Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pavilion-ths, Llc during CMS and state inspections, most recent first.
Failure to Follow Ordered Wound Treatment: An LPN did not follow the current wound care order for a resident with a sacral pressure ulcer, hemiplegia, and severe cognitive impairment. During observed wound care, the LPN applied a nonadherent dressing and border gauze but did not apply the ordered hydrogel to the wound bed. The DON and wound care doctor both confirmed the hydrogel was expected with each dressing change.
Failure to Follow Ordered Oxygen Therapy: A resident with COPD, respiratory failure, and severe cognitive impairment had an order for oxygen at 2 L/min by nasal cannula at all times, but was observed multiple times in the dining room without oxygen and without a portable tank or concentrator present. In the resident’s room, the concentrator was turned off, and later the resident was observed receiving oxygen at 2.5 L/min instead of the ordered 2 L/min. Staff interviews showed conflicting understanding of the order, while the DON confirmed the oxygen was ordered continuous and should have been on.
A resident with ESRD, dementia, CKD, hemodialysis, and a central IV access site was not placed on EBP per facility policy. The facility did not obtain a physician order, the care plan did not include EBP, and repeated observations showed no EBP signage outside the resident’s room. The ICP stated the resident should have been care planned for EBP and should have had signage posted.
The facility failed to include CPR code status in the care plans of 21 residents, despite having POST forms indicating their resuscitation preferences. Additionally, a resident identified as a high fall risk did not have the 'Frequent Flyer Program' intervention applied, as staff were unaware of the resident's fall risk status. Interviews with staff revealed a lack of adherence to care planning policies.
A facility failed to accurately document a resident's advance directive, resulting in a discrepancy between the facility's and hospice's records regarding the resident's code status. The resident, with severe cognitive impairment and multiple health issues, had conflicting POST forms indicating both resuscitation and DNR orders. This inconsistency was confirmed by staff interviews.
A facility failed to obtain a physician's orders for a resident's skin care treatment, specifically for a skin tear on the right elbow. Despite facility policies requiring physician notification and documentation of treatment orders, the care plan lacked interventions for the skin tear, and the physician's order did not address it. Observations showed the resident had a gauze on the elbow, and an LPN confirmed no treatment order was in place. The DON acknowledged the need for a physician's order for such care.
The facility failed to ensure proper storage of bedpans in several resident rooms, as they were found unlabeled and unbagged, contrary to facility policy. This was observed in the bathrooms of multiple residents, including those who were cognitively intact and those with cognitive impairments. The RN/IP Unit Manager and DON confirmed the deficiency, acknowledging that bedpans should be labeled and bagged.
Failure to Follow Ordered Wound Treatment
Penalty
Summary
The facility failed to follow the physician’s order for wound treatment for a resident admitted with hemiplegia, cerebrovascular disease, and a pressure ulcer of the sacral region. The resident’s admission MDS showed a BIMS score of 4, indicating severe cognitive impairment, and the resident required assistance with ADLs and had an unhealed unstageable pressure ulcer present on admission. The care plan identified a sacral deep tissue injury with necrosis and directed staff not to remove or disturb the wound bed, with secondary dressing changes as ordered. The physician’s order dated 6/5/2026 directed staff to apply hydrogel, a non-adherent pad, and a cover dressing to the sacral wound every day shift and as needed. During observation of wound care, an LPN removed the dressing and applied a nonadherent pad and border gauze dressing, but did not apply the hydrogel ordered for the wound bed. The DON stated staff were expected to follow the current order on the TAR and apply hydrogel at every dressing change, and the wound care doctor confirmed that nursing staff were expected to apply hydrogel daily with dressing changes.
Failure to Follow Ordered Oxygen Therapy
Penalty
Summary
The facility failed to follow the physician’s order for oxygen therapy for one resident with COPD, respiratory failure, and anxiety. The resident’s order directed oxygen at 2 L/min by nasal cannula at all times, and the care plan also directed oxygen therapy as ordered. The resident’s MDS showed severe cognitive impairment, bilateral upper extremity impairment, and use of oxygen therapy. Observations showed the resident sitting in the dining room on multiple occasions without oxygen therapy and without a portable oxygen tank or concentrator present. In the resident’s room, the oxygen concentrator was observed turned off, and later the resident was observed receiving oxygen at 2.5 L/min by nasal cannula instead of the ordered 2 L/min. During interviews, an LPN stated the resident’s order was for 2 liters at all times, then acknowledged the flow rate was set at 2.5 L/min and should have been 2 L/min. Another LPN described the order as “2 Liters as tolerated,” while the DON stated the order was 2 liters by nasal cannula, continuous, and confirmed the resident should have been receiving oxygen when observed without it.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure infection control practices to prevent the spread of communicable diseases for one resident reviewed for Enhanced Barrier Precautions (EBP). The resident was admitted with diagnoses including End Stage Renal Disease, Dementia, and Chronic Kidney Disease, had a BIMS score of 10 indicating moderate cognitive impairment, and received hemodialysis with a central IV access site. Physician orders documented dialysis at an outside clinic and monitoring of a Perma-cath site to the right upper chest every shift, but the facility did not obtain a physician order for EBP in accordance with its policy. The resident's care plan dated 6/6/2026 did not include EBP, and observations of the resident's doorway and room on multiple occasions showed no visible EBP signage. During interview, the Infection Control Preventionist stated that residents with outside-to-inside devices and dialysis patients require EBP, that EBP is care planned and a sign is placed outside the room, and that this resident should have been care planned for EBP and should have had signage outside the door. The ICP also stated the resident was not on the master isolation list and that no EBP sign was posted.
