Harrison Pavilion Care Center

Federal health inspectors cited HARRISON PAVILION CARE CENTER in CINCINNATI, OH for a deficiency under regulatory tag F-F0644 during a standard health inspection conducted on 2025-09-11.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of HARRISON PAVILION CARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-20.

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on medical record review, resident interview, and staff interview, the facility failed to ensure residents received timely treatment for respiratory infections. This affected one (Resident #7) of seven residents sampled for respiratory infections. The facility census was 79 residents. Findings include: Review of the medical record for Resident #7 revealed an admission date of 08/03/18 with a diagnosis of major depressive disorder Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 06/18/25 revealed the resident had moderately impaired cognition. Review of the progress note for Resident #7 dated 09/03/25 revealed the nurse practitioner (NP) assessed Resident #7 for complaints of complaint of cough for several days. Lung auscultation revealed concerns for wheezes bilaterally. The NP gave orders for

a stat (immediate) chest x-ray and Tylenol cold & flu medication. Review of the physician's orders for Resident #7 revealed an order dated 09/03/25 for a stat chest x-ray. There was no written order for Tylenol cold and flu medication. Interview on 09/08/25 at 11:34 A.M. with Resident #7 confirmed he had for medicine for flu and had been having symptoms for a week or two including a cough and a runny nose.

Interview on 09/10/25 at 10:00 A.M. NP #492 confirmed she had assessed Resident #7 on 09/03/25 and gave a verbal order to the nurse to implement the standing order for Tylenol cold and flu medication and to give a dose immediately. NP #492 stated she was unaware the order had not been placed and verified the Tylenol cold and flu medication was not on Resident #7's profile.This deficiency represents noncompliance investigated under Complaint Number OH00162888 (iQIES 1311544)

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harrison Pavilion Care Center

2171 Harrison Avenue Cincinnati, OH 45211

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to complete root cause analysis following resident falls. This affected one (Resident #39) of three residents reviewed for falls. The facility census was 79 residents.Findings include:Review of the medical record for Resident #39 revealed an admission date of 06/17/24 with diagnoses including Parkinson's disease, type two diabetes, depression, generalized anxiety disorder, and unspecified dementia. Review of care plan for Resident #39 dated 06/18/24 revealed the resident was at risk for falls. Interventions included anticipating resident needs, keeping the call light within reach, maintaining a safe environment, and educating the resident regarding appropriate footwear, using call light for assistance, and safe use of mobility devices.

Review of the progress note for #39 dated 02/24/25 revealed the resident had an unwitnessed fall in her room. Staff found Resident #39 seated on the floor in front of her walker. Resident #39 stated she hit her head during the fall. Review of the facility incident report and investigation of Resident #39's fall on 02/24/25 revealed it did not include a root cause analysis of the events and factors leading to the resident's fall.

Review of the Minimum Data Set (MDS) assessment for Resident #39 dated 06/24/25 revealed the resident was cognitively intact, had no behaviors, did not wander, and did not reject care. Interview on 09/11/25 at 10:00 A.M. with the Director of Nursing (DON) confirmed the facility did not complete a root cause analysis of Resident #39's fall on 02/24/25. The DON confirmed part of the facility's fall investigation process should include a root cause analysis. Review of the facility policy titled Managing Falls and Fall Risk dated December 2007 revealed the facility evaluated falls and identified interventions related to the resident's specific risks and causes to try to prevent the resident from falling. This deficiency represents noncompliance investigated under Complaint Number OH00162646 (1311543).

Event ID:

Facility ID:

If continuation sheet

Federal health inspectors cited HARRISON PAVILION CARE CENTER in CINCINNATI, OH for a deficiency under regulatory tag F-F0759 during a standard health inspection conducted on 2025-09-11.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure medication error rates are not 5 percent or greater.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of HARRISON PAVILION CARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-20.

Federal health inspectors cited HARRISON PAVILION CARE CENTER in CINCINNATI, OH for a deficiency under regulatory tag F-F0760 during a standard health inspection conducted on 2025-09-11.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure that residents are free from significant medication errors.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of HARRISON PAVILION CARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-20.

Federal health inspectors cited HARRISON PAVILION CARE CENTER in CINCINNATI, OH for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-09-11.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of HARRISON PAVILION CARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-20.

Federal health inspectors cited HARRISON PAVILION CARE CENTER in CINCINNATI, OH for a deficiency under regulatory tag F-F0804 during a standard health inspection conducted on 2025-09-11.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of HARRISON PAVILION CARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-20.

Federal health inspectors cited HARRISON PAVILION CARE CENTER in CINCINNATI, OH for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-09-11.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of HARRISON PAVILION CARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-20.

Federal health inspectors cited HARRISON PAVILION CARE CENTER in CINCINNATI, OH for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-09-11.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of HARRISON PAVILION CARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-20.