Inspection visit
Fire Safety inspection
Citations
11 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0022GeneralS&S Fpotential for harm
Establish policies and procedures for sheltering.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0023GeneralS&S Fpotential for harm
Establish policies and procedures for medical documentation.
- 0041GeneralS&S Fpotential for harm
Implement emergency and standby power systems.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0712GeneralS&S Fpotential for harm
Have simulated fire drills held at unexpected times.
- 0741GeneralS&S Epotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0916GeneralS&S Fpotential for harm
Have a battery powered remote alarm panel in a location accessible by operating personnel.
- 0920GeneralS&S Epotential for harm
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the September 28, 2023 survey of PAVILION ON MAIN STREET, THE?
This was a inspection survey of PAVILION ON MAIN STREET, THE on September 28, 2023. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PAVILION ON MAIN STREET, THE on September 28, 2023?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Establish policies and procedures for sheltering."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.