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.

Back to Pavilion Health Center at Brightmore

Last standard health inspection on record

July 3, 2025

Showing 1 to 19 of 19 citations

  1. 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.

    Isolated (one or a few residents). CMS level J.

    Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of March 26, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  2. Immediate jeopardy to resident health or safety

    Ensure that residents are free from significant medication errors.

    Isolated (one or a few residents). CMS level J.

    Health citation F-0760, Pharmacy Service Deficiencies. Inspection of March 26, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  3. No harm, with potential for more than minimal harm

    Ensure each resident receives an accurate assessment.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0641, Resident Assessment and Care Planning Deficiencies. Inspection of March 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  4. No harm, with potential for more than minimal harm

    Provide activities to meet all resident's needs.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0679, Quality of Life and Care Deficiencies. Inspection of March 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  5. 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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0867, Administration Deficiencies. Inspection of March 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  6. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of March 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  7. 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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0557, Resident Rights Deficiencies. Inspection of March 26, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  8. 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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of March 26, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  9. No harm, with potential for more than minimal harm

    Protect each resident from the wrongful use of the resident's belongings or money.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0602, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of March 26, 2024. Found during a standard inspection and a complaint inspection.

    Past non-compliance: already corrected by the time of the inspection (January 6, 2024).

  10. 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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0604, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of March 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  11. 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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of March 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  12. 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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of March 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  13. No harm, with potential for more than minimal harm

    Ensure services provided by the nursing facility meet professional standards of quality.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0658, Resident Assessment and Care Planning Deficiencies. Inspection of March 26, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  14. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of March 26, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  15. 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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0688, Quality of Life and Care Deficiencies. Inspection of March 26, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  16. No harm, with potential for more than minimal harm

    Provide enough food/fluids to maintain a resident's health.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0692, Quality of Life and Care Deficiencies. Inspection of March 26, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  17. 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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0842, Resident Assessment and Care Planning Deficiencies. Inspection of March 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  18. 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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0919, Environmental Deficiencies. Inspection of March 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 18, 2024).

  19. No harm, with potential for minimal harm

    Post nurse staffing information every day.

    Widespread (many residents). CMS level C.

    Health citation F-0732, Nursing and Physician Services Deficiencies. Inspection of March 26, 2024. Found during a standard inspection.

    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.