Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

PAVILION , THE

HYANNIS, MA · 82 certified beds · Last Life Safety survey June 17, 2025

CMS Certification Number 225503 · first certified July 1990

Ownership

Independently operated (no chain recorded by CMS) · For profit - Limited Liability company

No change of ownership on CMS record since January 1, 2016, when the records begin.

12
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
9
Inspection & testing records
Of the citations on file

Position within MA

12 citations — more than 54% of the 341 certified nursing homes in MA. Compared within MA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 4 citations; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (June 2026 to September 2026), and past the point by which nine in ten MA facilities have been surveyed. This facility’s last Life Safety survey was June 2025. Facilities in MA are typically surveyed 12–15 months after the last one (median 13), measured over 556 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

1 of the 12 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

How that compares

Citations on file over three years

Compared with the median facility in MA, and nationally. Surveyors differ markedly between states, so the MA figure is the meaningful one.

This facility12MA median11National median11
Citations on file over three years, compared
MeasureCitations
This facility12
Median facility in MA11
Median facility nationally11

Survey history

Citations at each Life Safety survey
82023-0402024-0642025-06
Citations at each Life Safety survey
Survey dateCitations
April 5, 20238
June 13, 20240
June 17, 20254

Most-cited tags

Most-cited tags at this facility
K-05212K-09111K-03241K-03451K-07121K-09181K-02911K-03551
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.22025-06-17
K-0911Meet requirements for the installation and maintenance of electrical systems.12025-06-17
K-0324Provide properly protected cooking facilities.12023-04-05
K-0345Have approved installation, maintenance and testing program for fire alarm systems.12023-04-05
K-0712Have simulated fire drills held at unexpected times.12023-04-05
K-0918Have generator or other power source capable of supplying service within 10 seconds.12023-04-05
K-0291Install emergency lighting that can last at least 1 1/2 hours.12025-06-17
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.12023-04-05

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 4
  • Services Deficiencies 2
  • Gas, Vacuum, and Electrical Systems Deficiencies 2
  • Construction Deficiencies 1
  • Other 3
Citations by CMS category
CategoryCitations
Smoke Deficiencies4
Services Deficiencies2
Gas, Vacuum, and Electrical Systems Deficiencies2
Construction Deficiencies1
Miscellaneous Deficiencies1
Egress Deficiencies1
Emergency Preparedness Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

June 17, 2025 — 4 citations

Citations issued on June 17, 2025
TagWhat the surveyor checksStatus
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (August 1, 2025)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (August 1, 2025)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (September 3, 2025)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (August 14, 2025)

April 5, 2023 — 8 citations

Citations issued on April 5, 2023
TagWhat the surveyor checksStatus
E-0041Implement emergency and standby power systems.Deficient, Provider has date of correction (April 27, 2023)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (April 14, 2023)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (May 12, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (April 14, 2023)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (April 14, 2023)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (May 17, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (April 14, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (April 27, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.