refrigerated items, and frozen items were unlabeled, undated, or expired; and the freezer floor, robot coupe, stove hood, wall, and air vent had visible soil or buildup. The DM confirmed the storage and sanitation issues during observation.
Failure to Update PASARR After New Psychiatric Diagnoses: The facility failed to complete updated PASARR assessments for two residents after new psychiatric diagnoses were added. One resident had CVA, anxiety disorder, schizoaffective disorder, and depression, but the PASARR did not reflect schizoaffective disorder; another resident had major depressive disorder and later bipolar disorder, but the PASARR was not updated to include the new diagnosis. Staff confirmed the missing significant change PASARR updates.
The facility had a 12% medication error rate, with 3 errors in 25 medication opportunities. One resident did not receive ordered spironolactone and cyanocobalamin because the meds were unavailable, and an LPN administered Novolog insulin without priming the pen first for another resident. The facility policy stated meds were to be given safely, timely, and as prescribed.
An LPN administered Novolog to a resident with DM without priming the insulin pen first. The resident had COPD, DM2, and depression, and the order was for sliding-scale insulin. Surveyors observed the LPN give four units without an air shot, and the LPN confirmed she did not prime the pen as required by the manufacturer instructions.
Improper portion measurement affected a resident on a pureed diet when a DS used a spatula to plate pureed stuffed peppers and a 3-ounce scoop for mashed potatoes even though the recipe called for a 4-ounce portion. The DS confirmed the correct scoop was not available, and the facility policy required proper measurements for portion control.
Staff failed to maintain sterile technique during trach care for a resident with a trach and severe cognitive impairment when an LPN handled sterile supplies with clean gloves before donning sterile gloves. Staff also failed to follow EBP for another resident on EBP for tube feeding-related infection risk when two CNAs provided incontinence care wearing gloves but no isolation gowns, despite a door sign requiring gown and glove use.
A resident with cognitive impairment and a history of major depressive disorder was assessed for a cough and bilateral wheezes, and an NP ordered a stat chest x-ray and verbally directed staff to give Tylenol cold and flu immediately. However, the medication order was not entered in the chart and was not on the resident’s profile, while the resident reported having cough and runny nose symptoms for one to two weeks.
Failure to Complete Root Cause Analysis After a Resident Fall: A resident with Parkinson's disease, DM2, depression, anxiety, and dementia was identified as a fall risk and later had an unwitnessed fall in her room, where she was found on the floor in front of her walker and stated she hit her head. The incident report and investigation did not include a root cause analysis of the events and factors leading to the fall, and the DON confirmed the facility did not complete one.
The facility restricted cognitively intact residents from independently signing out, citing safety concerns. Residents were required to sign behavior agreements, limiting their ability to leave unless medically necessary. This affected several residents, leading to behavior contracts and discharges against medical advice for non-compliance.
The facility failed to provide proper documentation and justification for the discharge of two residents. One resident was discharged without a documented notice, and the discharge summary lacked essential information. Another resident was discharged AMA before the end of a 30-day notice period due to behavioral issues, but the discharge process did not comply with regulatory requirements. Interviews with staff revealed a policy prohibiting unsupervised departures due to safety concerns, but the facility did not follow proper procedures for the discharges.
A resident was discharged from an LTC facility without a complete discharge summary, missing key information such as admission and discharge details, treatment, and progress. The resident, who had a behavior agreement due to non-compliance with facility rules, was discharged for smoking marijuana. Interviews revealed no documentation of a discharge notice being provided, contrary to the facility's policy.
Failure to Prevent and Timely Treat Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess and monitor the skin integrity of a resident who was admitted without pressure ulcers but was identified as high risk for developing them due to factors such as bowel and bladder incontinence, limited mobility, and decreased ability to perform activities of daily living. Despite a care plan and physician orders in place for preventive interventions, including the use of a pressure reduction device and application of barrier cream, staff did not consistently implement or document these interventions. Notably, after the resident returned from a hospital stay, a wound nurse practitioner assessed the resident and provided treatment orders for incontinence-associated dermatitis, but these orders were not carried out for several days. During this period, the resident's skin condition deteriorated, with red areas and bleeding noted on the buttocks, and the development of two pressure ulcers: a stage III ulcer on the sacrum and a stage II ulcer on the left buttock. Documentation revealed that staff failed to identify and report these changes in a timely manner, and there was a lack of ongoing, comprehensive skin assessments as recommended by national guidelines. The resident was dependent on staff for turning, repositioning, and incontinence care, but these interventions were not consistently provided or documented according to the care plan and physician orders. Interviews with facility staff, including the wound nurse practitioner, LPN unit manager, and DON, confirmed that treatment orders were not implemented promptly and that the resident's wounds were avoidable with proper care. The failure to follow established protocols and timely implement provider-ordered interventions resulted in actual harm to the resident, who developed avoidable, facility-acquired pressure ulcers.