Failure to Implement Person-Centered Care Plans and Fall Interventions
Penalty
Summary
The facility failed to implement a person-centered care plan to address the code status for 21 of 24 sampled residents. The facility's policy requires the development and implementation of a comprehensive care plan for each resident, which should include the resident's medical, nursing, and psychosocial needs. However, the care plans for these residents did not include their CPR code status, despite the presence of Physician Orders for Scope of Treatment (POST) forms indicating their preferences for resuscitation and other medical interventions. This omission was noted across multiple residents with varying cognitive impairments and medical conditions, such as dementia, heart disease, and chronic obstructive pulmonary disease. Additionally, the facility failed to implement a fall intervention for one resident reviewed for accidents. The resident, who had a history of falls and was identified as a high fall risk, did not have the designated intervention of the 'Frequent Flyer Program' applied. This program involves placing an airplane symbol on the resident's door to alert staff of the high fall risk and ensure frequent checks and assistance. Despite the care plan indicating this intervention, the symbol was not present on the resident's door, and staff were unaware of the resident's fall risk status. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), revealed a lack of adherence to the facility's policies regarding care planning and resident safety interventions. The MDS Coordinator admitted to not including DNR status in care plans, while the DON acknowledged the importance of having POST forms on the chart but did not ensure their integration into care plans. The oversight in both code status documentation and fall risk intervention highlights significant deficiencies in the facility's care planning processes.
Discrepancy in Advance Directive Documentation
Penalty
Summary
The facility failed to accurately address an advance directive for a resident, leading to a discrepancy in the resident's code status between the facility's records and the hospice records. The facility's policy mandates that residents' rights to formulate advance directives be supported and facilitated, with decisions documented in the medical record and communicated to the interdisciplinary team. However, for this resident, the facility's records indicated a preference for resuscitation, while the hospice records indicated a Do Not Resuscitate (DNR) order. This inconsistency was confirmed by both a Registered Nurse and the Director of Nursing during interviews. The resident in question was admitted with multiple diagnoses, including hypertensive heart disease, chronic kidney disease, and chronic heart failure, and was noted to have severe cognitive impairment. The resident's care plan focused on hospice care but failed to address advance directives or CPR code status. The discrepancy in the POST forms between the facility and hospice records was acknowledged by the Director of Nursing, who confirmed that the forms should have been consistent across both records.
Failure to Obtain Physician's Orders for Skin Care Treatment
Penalty
Summary
The facility failed to obtain a physician's orders for skin care treatments for a resident with a skin tear on the right elbow. The facility's policies require that in the absence of treatment orders, a licensed nurse should notify the physician to obtain such orders, and treatments should be documented on the Treatment Administration Record. However, the medical record review revealed that there were no interventions in the care plan to address the skin tear, and the physician's order did not address the skin condition on the resident's right elbow. Additionally, the Non-Pressure Skin Report failed to address the skin conditions on the resident's right elbow. Observations and interviews indicated that the resident had a border gauze on the right elbow, which was requested by the resident due to bleeding. The resident also reported soreness in the groin area, for which cream was applied upon request. An LPN confirmed that there was no treatment order for the resident's right elbow or groin. The Director of Nursing acknowledged that a physician's order should be in place for such care, indicating a lapse in following the facility's policy for obtaining and documenting treatment orders.
Improper Storage of Bedpans in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for several residents, as evidenced by the improper storage of bedpans in multiple resident rooms. Observations revealed that bedpans were unlabeled and unbagged in the bathrooms of six resident rooms, contrary to the facility's policy which requires bedpans to be labeled with the resident's name and stored in a plastic bag. This deficiency was confirmed through interviews with the RN/IP Unit Manager and the Director of Nursing, who acknowledged that bedpans should be labeled and bagged, and if not, they should be discarded. Resident #8, who was cognitively intact, had an unlabeled and unbagged yellow bedpan in their bathroom. Similarly, Residents #11 and #14, both cognitively intact, shared a bathroom where an unlabeled and unbagged bedpan was found. The RN/IP Unit Manager confirmed the oversight during an interview. In the shared bathroom of Residents #25 and #27, a bedpan labeled for Resident #27 was found unbagged, despite Resident #27 being moderately cognitively impaired. Further observations in the shared bathrooms of Residents #31 and #33, as well as Residents #48 and #51, revealed unlabeled and unbagged bedpans. Resident #31 was moderately cognitively impaired, while Resident #33 was cognitively intact. Resident #48 was severely cognitively impaired, and Resident #51 was cognitively intact. Additionally, Resident #207, a new admission with no MDS assessment available, had both a yellow and a pink bedpan unlabeled and unbagged in their bathroom. The RN/IP Unit Manager confirmed these findings, reiterating the facility's policy on proper bedpan storage.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lebanon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lebanon Center For Rehabilitation And Healing, Llc | 1.4 mi | ★★★★★ | 0 | 0 |
| Quality Center For Rehabilitation And Healing Llc | 3.4 mi | ★★★★★ | 2 | 0 |
| Cedar Creek Post Acute | 10.4 mi | ★★★★★ | 0 | 0 |
| The Waters Of Gallatin | 13 mi | ★★★★★ | 14 | 0 |
| Nhc Place Sumner | 13.5 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.