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 8 of 8 citations

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

    Address subsistence needs for staff and patients.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0015, 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).

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

    Establish policies and procedures for sheltering.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0022, 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).

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

    Establish policies and procedures for medical documentation.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0023, 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

    Establish staff and initial training requirements.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0037, Emergency Preparedness Deficiencies. Inspection of July 28, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 12, 2022).

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

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of July 28, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 12, 2022).

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

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of July 28, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 12, 2022).

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

    Have generator or other power source capable of supplying service within 10 seconds.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of July 28, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 12, 2022).

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

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

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

    Fire safety citation K-0374, Smoke Deficiencies. Inspection of July 28, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 12, 2022).

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.