Failure to Notify POA of Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's power-of-attorney (POA) of significant changes in the resident's condition and subsequent transfer to the hospital. The resident, who had diagnoses including cognitive communication deficit, altered mental status, mood disorder, major depressive disorder, dementia, and Alzheimer's disease, experienced a change in mental status characterized by increased confusion, refusal of care, hallucinations, and agitation. Despite these changes and the eventual transfer to the emergency room as ordered by the physician, there was no documented evidence that the resident's POA was informed at any point during these events. Staff interviews confirmed that the facility's policy required prompt notification of the resident's representative in the event of a change in condition or transfer to a hospital. Both the LPN Unit Manager and the Director of Nursing acknowledged that the POA was not notified as required. Review of the facility's policy further supported the expectation for such notifications, but documentation and staff statements indicated this did not occur for the resident in question.
Failure to Administer Prescribed IV Antibiotic Due to Medication Unavailability and Staff Oversight
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by missed doses of Meropenem IV solution prescribed for an infected sacral wound. The resident, who had diagnoses including hyperosmolality, hypernatremia, major depressive disorder, and a pressure ulcer, was admitted with moderate cognitive impairment. Physician orders specified Meropenem IV every eight hours for 14 days, but the medication administration record showed multiple missed doses over several days. Pharmacy records and progress notes confirmed that the medication was not administered because it was reported as being on order, and there were delays in receiving the medication supply. Interviews with facility staff and the pharmacy representative revealed that the initial supply of Meropenem was delivered, but subsequent doses were missed due to a lack of medication availability and a failure by an agency nurse to locate the IV medications. The Director of Nursing verified the missed doses and attributed the issue to the agency nurse not asking about the storage location of IV medications. Facility policy required medications to be administered in a safe and timely manner, within one hour of the prescribed time, but this was not followed in this instance.
Unclean Dishware Used for Pureed Meal Service
Penalty
Summary
A deficiency occurred when staff failed to ensure dishware was clean prior to serving a pureed meal to a resident. The resident, who had diagnoses including dysphagia, epilepsy, mood disorder, and hemiplegia and hemiparesis following cerebrovascular disease, was on a physician-ordered regular diet with pureed texture and regular thin consistency. During meal service, a staff member obtained a divided plate that still had food particles from a previous meal, rinsed it with water at the sink, and then placed pureed pasta onto the plate before serving it to the resident. The staff member confirmed during interview that the plate was not clean and had food on it from a previous meal, and that she only rinsed it with water before use. Facility policy required food and nutrition services employees to prepare and serve food in compliance with safe food handling practices, and specified that dishwashing areas should be separate from the food service line to maintain a sanitary environment.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
During a wound care observation for Resident #09, who had diagnoses including cellulitis and a stage three pressure ulcer to the sacrum, it was found that infection control protocols were not followed. The resident, who was cognitively impaired and dependent on staff for care, had a physician's order for daily wound care to the right buttocks. The LPN performing the wound care did not remove her soiled gloves or perform hand hygiene after removing the old dressing, instead wearing the same gloves throughout the entire dressing change procedure. The LPN confirmed during an interview that she did not change gloves or perform hand hygiene as required by facility policy, which specifies that gloves should be removed and hands washed after removing the old dressing and before continuing treatment. This failure to follow established infection control measures was observed directly and was not in accordance with the facility's wound care policy.
