Health inspection·November 26, 2025

F 0580 transfer the resident to a hospital/treatment center.This deficiency represents non-compliance investigated under Complaint Number 2622250. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 2 of 8 Printed: 05/15/2026 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interviews, policy review, and review of the guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to adequately assess Resident #09's skin, failed to timely identify the resident's pressure ulcer (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), until it had reached an advanced stage and failed to timely implement provider ordered interventions to prevent the development of pressure ulcers and/or aid in the healing of existing pressure ulcers. This resulted in Actual Harm to Resident #09, who was admitted without pressure ulcers but was at risk for the development of pressures and subsequently developed an avoidable, facility acquired pressure ulcer. Resident #09 was assessed by Wound Nurse Practitioner (WNP) #60 on 11/04/25 and treatment orders were recommended but not implemented until 11/11/25. On 11/10/25, Resident #09 had red areas to both buttocks with bleeding. Resident #09 was assessed on 11/13/25 by WNP #60 with two pressure ulcers, one of which was first identified as a stage III pressure ulcer (full-thickness skin loss in which adipose [fat] is visible) to the resident's sacrum and a stage II pressure ulcer (partial thickness loss of skin with exposed dermis) to the residents left buttock. This affected one (Resident #09) of three residents reviewed for pressure ulcers. The facility census was 78.Findings include: Review of the medical record of Resident #09 revealed an admission date of 10/20/25. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included cellulitis, stage III pressure ulcer to sacrum, atrial fibrillation, and hemiparesis and hemiplegia to right dominant side. Review of the admission care plan initiated on 10/21/25, revealed Resident #09 was at risk for altered skin integrity and pressure ulcers related to bowel and bladder incontinence, limited mobility, decreased ADL self-performance, medical diagnoses, and overall medical conditions. Interventions included a pressure reduction device to bed (low air loss mattress with bolsters). Review of the Braden Scale for Predicting Pressure Sore Risk dated 10/21/25, revealed Resident #09 was at high risk for developing pressure ulcers.Review of the physician order dated 10/21/25, revealed Resident #09 was ordered to receive house barrier cream applied to peri-area buttocks after each incontinent episode and as needed (PRN) to prevent skin breakdown.Review of the progress note dated 11/04/25 at 2:38 P.M. and authored by Wound Nurse Practitioner (WNP) #60, revealed Resident #09 returned from the hospital and had incontinent associated dermatitis to the right buttock that measured 3.0 centimeters (cm) in length by 2.0 cm in width by 0.1 cm in depth. Treatment orders were to cleanse area with normal saline, apply Venelex (topical cream to promote the healing of skin ulcers and wounds) to base of the wound, leave open to air every shift and as needed and provide turning and repositioning per protocol for pressure prevention. Review of November 2025 Treatment Administration Record (TAR) for Resident #09 from 11/04/25 through 11/10/25, revealed no documented treatments per WNP #60's treatment orders on 11/04/25. Review of the Five-Day Medicare Minimum Data Set (MDS) assessment for Resident #09 dated 11/07/25, revealed the resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 99. This resident was dependent on staff for activities of daily living (ADL). Section M (skin conditions) revealed the resident did not have a pressure ulcer but was at risk.Review of the skilled nurse's note dated 11/09/25, revealed Resident #09's skin appearance was within normal limits with no new changes to skin integrity. Review of the progress note dated 11/10/25 at 7:52 A.M., revealed the staff noted red areas to Resident #09's bilateral buttocks with minimal bleeding. Resident #09 made groaning and moaning noises when the area was cleaned. Resident #09's sister and other parties were notified. Review of the Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 3 of 8 Printed: 05/15/2026 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few physician order dated 11/11/25, revealed Resident #09 was ordered to have his right buttocks cleansed with normal saline, Venelex applied, and leave open to air every shift. This order was originally supposed to be implemented on 11/04/25 per WNP #60's treatment orders. Review of the progress note dated 11/13/25 at 9:39 A.M. and authored by WNP #60, revealed Resident #09 had the following skin concerns: right buttock had incontinence associated dermatitis which measured 5.5 cm in length by 4.0 cm in width by 0.2 cm in depth with 80 percent (%) granulation (new tissues) and 20 % slough (peeling skin), sacrum had a stage III pressure ulcer which measured 3.0 cm in length by 1.5 cm in width by 0.3 cm in depth with 90 % granulation and 10 % slough, and left buttock had a stage II pressure ulcer which measured 2.5 cm in length by 3.5 centimeters in width by 0.1 cm in