Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pavilion At Brandon Wilde during CMS and state inspections, most recent first.
A resident with cognitive impairment was left waiting during mealtime due to insufficient staff and space, compromising their dignity. Additionally, a resident with diabetes had their blood glucose tested in a public area, violating privacy protocols. Staff interviews confirmed these practices were against facility policy, highlighting deficiencies in maintaining resident dignity.
A resident with hypertension and atrial fibrillation had their medications withheld by an RN without consulting the physician, despite the absence of parameters for withholding. The RN based the decision on the resident's blood pressure and pulse, but did not notify the physician or obtain parameters for future reference. Interviews revealed inconsistencies in nursing judgment and a lack of standardized guidelines for withholding medications.
A facility failed to maintain a medication error rate below 5%, resulting in a 12.9% error rate. Two residents were affected: one had medications withheld without physician orders, and another had a medication omitted due to being out of stock. The errors were due to non-compliance with facility policies and lack of physician notification.
A resident with hypertension and atrial fibrillation experienced a medication labeling error during administration. The RN found discrepancies between the pharmacy packet descriptions and the actual medications, leading to difficulty in identifying the correct pills. The pharmacist confirmed the error, which was attributed to outdated descriptions not matching the medications, highlighting a need for process improvements.
A facility failed to maintain infection control during medication administration, as a nurse used an ungloved fingernail to remove medications from a cup and placed a glucometer on an unclean surface. An overflowing sharps container and an open beverage on the medication cart were also noted, indicating lapses in infection control protocols.
Deficiencies in Resident Dignity During Mealtime and Medical Procedures
Penalty
Summary
The facility failed to uphold the dignity of a resident during mealtime. A resident with severe cognitive impairment and malnutrition was observed sitting off to the side of the dining room, watching other residents eat for over 30 minutes due to insufficient dining table space and staff availability. Despite the resident's attempts to gain attention, they were not provided a meal until a staffing coordinator arrived and assisted them. Interviews with staff revealed that this was a common occurrence due to a lack of staff and space, resulting in residents having to wait for assistance with meals. Another deficiency was noted during the medication administration process for a resident with diabetes mellitus. The resident's blood glucose testing was conducted in a public area, the therapy gym, rather than in a private setting. This was done in the presence of other residents and staff, compromising the resident's privacy and dignity. Staff interviews confirmed that blood glucose testing should be conducted in the resident's room to maintain privacy, and performing such procedures in public areas was against the facility's policy. The Director of Nursing and the Administrator both expressed that residents should be treated with dignity at all times, including during dining and medical procedures. However, the observations and staff interviews indicated that the facility's practices did not align with these expectations, leading to the noted deficiencies in resident care and dignity.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with accepted professional standards during a medication administration for a resident with hypertension, atrial fibrillation, and heart disease. The resident, identified as having moderate cognitive impairment, was observed during a medication pass where the RN withheld physician-ordered medications without consulting the physician. The medications withheld were amlodipine besylate-valsartan and Cardizem, both prescribed for the resident's conditions, and there were no parameters in the orders for withholding these medications. The RN decided to hold the medications based on the resident's blood pressure reading of 107/61 and a pulse of 48 beats per minute, documenting the action on the Medication Administration Record (MAR) with a code indicating vital signs outside of parameter. However, the RN did not notify the physician of the decision to withhold the medications or obtain orders for parameters for withholding them. Interviews with other nursing staff revealed that they would typically contact the physician if there were no parameters for withholding medication, but the RN in question did not follow this protocol. The Director of Nursing (DON) and the Medical Director both expressed expectations that nurses should notify physicians when withholding medications and obtain parameters for future reference. The facility's policies did not specify blood pressure parameters for withholding medications, leading to inconsistencies in nursing judgment. The DON acknowledged that every nurse might have a different idea of what constitutes low blood pressure, highlighting a lack of standardized guidelines within the facility.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 12.9% error rate during a medication administration observation. This deficiency involved two residents, R55 and R29, out of three observed. For R55, the Registered Nurse (RN) held two medications, amlodipine besylate-valsartan and Cardizem, without physician orders or parameters for withholding. The RN based her decision on the resident's blood pressure and pulse readings, but did not notify the physician or document the withholding of medications, leading to two medication errors. R55 had a medical history of essential hypertension, atrial fibrillation, and heart disease, with moderate cognitive impairment. The resident's care plan required antihypertensive medications to be administered as ordered and monitored for effectiveness. However, the RN held the medications due to low blood pressure and pulse, without consulting the physician, which was against the facility's policy and expectations. For R29, the RN failed to measure polyethylene glycol accurately and omitted a cholecalciferol tablet during medication administration. R29 had a history of anxiety and cognitive communication deficit, with intact cognition and required total assistance with activities of daily living. The omission of the cholecalciferol tablet was due to the medication being out of stock, which was not addressed prior to the medication pass. These actions contributed to the facility's medication error rate exceeding the acceptable threshold.
