Cycle 1
Health 2025-03-27 · Fire 2025-03-27
4 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Lebanon, TN
Pavilion-Ths, LLC
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1406 Medical Center Drive, Lebanon, TN
(615) 444-2882
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-12-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing
LPN hours / resident day
1.28
Licensed practical nurse staffing
Aide hours / resident day
2.39
Nurse aide staffing
Weekend hours
3.60
Weekend nurse staffing
RN turnover
14%
Annual RN turnover
Total nurse turnover
23%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.6
0.6 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
89.9%
6.6 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.9% |
94.5%
0.4 pts better
|
95.5%
0.6 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.6%
1.5 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
11.8%
11.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 11.0% |
6.2%
4.8 pts worse
|
5.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.7% |
32.2%
3.5 pts worse
|
19.6%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
18.1%
2.9 pts better
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 33.6% |
19.9%
13.7 pts worse
|
16.3%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.8% |
15.3%
15.5 pts worse
|
14.9%
15.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.9%
0.5 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.8% |
20.2%
15.6 pts worse
|
19.8%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.4%
1.9 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.9% |
79.6%
5.3 pts better
|
81.7%
3.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
11.2%
4.5 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.1% |
79.8%
16.7 pts worse
|
79.7%
16.6 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.9% |
22.2%
8.3 pts better
|
23.9%
10 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-29 · Fire 2019-10-29
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2018-11-07 · Fire 2018-11-07
3 health deficiencies
Top issue: Environmental (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-27
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-05-01
D · Potential for more than minimal harm
2025-03-27
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-27
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-05-01
D · Potential for more than minimal harm
2019-10-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-13
C · Minimal harm
2018-11-07
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2018-12-19
C · Minimal harm
2018-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-11-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-27
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-27
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-04-21
D · Potential for more than minimal harm
2019-10-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-11-15
D · Potential for more than minimal harm
2018-11-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-11-23
D · Potential for more than minimal harm
2018-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-11-23
D · Potential for more than minimal harm
2018-11-07
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2018-11-23
Penalties and ownership
What sits behind the stars
Ownership
Pavilion-Ths, LLC
5% Or Greater Direct Ownership Interest · Organization
Bone, Harold
Corporate Officer · Individual
Bone, Margaret
Corporate Officer · Individual
L4 Lifestyles LLC
Operational/Managerial Control · Organization
Njezic, Joseph
Operational/Managerial Control · Individual
Njezic, Joseph
W-2 Managing Employee · Individual
Pound, Kevin
Operational/Managerial Control · Individual
Stein & Associates LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Lebanon, TN
5-star overall rating with 4-star inspections with 1 recent health deficiencies
#2
Quality Center For Rehabilitation And Healing LLC
Lebanon, TN
1-star overall rating with 2-star inspections with $21,206 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Cedar Creek Post Acute
Mount Juliet, TN
1-star overall rating with 1-star inspections with $211,244 in total fines with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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