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Pavilion Ths, Llc

For profit - Limited Liability company  ·  1406 Medical Center Drive, Lebanon, TN 37087  ·  See home’s Medicare page

Inspections Delayed
The most recent standard inspection occurred more than two years ago. Inspections are supposed to occur every 18 months.
3.84
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 3.7
46.3%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 53.4%
60
Certified beds
Qualifying beds in the certified provider or supplier facility.
54
Average residents/day
Average number of residents based on daily census.
Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
Direct owners
Pavilion Ths, Llc (100%)
Indirect owners
No indirect owner information
Managerial control
L4 Lifestyles Llc since Jan, 2019
Stein & Associates Llc since Nov, 2011
Joseph Njezic since Jan, 2019
Kevin Pound since Nov, 2011
Managing employee(s)
Joseph Njezic since Nov, 2011

Inspection Reports

8

total deficiencies

1

infection-related deficiency

This home violated federal standards protecting residents from the spread of infections.

Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
Oct 29, 2019
Standard report
1 deficiency
D

Nutrition and Dietary Deficiency — F0812
Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Nov 7, 2018
Standard report
3 deficiencies
(1 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

D

Quality of Life and Care Deficiency — F0695
Failure to: Provide safe and appropriate respiratory care for a resident when needed.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Environmental Deficiency — F0908
Failure to: Keep all essential equipment working safely.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Sep 7, 2017
Standard report
4 deficiencies
D

Resident Rights Deficiency — F0157
Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0278
Failure to: Ensure each resident receives an accurate assessment by a qualified health professional.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0279
Failure to: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0281
Failure to: Ensure services provided by the nursing facility meet professional standards of quality.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Penalties

$4,857

total fines

A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
Aug 2, 2022
No corresponding inspection report.
Feb 7, 2022
$663 fine
No corresponding inspection report.