The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited September 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
PAVILION ON MAIN STREET, THE
SANDWICH, IL · Medicare-certified · 113 beds
Needs attention
For-profitChain member
2 of 5 overall
Pavilion on Main Street in Sandwich, IL has an overall rating of 2 out of 5 stars, with 2-star health inspection and staffing ratings but 4-star quality measures. It reported 2.93 nurse staffing hours per resident per day versus the 4.1 federal benchmark, and it had $80,360 in fines in the last 24 months with a recent federal penalty.
Facility ratings
Health inspections
Staffing
2.9276 hrs/resident/day
Quality measures
Last inspection: October 9, 2025Penalties, last 24 months: $80,360recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 2.9276.
Staffing detail
- Registered nurses
- 0.79
- Licensed practical nurses
- 0.34
- Nurse aides
- 1.80
- Weekend nursing
- 2.69
Hours per resident per day.
Total staff turnover: 32%
Registered nurse turnover: 33%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
15.9%Worsening
Residents with a fall causing major injury
1.5%Steady
Residents with pressure ulcers (bedsores)
5.8%Worsening
Residents with a urinary tract infection
0.6%Improving
Residents who lost too much weight
5.7%Worsening
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
12.8%Worsening
Residents whose ability to walk got worse
19.2%Improving
Show all measures
Long-stay residents on antianxiety or sleep medication
25.2%Worsening
Short-stay residents newly given an antipsychotic
1.6%Worsening
Residents with a long-term catheter
0.2%Worsening
Residents with new or worsening incontinence
30.3%Improving
Residents with depressive symptoms
94.1%Worsening
Long-stay residents given the seasonal flu vaccine
96.5%Steady
Long-stay residents given the pneumonia vaccine
86%Worsening
Short-stay residents given the seasonal flu vaccine
23.8%Steady
Short-stay residents given the pneumonia vaccine
19.6%Worsening
What the inspectors found
The home failed to provide enough food and fluids to keep residents healthy. Cited August 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 692 — 42 CFR §483.25(g) — S/S: G
The home failed to provide safe, appropriate pain management for a resident who needed it. Cited September 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 697 — 42 CFR §483.25(k) — S/S: G
The home failed to ensure meals and menus were planned, updated, and followed to meet residents’ nutritional needs. Cited August 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 803 — 42 CFR §483.60 — S/S: F
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited August 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 2 health deficiencies.
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- PENALTY
A federal payment denial was recorded.
- PENALTY
A federal fine of $80,360 was recorded.
- INSPECTION
Health inspection found 10 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 2 fines · $122,009 in total fines · 2 payment denials.
- 48 days
Medicare/Medicaid payment denial
Aug 27, 2025
- $80,360
Federal fine
Aug 27, 2025
- 9 days
Medicare/Medicaid payment denial
Sep 28, 2023
- $41,649
Federal fine
Sep 28, 2023
Operator & ownership
- Ownership
- For profit - Individual
- Chain
- Part of PAVILION HEALTHCARE · 5 homes · 2.4 stars avg
- Occupancy
- 89.4 residents on an average day (79% of 113 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 34 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.