Expired Medications and Poor Medication Storage
Penalty
Summary
The facility failed to ensure medications were stored appropriately and failed to discard expired medications and supplies. During observation of the medication room with an LPN, expired house stock items were found, including two bottles of multi-vitamin with iron expired in August 2025, a negative pressure wound therapy foam kit expired in February 2020, and expired Vital 1.5 tube feeding bottles, including 10 bottles expired in May 2025 and 41 bottles expired in August 2025. The LPN confirmed these expired items were house stock and should have been discarded. Observations of three medication carts also revealed poor storage conditions and loose medications. Medication cart number two had 11 loose unidentified pills in the top drawer, 11 tablets out of packaging in the second drawer, and a brown sticky substance with paper stuck to it in another drawer. The short front cart had sticky pink substance in two drawers, three bottles of hydrogen peroxide expired in January 2025, an IV start kit with chloraprep expired on 03/31/25, and a light brown substance with particles in the bottom drawer. The short back hall cart had 61 loose unidentified pills in the top drawer, a sticky clear substance with one pill stuck in it, and a pink and brown sticky substance covering the bottom of another drawer. An LPN confirmed the loose pills and sticky substances should have been discarded or cleaned. The facility policy stated nursing staff were responsible for keeping medication storage and preparation areas clean, safe, and sanitary, and that discontinued, outdated, or deteriorated drugs or biologicals were to be returned to the dispensing pharmacy or destroyed.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food items were not stored properly and the kitchen was not maintained in a clean, sanitary manner. During observation with the Dietary Manager, a bottle of cleaning spray was found on the clean dish rack along with a piece of cardboard, a soiled rag, and an opened bottle of soda on clean dishes. In the dry storage area, several items were observed unlabeled and undated, including two bags of elbow pasta, a bag of egg noodles, a container of rolled oats, and a bag of croutons, and a package of gravy had an expiration date of 07/07/25. The Dietary Manager confirmed that items should not be stored in the clean dish area, that dry storage items should be labeled and dated, and that expired items should be discarded. In cold storage, the walk-in refrigerator contained unlabeled and undated gallon containers of orange juice and grape juice, as well as opened packages of Swiss cheese and cheddar cheese. The walk-in freezer contained an unlabeled and undated package of chicken nuggets, dirty gloves on the floor, and a dried brown substance on the floor. The stand-up refrigerator also contained unlabeled and undated items, including 12 cups of fruit, two cups of shredded cheddar cheese, and two cups of cottage cheese. In the kitchen prep station, containers of sugar, flour, and breadcrumbs were unlabeled and undated. The robot coupe had not been cleaned after use, the hood above the stove had a dark brown substance on top and on the wall, and the air vent above the kitchen prep and serving area had a build-up of a dark fuzzy substance. The facility policy stated staff should label and date all food items and use perishable items within seven days after opening.
Failure to Update PASARR After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to complete significant change PASARR assessments after two residents received new psychiatric diagnoses. Resident #76 was admitted with diagnoses including CVA with hemiplegia and hemiparesis, anxiety disorder, schizoaffective disorder, and depression, but the PASARR dated 10/21/21 did not include schizoaffective disorder. The resident’s MDS dated 07/22/25 showed the resident was cognitively intact and required staff assistance with ADLs. The Administrator confirmed the facility should have completed an updated PASARR when Resident #76 was admitted with schizoaffective disorder. Resident #7 was admitted with major depressive disorder, and bipolar disorder was added as a diagnosis on 07/07/24. The PASARR dated 02/22/22 listed only major depressive disorder as the psychiatric diagnosis. The MDS dated 06/18/25 showed Resident #7 had moderately impaired cognition. The Social Worker confirmed the facility did not complete an updated PASARR in 2024 when bipolar disorder was added, and the Corporate RN confirmed the facility should complete a significant change PASARR within 72 hours of any new psychiatric diagnosis.
