Harrison Pavilion Care Center: Medication Errors - OH
The citation, issued September 11, 2025, fell under pharmacy service deficiencies. The specific finding: the facility had failed to keep its medication error rate below five percent. Inspectors documented no actual harm to residents, but noted the potential for more than minimal harm was real.
That distinction matters. A medication error rate above five percent does not mean something has already gone wrong in a way that showed up in a chart or a complaint. It means the conditions for something going wrong are already in place, repeated often enough to clear a threshold that regulators set precisely because patterns of error, not isolated mistakes, are what tend to eventually hurt people.
Nine deficiencies in a single inspection is not a minor outcome. Complaint inspections are not routine sweeps. They are triggered. Someone, whether a resident, a family member, or a staff member, contacted regulators with a concern serious enough to send inspectors through the door. What they found when they arrived included the medication error problem alongside eight other cited failures.
The facility reported a correction date of October 20, 2025, roughly five weeks after the inspection. Whether the underlying conditions that produced an error rate above the federal threshold have actually been addressed is a question the correction date alone cannot answer.
Medication errors in nursing homes take many forms. A resident receives the wrong drug. A dose is given at the wrong time, or skipped entirely. A medication meant for one person reaches another. Some errors are caught before they cause harm. Some are not. The five percent threshold exists because research on medication safety in long-term care has consistently shown that facilities operating above it are facilities where the systems meant to prevent errors, the checks, the documentation, the handoffs between staff, have broken down in ways that are not incidental.
Harrison Pavilion is not the first Cincinnati-area nursing home to receive this citation, and the deficiency itself is not rare nationally. But the context here, a complaint inspection, nine total deficiencies, a pharmacy citation that acknowledges potential for harm, adds up to a picture of a facility that was not running cleanly when regulators arrived.
The residents living at Harrison Pavilion when inspectors came through on September 11 were people who depend on staff to manage their medications correctly, often because they cannot do it themselves. Many nursing home residents take multiple drugs daily for conditions including heart disease, diabetes, pain, and psychiatric illness. The margin for error in that environment is not wide.
A correction date of October 20 means the facility told regulators it had fixed the problem within five weeks. Regulators will verify that claim. What they will be looking for is not just a policy update or a staff meeting, but evidence that the error rate itself has come down, that whatever was producing errors above the five percent line has been identified and stopped.
What produced that rate at Harrison Pavilion, whether it was staffing, documentation failures, a breakdown in the pharmacy delivery process, or something else entirely, is not detailed in the inspection record. The citation names the outcome. It does not name the cause.
That gap is where families of residents tend to get stuck. The inspection report tells them something was wrong with how medications were being handled. It does not tell them which medications, which residents, which shifts, or how long the problem had been building before an inspector walked in and measured it.
For the residents at Harrison Pavilion, the inspection is already history. The correction date has passed. They are still there, still relying on the same staff, the same systems, the same facility to get their medications right every day.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
HARRISON PAVILION CARE CENTER in CINCINNATI, OH was cited for violations during a health inspection on September 11, 2025.
The citation, issued September 11, 2025, fell under pharmacy service deficiencies.
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.