Cycle 1
Health 2025-08-27 · Fire 2024-10-30
15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Sandwich, IL
Pavilion On Main Street, The
2-star overall rating with 2-star inspections with $41,649 in total fines with 15 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
515 North Main, Sandwich, IL
(815) 786-8426
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
113
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pavilion Healthcare
Operator or chain grouping
Approved since
1992-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.75
Registered nurse staffing
LPN hours / resident day
0.35
Licensed practical nurse staffing
Aide hours / resident day
1.86
Nurse aide staffing
Weekend hours
2.65
Weekend nurse staffing
RN turnover
31%
Annual RN turnover
Total nurse turnover
26%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
2.0
1.3 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
2.3
0.6 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
89.6%
0.1 pts worse
|
93.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.5% |
91.6%
4.9 pts better
|
95.5%
1 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.3%
1.4 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 90.9% |
50.3%
40.6 pts worse
|
11.4%
79.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.1% |
6.5%
1.4 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.8% |
18.5%
6.3 pts worse
|
19.6%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
22.8%
7.8 pts better
|
16.7%
1.7 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 | 21.8% |
17.2%
4.6 pts worse
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
15.0%
2.2 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.7%
0.8 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.1% |
21.3%
8.8 pts worse
|
19.8%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.2%
0.2 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 29.0% |
68.8%
39.8 pts worse
|
81.7%
52.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
14.0%
0.3 pts better
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
2.3%
1.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 23.8% |
63.0%
39.2 pts worse
|
79.7%
55.9 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
26.2%
8.3 pts better
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-30 · Fire 2023-09-28
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2023-09-28 · Fire 2022-07-28
15 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-10-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-10-30
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-30
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Not marked corrected
E · Potential for more than minimal harm
2024-10-30
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-30
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-30
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Not marked corrected
E · Potential for more than minimal harm
2024-10-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-13
F · Potential for more than minimal harm
2023-09-28
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-09-28
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-09-28
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-09-28
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-09-28
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-09-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-09-28
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-11-22
E · Potential for more than minimal harm
2023-09-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-09-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-09-28
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-09-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-03
F · Potential for more than minimal harm
2022-07-28
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-09-12
F · Potential for more than minimal harm
2022-07-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-12
F · Potential for more than minimal harm
2022-07-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-09-12
F · Potential for more than minimal harm
2022-07-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-12
E · Potential for more than minimal harm
2022-07-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-09-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-10
G · Actual harm
2025-09-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-09-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-11-11
G · Actual harm
2025-08-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-23
G · Actual harm
2025-08-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-23
F · Potential for more than minimal harm
2025-08-27
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-09-23
F · Potential for more than minimal harm
2025-08-27
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 2025-09-23
E · Potential for more than minimal harm
2025-08-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-08-27
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-08-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-08-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-08-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-08-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-23
F · Potential for more than minimal harm
2025-07-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-05
F · Potential for more than minimal harm
2025-07-23
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-08-05
E · Potential for more than minimal harm
2024-10-30
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 2024-11-11
D · Potential for more than minimal harm
2024-10-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-06-26
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2024-07-05
G · Actual harm
2023-09-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-23
F · Potential for more than minimal harm
2023-09-28
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-23
E · Potential for more than minimal harm
2023-09-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-09-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-09-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-09-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-09-28
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-09-28
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-09-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-28
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-09-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-05-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-05-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-05-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-05-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-12
Penalties and ownership
What sits behind the stars
$41,649
2023-09-28
Fine
Fine · fine $41,649
Fine
$0
2023-09-28
Payment Denial
Payment Denial · denial start 2023-10-25 · 9 days
9 day denial
Ownership
Jonathan H Aaron Revocable Trust
5% Or Greater Direct Ownership Interest · Organization
Emst LLC
5% Or Greater Direct Ownership Interest · Organization
Stern Family Investment Tr
5% Or Greater Direct Ownership Interest · Organization
Todd A Stern 2015 Irrv Ins Tr
5% Or Greater Direct Ownership Interest · Organization
Ilana D Aaron Trust C/U Maurice Aaron 2014 Family Gift Trust
5% Or Greater Direct Ownership Interest · Organization
Ilana D Aaron Trust C/U Maurice Aaron 2014 Legacy Gift Trust
5% Or Greater Direct Ownership Interest · Organization
Aaron, Jonathan
Operational/Managerial Control · Individual
Graf, Marcella
Operational/Managerial Control · Individual
Mcdonald, Nancy
Operational/Managerial Control · Individual
Robin, Jason
Operational/Managerial Control · Individual
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#3
Pearl At The Tillers
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