Pavilion , The
Hyannis, Massachusetts · CCN 225503
14 surveys since 2010, 4 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 63
- Surveys
- 14
- Harm or worse
- 4
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 82
- Ownership
- For profit - Limited Liability company
- Chain
- Independent
- County
- Barnstable
- Medicare-certified since
- 1990
CMS ratings
- Overall
- 5
- Health inspection
- 5
- Staffing
- 3
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Not shown for this facility: too few citations in window (n=4, floor 20).
Last survey on record
Jun 13, 2024
879 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.22 | 3.58 |
| Registered-nurse hours per resident day | 0.70 | — |
| Annual nurse turnover | 32.9% | 39.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D4100.0% | E— | F— |
| No harm, potential for minimal | A— | B— | C— |
In the surveyor’s words
From the most serious findings on record at Pavilion , The, in the surveyor’s own words.
- No harm, potential for more than minimal, isolatedF695Jun 13, 2024
Based on observation, interview, record review, and policy review, the facility failed for two Residents (#22 and #213), out of a total sample of 17 residents, to maintain and store respiratory equipment in a safe and sanitary manner. Specifically, the facility failed: 1. For Resident #22, to ensure oxygen (O2) equipment was maintained per physician's orders to ensure sanitary conditions to help decrease the risk of potential contamination and infection; and 2. For Resident #213, to store his/her continuous positive airway pressure (CPAP) respiratory tubing and nasal pillow mask in a sanitary way when not in use by the Resident to prevent potential contamination by germs and environmental debris. […]
- No harm, potential for more than minimal, isolatedF699Jun 13, 2024
Based on record review, interviews, and policy review, the facility failed to develop a person-centered plan of care which included post-traumatic stress disorder (PTSD- a mental health condition that is triggered by an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being) identified triggers to avoid potential re-traumatization for one Resident (#37), out of a total sample of 17 residents. […]
- No harm, potential for more than minimal, isolatedF756Jun 13, 2024
Based on interview, record review, and policy review, the facility failed to ensure monthly medication regimen reviews were maintained as part of the permanent medical record and failed to ensure recommendations made by the pharmacy consultant were addressed timely for one Resident (#9), out of a total sample of 17 residents. Findings include: Review of the facility's policy titled Medication Regimen Review (MRR), dated as last revised 6/1/24, indicated but was not limited to the following: - The consultant pharmacist will provide required recipients of residents' MRR on the MRR report to the Director of Nursing (DON) and/or the attending physician, and to the Medical Director. […]
- No harm, potential for more than minimal, isolatedF842Jun 13, 2024
Based on record review and interview, the facility failed to maintain accurate medical records in accordance with professional standards of practice for one Resident (#31), out of a total sample of 17 residents. Specifically, the facility failed to ensure the Resident's Massachusetts Medical Order for Life-Sustaining Treatment (MOLST- form that indicates a person's medical wishes regarding life sustaining treatments) was consistent with current physician's orders. Findings include: Review of the facility's policy titled Health Information Management Policy, undated, indicated but was not limited to the following: Purpose: -To ensure that health information, including but not limited to clinical records, is maintained in accordance with state, federal regulations, and professional practice… […]
Read 23 findings in full →The most serious and the most recent: 23 of 63 on record.
Every survey on record
FindingsAt actual harm or above
- Jun 13, 2024Standard4 findings
- Dec 6, 2019Standard1 finding
- Jun 10, 2019Complaint1 finding
- Mar 20, 2019Complaint1 finding
- Oct 29, 2018Standard4 findings
- Jun 19, 2017Standard9 findings
- Mar 9, 2016Standard5 findings
- Apr 13, 2015Complaint1 finding · 1 harm
Show the 6 earlier surveys
- Feb 18, 2015Standard5 findings
- Oct 8, 2014Complaint1 finding · 1 harm
- Dec 20, 2013—8 findings
- Apr 5, 2012—8 findings
- Oct 28, 2011—14 findings · 2 harm
- Oct 7, 2010—1 finding
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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