ElderGrade

Inspection citations at Care Pavilion Nursing And Rehabilitation Center

96 citations on record, 5 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 3 0
2025 60 2
2024 22 1
2023 11 2
D May 14, 2026 Tag F0804 Complaint investigation

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

E May 4, 2026 Tag F0684 Complaint investigation

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

E April 8, 2026 Tag F0925 Complaint investigation Corrected May 2026

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0940 Corrected Jan 2026

Administration Deficiencies

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0924 Corrected Jan 2026

Environmental Deficiencies

Put firmly secured handrails on each side of hallways.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0908 Corrected Jan 2026

Environmental Deficiencies

Keep all essential equipment working safely.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0880 Corrected Jan 2026

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0849 Complaint investigation Corrected Jan 2026

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0814 Corrected Jan 2026

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0791 Corrected Jan 2026

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0755 Corrected Jan 2026

Pharmacy Service Deficiencies

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

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0726 Corrected Jan 2026

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0695 Corrected Jan 2026

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0694 Corrected Jan 2026

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0693 Corrected Jan 2026

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0689 Complaint investigation Corrected Jan 2026

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0688 Corrected Jan 2026

Quality of Life and Care Deficiencies

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.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0657 Complaint investigation Corrected Jan 2026

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0655 Corrected Jan 2026

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0645 Corrected Jan 2026

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0641 Complaint investigation Corrected Jan 2026

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0628 Corrected Jan 2026

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0606 Corrected Jan 2026

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0576 Corrected Jan 2026

Resident Rights Deficiencies

Ensure residents have reasonable access to and privacy in their use of communication methods.

No actual harm, potential for more than minimal harm

D December 22, 2025 Tag F0561 Corrected Jan 2026

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

No actual harm, potential for more than minimal harm

E December 22, 2025 Tag F0921 Complaint investigation Corrected Jan 2026

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

No actual harm, potential for more than minimal harm

E December 22, 2025 Tag F0883 Corrected Jan 2026

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

No actual harm, potential for more than minimal harm

E December 22, 2025 Tag F0804 Corrected Jan 2026

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

E December 22, 2025 Tag F0692 Corrected Jan 2026

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

F December 22, 2025 Tag F0812 Corrected Jan 2026

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

E November 13, 2025 Tag F0842 Complaint investigation Corrected Dec 2025

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D September 11, 2025 Tag F0656 Complaint investigation Corrected Oct 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

G September 11, 2025 Tag F0689 Complaint investigation Corrected Sep 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

E June 26, 2025 Tag F0925 Complaint investigation Corrected Jul 2025

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

No actual harm, potential for more than minimal harm

D June 11, 2025 Tag F0726 Complaint investigation Corrected Jul 2025

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

No actual harm, potential for more than minimal harm

D May 29, 2025 Tag F0880 Complaint investigation Corrected Jul 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D May 29, 2025 Tag F0689 Complaint investigation Corrected Jul 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D May 29, 2025 Tag F0684 Complaint investigation Corrected Jul 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D April 23, 2025 Tag F0919 Complaint investigation Corrected May 2025

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

No actual harm, potential for more than minimal harm

D April 23, 2025 Tag F0609 Complaint investigation Corrected May 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.