Medication error rate exceeded 5%
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with surveyors identifying 3 medication errors in 25 medication opportunities for a 12% error rate. This involved two of the three residents observed during medication administration, out of a census of 79 residents. For one resident with diagnoses including anxiety disorder, CHF, and type 2 diabetes mellitus, the resident had physician orders for spironolactone 25 mg daily and cyanocobalamin 100 mcg daily, but the LPN did not administer either medication because they were not available. For another resident with diagnoses including COPD, type 2 diabetes mellitus, and depression, the resident had an order for Novolog insulin per sliding scale, and the LPN administered 4 units without priming the insulin pen with 2 units prior to administration. The facility policy stated medications were to be administered in a safe and timely manner, as prescribed.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to prime an insulin pen before administering Novolog insulin to Resident #44. Resident #44 was admitted on 10/31/24 with diagnoses including COPD, type 2 diabetes mellitus, and depression, and the MDS dated 08/07/25 indicated intact cognition and assistance with ADLs. The physician's order dated 11/11/24 directed Novolog insulin to be given subcutaneously per sliding scale. During observation on 09/09/25 at 12:14 P.M., LPN #313 administered four units of Novolog to Resident #44 without priming the insulin pen first. During interview at 12:25 P.M., LPN #313 confirmed she did not prime the pen with two units before administration. Manufacturer instructions reviewed by surveyors stated the insulin pen should always be primed before each injection by dialing two units and pressing the button to shoot insulin into the air.
Improper Portion Measurement for Pureed Diet Meal
Penalty
Summary
The facility failed to measure correct portion sizes to meet the nutritional needs of one resident who had physician’s orders for a pureed diet. During food preparation, Dietary Staff #404 used a spatula to scoop pureed stuffed peppers onto the resident’s plate because he did not have the proper scoop. Later, he used a three-ounce scoop to plate the resident’s mashed potatoes even though the recipe called for a four-ounce portion, and he confirmed he used the smaller scoop because a four-ounce scoop was not available. Review of the facility policy titled Kitchen Weights and Measurements dated April 2007 showed that the facility should use proper measurements for portion control of foods.
Infection Control Failures During Tracheostomy Care and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to maintain sterile technique during tracheostomy care for one resident who was admitted with diagnoses including anoxic brain damage, anxiety disorder, tracheostomy status, and schizophrenia. The resident had severe cognitive impairment, was dependent on staff for activities of daily living, and had an order for tracheostomy care every day and night shift and as needed. During observation of tracheostomy care, an LPN used clean gloves to place sterile items onto the sterile field, including sterile gloves, and did not remove the clean gloves before donning the sterile gloves. The LPN later confirmed that all sterile items were touched with clean gloves before trach care was provided. Staff also failed to wear the required PPE for a resident on Enhanced Barrier Precautions who had diagnoses including anoxic brain damage, chronic respiratory failure with hypoxia, affective mood disorder, and hemiplegia and hemiparesis following cerebral infarction. The resident had severely impaired cognition and was on EBP due to increased risk for infection related to tube feeding. During observed incontinence care, two CNAs wore gloves but neither wore an isolation gown, despite a sign on the resident's door indicating that gloves and isolation gowns were required for direct care. Both CNAs confirmed they did not wear isolation gowns while providing care.
Delayed Treatment for Respiratory Infection Symptoms
Penalty
Summary
The facility failed to ensure timely treatment for a resident with respiratory infection symptoms. Resident #7, who had a history of major depressive disorder and moderately impaired cognition, was assessed by the nurse practitioner for a cough that had been present for several days, with wheezes noted in both lungs. The nurse practitioner ordered a stat chest x-ray and gave a verbal order to the nurse to implement the standing Tylenol cold and flu medication order and administer a dose immediately, but there was no written order for the Tylenol cold and flu medication and it was not on the resident’s profile. The resident later stated he had been given medicine for flu symptoms and had been experiencing a cough and runny nose for one to two weeks.
Failure to Complete Root Cause Analysis After Resident Fall
Penalty
Summary
The facility failed to complete a root cause analysis after a resident fall. Resident #39 was admitted with diagnoses including Parkinson's disease, type 2 diabetes, depression, generalized anxiety disorder, and unspecified dementia, and was identified in the care plan as being at risk for falls with interventions such as keeping the call light within reach, maintaining a safe environment, and educating the resident on footwear, call light use, and safe mobility device use. On 02/24/25, the resident had an unwitnessed fall in her room and was found seated on the floor in front of her walker. The resident stated she hit her head during the fall. Review of the incident report and investigation for the fall showed that it did not include a root cause analysis of the events and factors leading to the fall. During interview on 09/11/25, the DON confirmed the facility did not complete a root cause analysis for the fall and stated that part of the fall investigation process should include one. Review of the facility policy titled Managing Falls and Fall Risk dated December 2007 showed the facility evaluated falls and identified interventions related to the resident's specific risks and causes to try to prevent the resident from falling.