Medication Labeling Error During Administration
Penalty
Summary
The facility failed to ensure medications were accurately labeled for a resident during medication administration. The resident, who had a medical history of essential hypertension, atrial fibrillation, and heart disease, was observed during a medication pass. The registered nurse (RN) checked the resident's blood pressure and pulse, which were 107/61 and 48 beats per minute, respectively. Due to the low blood pressure reading, the RN decided to hold the administration of amlodipine besylate-valsartan and Cardizem extended-release. However, the RN encountered difficulty identifying the medications because the descriptions on the pharmacy packets did not match the actual medications inside. The RN attempted to remove the specific medications from the cup but had to refer to a strip of the next day's medications to identify the Cardizem, as the pharmacy descriptions were outdated. The RN noted that manufacturers sometimes changed the appearance of medications, and the pharmacy did not update the packets accordingly, making it challenging for nurses to verify medications without additional resources. The RN ultimately removed and destroyed the two medications due to the labeling issue. The Director of Nursing (DON) and the pharmacist confirmed the discrepancy in medication labeling. The pharmacist identified that the amlodipine besylate-valsartan had an incorrect description on the packet, which was a pharmacy error that should have been caught in their quality assurance process. The pharmacist acknowledged the need for a process change to prevent such errors in the future. The DON and the facility administrator expressed their expectations for nurses to follow the medication administration policy and regulations.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration, as observed with one of the medication carts. A registered nurse was seen attempting to remove medications from a medication cup using an ungloved fingernail for a resident, which is against the facility's infection control policy. Additionally, the nurse had an open personal beverage on the medication cart and did not replace an overflowing sharps container, which was acknowledged but not addressed over several days. Another incident involved the same nurse performing a blood glucose test for a resident without disinfecting the bedside table or placing a barrier before placing the glucometer on it. This action was contrary to infection control protocols, as the glucometer was placed directly on an unclean surface. The nurse did disinfect the glucometer after returning to the medication cart, but the initial lapse in protocol posed a risk of contamination. The facility's policy on infection prevention and control emphasizes the importance of educating staff and ensuring adherence to proper techniques. However, interviews with other nursing staff revealed that the observed nurse did not follow the expected procedures, such as wearing gloves or using a medicine spoon to remove medications from a cup. The Director of Nursing and the Administrator both expressed expectations for adherence to infection control practices, but the observed deficiencies indicate a failure to meet these standards.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Evans
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Evans, Llc | 0.5 mi | — | 0 | 0 |
| Harrington Park Health And Rehabilitation | 3 mi | — | 8 | 0 |
| Harborview Health Center Of Augusta | 3.1 mi | — | 0 | 0 |
| Place At Martinez, The | 3.1 mi | — | 17 | 0 |
| Pruitthealth - Richmond, Llc | 3.4 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.