All citations for Pavilion Health Center at Brightmore
State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.
Last standard health inspection on record
July 3, 2025
Showing 1 to 24 of 24 citations
Immediate jeopardy to resident health or safety
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
The home gave a date the problem would be corrected (April 18, 2024).
Immediate jeopardy to resident health or safety
Ensure that residents are free from significant medication errors.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Ensure each resident receives an accurate assessment.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Provide activities to meet all resident's needs.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Have generator or other power source capable of supplying service within 10 seconds.
The home gave a date the problem would be corrected (July 19, 2024).
No harm, with potential for more than minimal harm
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Protect each resident from the wrongful use of the resident's belongings or money.
Past non-compliance: already corrected by the time of the inspection (January 6, 2024).
No harm, with potential for more than minimal harm
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Ensure services provided by the nursing facility meet professional standards of quality.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Provide enough food/fluids to maintain a resident's health.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Make sure that a working call system is available in each resident's bathroom and bathing area.
The home gave a date the problem would be corrected (April 18, 2024).
No harm, with potential for more than minimal harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
The home gave a date the problem would be corrected (July 19, 2024).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
The home gave a date the problem would be corrected (July 19, 2024).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
The home gave a date the problem would be corrected (July 19, 2024).
No harm, with potential for more than minimal harm
Have an externally vented heating system.
The home gave a date the problem would be corrected (July 19, 2024).
No harm, with potential for minimal harm
Post nurse staffing information every day.
The home has a plan to correct it (April 16, 2024).
Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.