Public Record
The Pavilion on Main Street
From CMS
Facility profile
- CMS overall rating
- 2 / 5
- Certified beds
- 113
- Avg. residents per day
- 89.4
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 58
- Inspections on file
- 12
- Last inspection
- 2025-10-09
*CMS
*CMS
*CMS
Citations
58 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0692Seriousactual harm
Provide enough food/fluids to maintain a resident's health.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0803Generalpotential for harm
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.
- 0584Generalpotential for harm
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.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0882Generalpotential for harm
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0531Generalpotential for harm
Have elevators that firefighters can control in the event of a fire.
- 0919Generalpotential for harm
Meet requirements for the use of electrical equipment.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0341Generalpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0225Generalpotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0281Generalpotential for harm
Install proper backup exit lighting.
- 0625Generalpotential for harm
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.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0022Generalpotential for harm
Establish policies and procedures for sheltering.
- 0026Generalpotential for harm
Establish roles under a Waiver declared by secretary.
- 0015Generalpotential for harm
Address subsistence needs for staff and patients.
- 0023Generalpotential for harm
Establish policies and procedures for medical documentation.
- 0041Generalpotential for harm
Implement emergency and standby power systems.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0741Generalpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0916Generalpotential for harm
Have a battery powered remote alarm panel in a location accessible by operating personnel.
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0694Generalpotential for harm
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- 0697Seriousactual harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0761Generalpotential for harm
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.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0037Generalpotential for harm
Establish staff and initial training requirements.
- 0761Generalpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0374Generalpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- Inspection1 deficiency
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview…
Read full statement of deficiencies - Inspection2 deficiencies
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record…
Read full statement of deficiencies - Inspection10 deficiencies
F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, interview, and…
Read full statement of deficiencies - Inspection2 deficiencies
F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to immediately isolate…
Read full statement of deficiencies - Inspection11 deficiencies
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to monitor…
Read full statement of deficiencies - View inspection reportInspection11 deficiencies
- View inspection reportInspection1 deficiency
- View inspection reportInspection22 deficiencies
- Inspection22 deficiencies
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility…
Read full statement of deficiencies - Inspection2 deficiencies
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on observation, interview, and record…
Read full statement of deficiencies
Showing the 10 most recent inspections. 2 earlier inspections are also on record.
FAQ
Questions and answers
- What is The Pavilion on Main Street?
- The Pavilion on Main Street is a Medicare- and Medicaid-certified nursing home in Sandwich, IL, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 145712.
- What is the CMS rating for The Pavilion on Main Street?
- The Pavilion on Main Street has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does The Pavilion on Main Street have?
- The Pavilion on Main Street is certified for 113 beds. It serves an average of 89.4 residents per day.
- How many citations does The Pavilion on Main Street have?
- The Pavilion on Main Street has 58 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was The Pavilion on Main Street last inspected?
- The Pavilion on Main Street was last inspected on October 9, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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