depth with 100% epithelial tissue. New treatment orders were recommended including a low air loss (LAL) mattress. Review of the physician order dated 11/13/25, revealed Resident #09 was ordered the following: Left buttock cleansed with normal saline, skin prep to peri-wound hydrogel, and covered with border foam daily, sacrum cleansed with normal saline, skin prep to peri-wound, hydrogel and covered with border foam daily and right buttock cleansed with normal saline, skin prep to peri-wound, hydrogel, and covered with border foam daily.Review of the revised care plan dated 11/14/25, revealed Resident #09 had an actual impairment to skin integrity related to stage II pressure ulcer to left buttock and a stage III pressure ulcer to sacrum. Interventions included administering medications as ordered, administering treatments as ordered, encouraging good nutrition, inspecting the skin on a daily basis when performing and assisting with personal care, and monitoring and documenting location, size, and treatments.Review of the physician order dated 11/20/25, revealed Resident #09 was ordered to be turned and repositioned every two hours and to have a LAL mattress, which was supposed to be implemented on 11/13/25 per WNP #60's treatment orders. During an interview on 11/26/25 at 7:58 A.M., WNP #60 stated she saw the resident on 11/04/25 after he returned from the hospital and he had incontinence associated dermatitis to the right buttock. WNP #60 reported she saw the resident again on 11/13/25 and he had developed a stage III pressure ulcer to his sacrum and a stage II pressure ulcer to the left buttock. WNP #60 stated Resident #09 was dependent on staff for ADLs including turning and repositioning. WNP #60 verified his wounds were avoidable with proper treatments, turning, repositioning and timely incontinence care. Observation on 11/26/25 at 10:05 A.M., revealed Resident #09's wound bed was about a half dollar in size with no signs of infection or drainage noted.During an interview on 11/26/25 at 11:53 A.M., Licensed Practical Nurse (LPN) Unit Manager #29 verified Resident #09's treatment orders were not implemented timely. LPN Unit Manager #29 stated when WNP #60 rounds, it was the responsibility of the nursing staff to enter the orders. LPN Unit Manager #29 reported the nurses should be thoroughly and accurately assessing residents' skin and documenting areas in the medical record.Interview on 11/26/25 at 11:58 A.M., the Director of Nursing (DON) verified Resident #09 was dependent on staff for ADLs and went from having no pressure ulcers to the development of stage II pressure ulcer on the left buttock and a stage III pressure ulcer to the sacrum which were first identified on 11/13/25.Review of the NPUAP guidelines dated 2014 pages 70-71 at (https://npiap.com/general/custom.asp?page=2014Guidelines), revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominence. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 4 of 8 Printed: 05/15/2026 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 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 0686 Level of Harm - Actual harm prominences including the sacrum, ischial tuberosity, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment.This deficiency represents non-compliance investigated under Complaint Number 2622250. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 5 of 8 Printed: 05/15/2026 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, review of pharmacy records, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #45) of three resident reviewed for medication administration. The facility census was 78.Findings include:Review of the medical record for Resident #45 revealed an admission date of 03/19/24. Diagnoses included hyperosmolality and hypernatremia, major depressive disorder, and pressure ulcer of the sacral region.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #45 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. Review of the physician order dated 11/11/25, revealed Resident #45 was ordered Meropenem (antibiotic) Intravenous (IV) Solution Reconstituted one gram (gm), use one gram intravenously every eight hours for infected sacral wound for 14 days.Review of the Pharmacy Delivery Receipt dated 11/11/25, revealed Resident #45 received 24 bags (an 8-day supply) of Meropenem IV solution.Review of the November 2025 medication administration record (MAR), revealed Resident #45 did not receive IV Meropenem IV solution on 11/14/25 at 9:00 P.M., 11/15/25 at 5:00 A.M., 1:00 P.M., and 9:00 P.M., 11/16/25 at 5:00 A.M., 1:00 P.M., and 9:00 P.M., and 11/17/25 at 5:00 A.M.Review of the pharmacy progress note dated 11/15/25 at 4:55 A.M., revealed Resident #45 did not receive Meropenem IV solution because the medication was on order.Review of the pharmacy progress note dated 11/15/25 at 11:09 P.M., revealed Resident #45 did not receive Meropenem IV solution because the medication was on order. Review of the pharmacy progress note dated 11/16/25 at 5:11 A.M., revealed Resident #45 did not receive Meropenem IV solution because the medication was on order. Review of the pharmacy progress note dated 11/16/25 at 4:15 P.M., revealed Resident #45 did not receive Meropenem IV solution because the medication