Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 2 | 0 |
| Clifton Healthcare Center | 2.4 mi | — | 1 | 0 |
| Terrace View Gardens | 2.5 mi | — | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.