Pavilion on Main Street, the
515 North Main · Sandwich, IL · 60548 · 8157868426
113 certified beds For profit - Individual Chain: Pavilion Healthcare
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $80,360 in fines in the last 24 months.
- Inspection results are getting worse cycle over cycle, not better.
- 4 citations involved actual harm to residents.
Red flags
3 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$80,360 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
Total nurse staffing below 3.0 hours per resident-day
2.93 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 2.93 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.79 | 0.55–0.75 |
| Weekend hours / resident-day | 2.69 | ≈ weekday level |
| Nursing turnover / year | 32% | median 45% |
| Fines (3-yr window) | 2 · $122,009 |
Inspection citations (29 in the current record)
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Potential for harm · D October 9, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 10, 2025 · Quality of Life and Care
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Actual harm · G September 18, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 26, 2025 · Quality of Life and Care
-
Potential for harm · D September 18, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected November 11, 2025 · Pharmacy Service
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Actual harm · G August 27, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 23, 2025 · Quality of Life and Care
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Actual harm · G August 27, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected September 23, 2025 · Quality of Life and Care
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Potential for harm · D August 27, 2025
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 September 23, 2025 · Resident Rights
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Potential for harm · D August 27, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 23, 2025 · Quality of Life and Care
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Potential for harm · D August 27, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected September 23, 2025 · Quality of Life and Care
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Potential for harm · D August 27, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected September 23, 2025 · Pharmacy Service
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Potential for harm · F August 27, 2025
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 September 23, 2025 · Nutrition and Dietary
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Potential for harm · E August 27, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected September 23, 2025 · Nutrition and Dietary
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Potential for harm · F August 27, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected September 23, 2025 · Nutrition and Dietary
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Potential for harm · D August 27, 2025
Provide and implement an infection prevention and control program.
Corrected September 23, 2025 · Infection Control
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Potential for harm · F July 23, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected August 5, 2025 · Infection Control
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Potential for harm · F July 23, 2025 · found via complaint
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected August 5, 2025 · Infection Control
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Potential for harm · D October 30, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected November 11, 2024 · Pharmacy Service
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Potential for harm · E October 30, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected November 11, 2024 · Nutrition and Dietary
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Potential for harm · D June 26, 2024 · found via complaint
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 July 5, 2024 · Resident Rights
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Actual harm · G September 28, 2023
Provide safe, appropriate pain management for a resident who requires such services.
Corrected October 23, 2023 · Quality of Life and Care
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Potential for harm · D September 28, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected October 23, 2023 · Quality of Life and Care
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Potential for harm · D September 28, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 23, 2023 · Quality of Life and Care
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Potential for harm · D September 28, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected October 23, 2023 · Quality of Life and Care
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Potential for harm · E September 28, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 23, 2023 · Quality of Life and Care
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Potential for harm · D September 28, 2023
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 October 23, 2023 · Quality of Life and Care
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Potential for harm · D September 28, 2023
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected October 23, 2023 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| August 27, 2025 | Fine | $80,360 |
| August 27, 2025 | Payment Denial | 48 days |
| September 28, 2023 | Fine | $41,649 |
| September 28, 2023 | Payment Denial | 9 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 145712 · certified since March 1, 1992. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.