Facility Restricts Resident Autonomy with Behavior Agreements
Penalty
Summary
The facility failed to honor the rights of cognitively intact residents to independently sign out of the facility, affecting four residents who were their own responsible parties. The facility had a policy that restricted residents from leaving the facility without supervision, citing safety concerns due to the surrounding area's violence. This policy was enforced through behavior agreements that residents were required to sign, which stipulated that they could not leave the facility unless medically necessary. Resident #16, who had been living at the facility for over four years, reported that he was previously allowed to sign himself out but was no longer permitted to do so unless accompanied by family. Resident #69 was presented with a behavior contract after leaving the facility with family, which he refused to sign. Resident #100 had a history of leaving the facility and consuming alcohol in the community, leading to a behavior agreement that he signed. Despite this, he continued to leave the facility without signing out, resulting in a 30-day discharge notice and eventual discharge against medical advice (AMA) after violating the agreement. Resident #400, who was cognitively intact and his own responsible party, was also subject to a behavior agreement due to leaving the facility without signing out. He was discharged from the facility after being found smoking marijuana, although there was no documentation of a discharge notice being given. Interviews with staff and the administrator confirmed the facility's policy of not allowing residents to leave without supervision, and the enforcement of behavior agreements to ensure compliance with this policy.
Improper Discharge Procedures for Two Residents
Penalty
Summary
The facility failed to provide proper documentation and justification for the discharge of Resident #400, who was admitted with diagnoses including major depressive disorder and schizoaffective disorder. The resident was discharged without a documented discharge notice, and the discharge summary lacked essential information such as the reason for discharge and treatment provided. The facility's Administrator stated that the resident was discharged for smoking marijuana, but there was no documentation to support this claim. The Director of Nursing confirmed the absence of a discharge notice in the resident's medical record. Resident #100 was also affected by the facility's failure to adhere to proper discharge procedures. Despite being on a 30-day discharge notice due to behavioral issues, the resident was discharged against medical advice (AMA) before the notice period ended. The resident's discharge summary was incomplete, missing details about follow-up care and community resources. The facility's staff reported that the resident violated a behavior agreement by leaving the facility without supervision, which led to the AMA discharge. However, the discharge process did not comply with regulatory requirements, as the resident was not allowed to remain in the facility for the duration of the discharge notice. Interviews with facility staff, including the Administrator and the Director of Nursing, revealed that the facility had a policy prohibiting residents from leaving without supervision due to safety concerns in the area. Both residents had signed behavior agreements that outlined conditions for their continued residency, but the facility did not provide adequate documentation or follow proper procedures for their discharges. The lack of proper discharge notices and incomplete discharge summaries indicate a deficiency in the facility's compliance with regulatory standards for resident transfers and discharges.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a resident's discharge summary included a comprehensive recapitulation of the resident's stay. This deficiency affected a resident who was admitted with diagnoses including major depressive disorder, acquired absence of both legs below the knee, schizoaffective disorder, and constipation. The resident was discharged to another long-term care facility without a complete discharge summary. The summary lacked critical information such as the resident's admission date, reason for admission, reason for discharge, treatment provided, progress in the facility, nutritional information, and therapy services. Interviews with the facility's Administrator and Director of Nursing (DON) revealed that the resident had a behavior agreement due to non-compliance with facility and CDC recommendations, which included not leaving the facility without supervision. The resident was discharged for smoking marijuana in the facility, but there was no documentation of a discharge notice being provided to the resident. The facility's discharge policy requires a detailed summary of the resident's stay, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ivy Woods Healthcare Center. | 0.8 mi | ★★★★★ | 10 | 0 |
| Edith Lane Of Cincinnati | 1 mi | ★★★★★ | 4 | 0 |
| Aventura At West Park | 1.5 mi | ★★★★★ | 5 | 0 |
| Clifton Healthcare Center | 2.4 mi | ★★★★★ | 13 | 0 |
| Terrace View Gardens | 2.5 mi | ★★★★★ | 6 | 0 |
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