C+
69/100PAVILION ON MAIN STREET, THE Inspection Report, Violations & Safety Grade (SANDWICH, Illinois)
515 NORTH MAIN, SANDWICH, Illinois 60548
Phone: 8157868426
CMS Overall:3/5
Overview & Bed Count
Certified Beds
113
Avg Residents/Day
91.3
Ownership
For profit - Individual
Provider Type
Medicare and Medicaid
County
De Kalb
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall3/5
Health3/5
Staffing2/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Illinois Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.73 | 0.71 | +0.02 |
| Total Nurse Hours per Resident per Day | 3.03 | 3.47 | -0.44 |
| CMS Staffing Rating | 2/5 | 2.2/5 | - |
| Nursing Staff Turnover | 36.3% | 43.7% | - |
Health Citation History
29 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-10-09 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-09-18 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2025-09-18 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-08-27 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2025-08-27 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | G – Actual Harm |
| 2025-08-27 | Nutrition and Dietary Deficiencies | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | F – Moderate Harm Potential |
| 2025-08-27 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2025-08-27 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2025-08-27 | Resident Rights Deficiencies | Honor 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. | D – Moderate Harm Potential |
| 2025-08-27 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2025-08-27 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2025-08-27 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2025-08-27 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2025-07-23 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2025-07-23 | Infection Control Deficiencies | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | F – Moderate Harm Potential |
| 2024-10-30 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2024-10-30 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2024-06-26 | Resident Rights Deficiencies | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | D – Moderate Harm Potential |
| 2023-09-28 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | G – Actual Harm |
| 2023-09-28 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F – Moderate Harm Potential |
| 2023-09-28 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E – Moderate Harm Potential |
| 2023-09-28 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2023-09-28 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2023-09-28 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2023-09-28 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2023-09-28 | Quality of Life and Care Deficiencies | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | D – Moderate Harm Potential |
| 2023-09-28 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2023-09-28 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D – Moderate Harm Potential |
| 2023-09-28 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
Fire Safety Citation History
25 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2024-10-30 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2024-10-30 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2024-10-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the use of electrical equipment. | F – Moderate Harm Potential |
| 2024-10-30 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | E – Moderate Harm Potential |
| 2024-10-30 | Egress Deficiencies | Install proper backup exit lighting. | E – Moderate Harm Potential |
| 2024-10-30 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2024-10-30 | Smoke Deficiencies | Install a fire alarm system that can be heard throughout the facility. | E – Moderate Harm Potential |
| 2024-10-30 | Services Deficiencies | Have elevators that firefighters can control in the event of a fire. | E – Moderate Harm Potential |
| 2024-10-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | E – Moderate Harm Potential |
| 2023-09-28 | Emergency Preparedness Deficiencies | Address subsistence needs for staff and patients. | F – Moderate Harm Potential |
| 2023-09-28 | Emergency Preparedness Deficiencies | Establish policies and procedures for sheltering. | F – Moderate Harm Potential |
| 2023-09-28 | Emergency Preparedness Deficiencies | Establish policies and procedures for medical documentation. | F – Moderate Harm Potential |
| 2023-09-28 | Emergency Preparedness Deficiencies | Establish roles under a Waiver declared by secretary. | F – Moderate Harm Potential |
| 2023-09-28 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | F – Moderate Harm Potential |
| 2023-09-28 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2023-09-28 | Gas, Vacuum, and Electrical Systems Deficiencies | Have a battery powered remote alarm panel in a location accessible by operating personnel. | F – Moderate Harm Potential |
| 2023-09-28 | Smoke Deficiencies | Install an approved automatic sprinkler system. | E – Moderate Harm Potential |
| 2023-09-28 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2023-09-28 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | E – Moderate Harm Potential |
| 2023-09-28 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2022-07-28 | Emergency Preparedness Deficiencies | Establish staff and initial training requirements. | F – Moderate Harm Potential |
| 2022-07-28 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2022-07-28 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2022-07-28 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2022-07-28 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
Total Penalties & Fines
$52,234
Total Fine Amount (CMS)
1
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-08-27 | Fine | $52,234 | - |
| 2025-08-27 | Payment Denial | - | 48 days starting 2025-09-24 |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the SANDWICH area at no cost.
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.