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.
Last standard health inspection on record
August 27, 2025
Showing 1 to 20 of 20 citations
Harm to a resident
Provide safe, appropriate pain management for a resident who requires such services.
The home gave a date the problem would be corrected (October 23, 2023).
No harm, with potential for more than minimal harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
The home gave a date the problem would be corrected (October 23, 2023).
No harm, with potential for more than minimal harm
Address subsistence needs for staff and patients.
The home gave a date the problem would be corrected (November 3, 2023).
No harm, with potential for more than minimal harm
Establish policies and procedures for sheltering.
The home gave a date the problem would be corrected (November 3, 2023).
No harm, with potential for more than minimal harm
Establish policies and procedures for medical documentation.
The home gave a date the problem would be corrected (November 3, 2023).
No harm, with potential for more than minimal harm
Establish staff and initial training requirements.
The home gave a date the problem would be corrected (September 12, 2022).
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 (September 12, 2022).
No harm, with potential for more than minimal harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
The home gave a date the problem would be corrected (September 12, 2022).
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 (September 12, 2022).
No harm, with potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
The home gave a date the problem would be corrected (October 23, 2023).
No harm, with potential for more than minimal harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
The home gave a date the problem would be corrected (September 12, 2022).
No harm, with potential for more than minimal harm
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
The home gave a date the problem would be corrected (July 5, 2024).
No harm, with potential for more than minimal harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
The home gave a date the problem would be corrected (October 23, 2023).
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 (October 23, 2023).
No harm, with potential for more than minimal harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
The home gave a date the problem would be corrected (October 23, 2023).
No harm, with potential for more than minimal harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
The home gave a date the problem would be corrected (October 23, 2023).
No harm, with potential for more than minimal harm
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
The home gave a date the problem would be corrected (October 23, 2023).
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.
The home gave a date the problem would be corrected (November 3, 2023).
No harm, with potential for more than minimal harm
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.
The home gave a date the problem would be corrected (October 23, 2023).
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 (October 23, 2023).
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.