Harrison Pavilion: Failed Fall Investigation - OH
The February 24 incident involved a woman who had lived at the facility since June 2024. Staff found her seated on the floor in front of her walker after an unwitnessed fall. She told them she had hit her head during the fall.
The facility's incident report documented what happened but failed to include a root cause analysis examining the events and factors that led to the fall. This violated the nursing home's own policy, which requires evaluating falls and identifying interventions related to specific risks and causes.
The resident's care plan from June 2024 had already identified her as being at risk for falls. Her diagnoses included Parkinson's disease, type two diabetes, depression, generalized anxiety disorder, and unspecified dementia. The plan outlined standard fall prevention measures: anticipating her needs, keeping the call light within reach, maintaining a safe environment, and educating her about appropriate footwear, using the call light for assistance, and safe use of mobility devices.
Despite these precautions, she fell.
A June assessment showed the resident was cognitively intact, displayed no problematic behaviors, did not wander, and did not reject care. This made the incomplete investigation more significant since facility staff had clear cognitive access to the resident who could have provided details about what happened.
The Director of Nursing confirmed during a September 11 interview that the facility had not completed a root cause analysis of the February fall. She acknowledged that such analysis should be part of the facility's fall investigation process.
The nursing home's policy, titled "Managing Falls and Fall Risk" and dating to December 2007, specifically states that the facility evaluates falls and identifies interventions related to residents' specific risks and causes to prevent future falls. The policy exists precisely for situations like this one, where understanding why someone fell could prevent the next incident.
Root cause analysis serves as a systematic approach to identifying underlying factors that contribute to adverse events. For a resident with Parkinson's disease, such analysis might examine medication timing, environmental hazards, mobility device effectiveness, or changes in the resident's condition. Without this investigation, the facility missed the opportunity to identify specific interventions that might prevent her from falling again.
The February fall represented exactly the kind of incident that demands thorough investigation. An unwitnessed fall by a resident with multiple risk factors, resulting in a head injury, should trigger the facility's most comprehensive review process. The resident's ability to communicate what happened made the investigation failure more glaring.
State inspectors reviewed three residents' falls during their complaint investigation. Only one resident's fall lacked the required root cause analysis, but that single failure violated federal standards requiring nursing homes to maintain accident-free environments and provide adequate supervision to prevent accidents.
The facility housed 79 residents at the time of the September inspection. Each resident depends on the facility's commitment to learning from incidents and preventing future harm. When nursing homes skip required investigations, they lose crucial opportunities to identify patterns and implement targeted interventions.
Harrison Pavilion's policy recognizes this principle. Written in 2007, it commits the facility to evaluating falls and identifying specific interventions based on individual risk factors and causes. The policy exists because falls represent a leading cause of injury and death among nursing home residents, particularly those with conditions like Parkinson's disease that affect balance and mobility.
The resident who fell in February deserved more than an incident report that documented what happened. She deserved a thorough investigation that examined why it happened and what could prevent it from happening again. The facility's failure to complete this analysis left her vulnerable to future falls and demonstrated a gap between written policy and actual practice.
Federal regulations require nursing homes to ensure their environments remain free from accident hazards and provide adequate supervision to prevent accidents. Root cause analysis represents a fundamental tool for meeting this standard. When facilities skip these investigations, they abandon one of their most important methods for protecting residents.
The violation affected one resident directly but potentially compromised safety for all 79 residents at Harrison Pavilion. A facility that fails to investigate one fall thoroughly may fail to investigate others, creating a pattern of missed opportunities to enhance resident safety and prevent future injuries.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harrison Pavilion Care Center from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
HARRISON PAVILION CARE CENTER in CINCINNATI, OH was cited for violations during a health inspection on September 11, 2025.
The February 24 incident involved a woman who had lived at the facility since June 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.