The Vardell Report.Pavilion Health Center at Brightmore

Across 4 inspections from March 2024 to September 2026, state surveyors documented 30 findings at Pavilion Health Center at Brightmore; 25 have a recorded correction and 5 await one; CMS lists 2 enforcement actions in the window.

Inspections

4

2024–2026, standard and complaint

Findings

30

Deficiencies cited by state inspectors

Corrected

25

Of 30 findings, with a recorded correction date

Penalties

2

2 fines; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Sep 32026

   Standard health inspection

   4 findings

   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Dec 92025

   Complaint investigation

   1 finding

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyPast Non-Compliance

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Jul 32025

   Standard health inspection

   6 findings

   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Jul 11, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jul 11, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jul 11, 2025
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jul 11, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jul 11, 2025
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jul 11, 2025

   Enforcement Action

   Civil money penalty, $16,985 imposed December 9, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 3, 2025, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Mar 262024

   Standard health inspection

   19 findings

   The same visit included a complaint investigation.

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Apr 18, 2024
   • F760Ensure that residents are free from significant medication errors.Level JImmediate jeopardyCorrected Apr 18, 2024
   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Apr 18, 2024
   • F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected Apr 18, 2024
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level ENo actual harm, potential for moreCorrected Apr 18, 2024
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Apr 18, 2024
   • F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Level DNo actual harm, potential for moreCorrected Apr 18, 2024
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Apr 18, 2024
   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Jan 6, 2024
   • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Apr 18, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Apr 18, 2024
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Apr 18, 2024
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Apr 18, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Apr 18, 2024
   • F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level DNo actual harm, potential for moreCorrected Apr 18, 2024
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Apr 18, 2024
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Apr 18, 2024
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Apr 18, 2024
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Apr 16, 2024

   Enforcement Action

   Civil money penalty, $86,450 imposed March 26, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 26, 2024, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Accurate Assessments, Cited in Two Inspections

   Inspectors cited F641 in March 2024 and July 2025. This citation covers whether each resident’s assessment correctly records their condition. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   24252526F641 across all 4 inspections, oldest to newest
2. 2

   Care Plans, Cited in Two Inspections

   Inspectors cited F656 in March 2024 and July 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   24252526F656 across all 4 inspections, oldest to newest
3. 3

   Care Plan Timing and Review, Cited in Two Inspections

   Inspectors cited F657 in March 2024 and July 2025. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   24252526F657 across all 4 inspections, oldest to newest
4. 4

   Citation F602, No Recorded Correction

   F602 was cited in March 2024 and September 2026. The agency describes it this way: Protect each resident from the wrongful use of the resident's belongings or money. The most serious was level D (no actual harm, potential for more). The September 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

   24252526F602 across all 4 inspections, oldest to newest
5. 5

   Coordinating Mental Health Screening, No Recorded Correction

   F644 was cited in September 2026. This citation covers whether assessments are coordinated with the state’s pre-admission screening for mental illness and intellectual disability (PASARR), and referrals made. The most serious was level D (no actual harm, potential for more). The September 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

   24252526F644 across all 4 inspections, oldest to newest
6. 6

   Pre-Admission Screening, No Recorded Correction

   F645 was cited in September 2026. This citation covers the required screening for mental illness or intellectual disability before admission (PASARR). The most serious was level D (no actual harm, potential for more). The September 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

   24252526F645 across all 4 inspections, oldest to newest
7. 7

   Accident Hazards and Supervision, No Recorded Correction

   F689 was cited in December 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious was level J (immediate jeopardy). The December 2025 citation has no recorded correction date; its status reads “Past Non-Compliance.” The record does not show whether the problem was fixed.

   24252526F689 across all 4 inspections, oldest to newest
8. 8

   Citation F742, No Recorded Correction

   F742 was cited in September 2026. The agency describes it this way: Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. The most serious was level D (no actual harm, potential for more). The September 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

   24252526F742 across all 4 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   Who completes resident assessments, and how are they checked for accuracy?

   Accurate Assessments: cited in two inspections, most seriously at level E.

2. 02

   How is a care plan written and reviewed here, and how do families take part in it?

   Care Plans: cited in two inspections, most seriously at level D.

3. 03

   How often are care plans revised, and who takes part in the review?

   Care Plan Timing and Review: cited in two inspections, most seriously at level D.

4. 04

   What changed after F602 was cited, and how do you check it now?

   Citation F602: cited in two inspections, most seriously at level D. The September 3, 2026 citation has no recorded correction date.

5. 05

   How do you arrange services for residents with a mental illness or an intellectual disability?

   Coordinating Mental Health Screening: cited in one inspections, most seriously at level D. The September 3, 2026 citation has no recorded correction date.

6. 06

   Was the required pre-admission screening done for every resident, and how is it tracked?

   Pre-Admission Screening: cited in one inspections, most seriously at level D. The September 3, 2026 citation has no recorded correction date.

7. 07

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in one inspections, most seriously at level J. The December 9, 2025 citation has no recorded correction date.

8. 08

   What changed after F742 was cited, and how do you check it now?

   Citation F742: cited in one inspections, most seriously at level D. The September 3, 2026 citation has no recorded correction date.

9. 09

   How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

   No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

10. 10

    What led to the 2025 fine, and has it been paid?

    A $16,985 civil money penalty was imposed December 9, 2025. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the North Carolina state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  North Carolina state survey agency

  Inspection Mar 26, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  North Carolina state survey agency

  Inspection Jul 3, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  North Carolina state survey agency

  Inspection Dec 9, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  North Carolina state survey agency

  Inspection Sep 3, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 345563

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.