Harrison Pavilion Care Center: Skin Care Failures - OH
A federal complaint inspection completed November 26, 2025 at Harrison Pavilion Care Center on Harrison Avenue found that staff were not conducting skin assessments at pressure points when they repositioned residents, a lapse that investigators classified as causing actual harm. The deficiency was investigated under Complaint Number 2622250.
The citation, tagged F0686, identified the sacrum, ischial tuberosity, greater trochanters, and heels as the specific sites that went unchecked. These are the bones closest to the skin's surface, the places where tissue breaks down first when a person lies in one position too long. Repositioning is the intervention. The skin check is how you know whether the intervention is working.
Nobody was looking.
The inspection report does not say how many residents were affected, only that it was a few. It does not name them. It does not describe what their skin looked like when inspectors arrived, or what it had looked like in the days before. What it says is that each repositioning event was an opportunity, and that the opportunity was not used.
Pressure injuries, which develop when sustained weight cuts off blood flow to tissue over a bony prominence, can progress from redness that doesn't fade to open wounds that reach bone. The sacrum, the flat triangular bone at the base of the spine, is among the most common sites. A resident who spends significant time in bed, who cannot reposition themselves, who depends entirely on staff to move them and to notice what is happening to their skin, has no margin for that check to be skipped.
The inspection was triggered by a complaint, not a routine survey. Someone reported a problem at this facility. Inspectors came and found one.
Harrison Pavilion Care Center sits at 2171 Harrison Avenue in the West Price Hill neighborhood of Cincinnati. The facility's provider identification number is 365065. The inspection was completed in late November 2025, and the report was printed in April 2026.
The plan of correction, if one has been submitted, is not included in the publicly available inspection document. The report directs anyone seeking that information to contact the facility or the state survey agency directly.
What the record shows is a finding of actual harm, not potential harm, not a paperwork deficiency, not a failure to document a process that was otherwise happening correctly. Actual harm means inspectors determined that residents were hurt, or that the conditions created by this failure were serious enough to constitute injury in themselves.
The residents affected were among the most vulnerable people in the building: those who needed to be repositioned at all, those whose skin could not tolerate being left in place, those who depended on a staff member pausing, looking, and noticing. The inspection report does not say whether any of them developed wounds. It does not say whether wounds that already existed got worse. It says the checks were not happening, and it says that caused actual harm.
That is where the public record ends.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harrison Pavilion Care Center from 2025-11-26 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: August 22, 2026 · Our methodology
HARRISON PAVILION CARE CENTER in CINCINNATI, OH was cited for violations during a health inspection on November 26, 2025.
The deficiency was investigated under Complaint Number 2622250.
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.