was on order. Review of the pharmacy progress note dated 11/16/25 at 8:41 P.M., revealed Resident #45 did not receive Meropenem IV solution because medication on order at pharmacy.Review of the pharmacy progress note dated 11/17/25 at 4:52 A.M., revealed Resident #45 did not receive Meropenem IV solution because the medication was on order. Review pf the pharmacy delivery receipt dated 11/18/25, revealed Resident #45 received 21 bags (a seven-day supply) of Meropenem IV solution.During an interview on 11/26/25 at 8:07 A.M., Pharmacy Representative (PR) #100, stated an order was submitted on 11/11/25 for Meropenem IV solution. PR #100 reported a seven-day supply (24 bags) was sent on 11/11/25. PR #100 also reported a seven-day supply (21 bags) was sent on 11/18/25.During an interview on 11/26/25 at 9:27 A.M., the Director of Nursing (DON) verified Resident #45 missed doses of Meropenem on 11/14/25, 11/15/25, 11/16/25, and 11/17/25.During an interview on 11/26/25 at 1:05 P.M., the DON stated Resident #45 was not given IV Meropenem on the above days because an agency nurse was working and didn't ask where the IV medications were stored.Review of the facility policy titled, Administering Medications, revised April 2019, revealed medications were administered in a safe and timely manner, and as prescribed. Medications were administered within one hour of their prescribed time, unless otherwise specified.This deficiency represents non-compliance investigated under Complaint Number 2639823. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 6 of 8 Printed: 05/15/2026 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy review, the facility failed to ensure dishware was clean prior to serving pureed meal service. This affected one (Resident #11) of one resident who the facility identified as receiving pureed diets. The facility census was 78.Findings include:Record of the medical record for Resident #11 revealed an admission date of 05/06/24. Diagnoses included dysphagia, epilepsy, mood disorder, and hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of three. Review of the physician order dated 11/21/25, revealed Resident #11 was ordered a regular diet, pureed texture, regular thin consistency.Observation on 11/25/25 at 11:46 A.M., revealed [NAME] #110 obtained a divided plate, which had food particles from previous meal on plate. [NAME] #110 went to sink and rinsed with water and then placed pureed pasta onto that divided plate.During an interview on 11/25/25 at 11:50 A.M. [NAME] #110 verified the divided plate was not clean and had food on it from previous meal. [NAME] #110 verified she rinsed off the plate with water and placed pureed pasta and placed onto lunch tray to be served.Review of the facility policy titled, Food Preparation and Service, revised October 2017 revealed food and nutrition services employees shall prepare and serve food in a manner that complied with safe food handling practices. Areas for cleaning dishes and utensils were located in a separate area from the food service line to ensure that a sanitary environment was maintained. Event ID: Facility ID: 365065 If continuation sheet Page 7 of 8 Printed: 05/15/2026 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interviews, and policy review, the facility failed to ensure infection control measures were implemented during wound care. This affected one (Resident #09) of three residents reviewed for wound care. The facility census was 78.Findings include:Review of the medical record of Resident #09 revealed an admission date of 10/20/25. Diagnoses included cellulitis, stage three pressure ulcer to sacrum, atrial fibrillation, and hemiparesis and hemiplegia to right dominant side.Review of the Five-Day Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #09 had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 99. This resident was assessed to require dependent with toileting, bathing, dressing, and transfers.Review of the physician order dated 11/20/25, revealed Resident #09 was ordered to have right buttocks cleansed with normal saline, skin prep to peri-wound, and covered with border foam one time a day for wound care.During an observation of wound care for Resident #09 on 11/26/25 at 10:05 A.M., by Licensed Practical Nurse (LPN) #23 with the assistance of Certified Nursing Assistant (CNA) #13, revealed LPN #23 did not remove her soiled gloves and perform hand hygiene after removing the old dressing from Resident #09. LPN #23 wore the same gloves for the entirety of the dressing change.During an interview on 11/26/25 at 10:26 A.M., LPN #23 verified she did not remove her soiled gloves after removing Resident #09's old dressing. LPN #23 verified she should have removed her soiled gloves and performed hand hygiene prior to cleaning and placing a new dressing to Resident #09's wound.Review of the facility policy titled, Wound Care revised October 2010, revealed the purpose was to provide guidelines for the care of wounds to promote healing. Wash and dry hands thoroughly and put on gloves. Loosen tape and remove dressing. Pull gloves over the dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Put on gloves and continue treatment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 8 of 8