All citations for Pavilion on Main Street, the

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 on Main Street, the

Last standard health inspection on record

August 27, 2025

Showing 1 to 12 of 12 citations

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

    Provide and implement an infection prevention and control program.

    Widespread (many residents). CMS level F.

    Health citation F-0880, Infection Control Deficiencies. Inspection of July 23, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 5, 2025).

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

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

    Widespread (many residents). CMS level F.

    Health citation F-0882, Infection Control Deficiencies. Inspection of July 23, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 5, 2025).

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

    Establish roles under a Waiver declared by secretary.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0026, Emergency Preparedness Deficiencies. Inspection of September 28, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 3, 2023).

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

    Implement emergency and standby power systems.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0041, Emergency Preparedness Deficiencies. Inspection of September 28, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 3, 2023).

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

    Have simulated fire drills held at unexpected times.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of September 28, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 3, 2023).

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

    Have a battery powered remote alarm panel in a location accessible by operating personnel.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0916, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of September 28, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 22, 2023).

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

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

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

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of October 30, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 11, 2024).

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

    Install an approved automatic sprinkler system.

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

    Fire safety citation K-0351, Smoke Deficiencies. Inspection of September 28, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 3, 2023).

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

    Install corridor and hallway doors that block smoke.

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

    Fire safety citation K-0363, Smoke Deficiencies. Inspection of September 28, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 3, 2023).

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

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

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

    Fire safety citation K-0741, Miscellaneous Deficiencies. Inspection of September 28, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 3, 2023).

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

    Ensure proper usage of power strips and extension cords.

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

    Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of September 28, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 3, 2023).

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

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

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

    Health citation F-0755, Pharmacy Service Deficiencies. Inspection of October 30, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 11, 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.