| Pavilion on Main Street, the | |
| 515 North Main, Sandwich, Illinois 60548 | |
| (815) 786-8426 | |
| Name | Pavilion on Main Street, the |
|---|---|
| Location | 515 North Main, Sandwich, Illinois |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 113 |
| Occupancy Rate | 81.06% |
| Medicare ID (CCN) | 145712 |
| Legal Business Name | Pavilion on Main Street LLC |
| Ownership Type | For Profit - Individual |
| Chain | Pavilion Healthcare (5 nursing homes) |
| Chain Average Overall Rating | 3 out of 5 |
| NPI Number | 1366180903 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Pavilion on Main Street LLC |
| Doing Business As | Pavilion on Main Street |
| Address | 515 N Main St, Sandwich, IL 60548 |
| Phone Number | 815-786-8426 |
| NPI Number | 1780661165 |
| Match | Possible same name, address or phone number |
| Organization Name | Willow Crest Nursing Pavillion, Ltd. |
| Address | 515 N Main St, Sandwich, IL 60548 |
| Phone Number | 815-786-8426 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 2.98 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.72 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 0.43 | 0.86 |
| Nurse aide hours per resident per day | 1.82 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 2.71 | 3.42 |
| RN hours per resident per day on the weekend | 0.6 | 0.48 |
| Physical therapist hours per resident per day | 0.07 | 0.07 |
| Total nursing staff turnover | 34.7% | 45.8% |
| Registered nurse turnover | 38.5% | 42.9% |
| Number of administrators who have left the nursing home | 0 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 2 |
| Total Amount of Fines in Dollars | $93,883 |
| Number of Payment Denials | 2 |
| Total Number of Penalties | 4 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Oct 9, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Complaint inspection | Potential for harm, isolated | Corrected by Oct 10, 2025 |
| Sep 18, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Complaint inspection | Actual harm, isolated | Corrected by Sep 26, 2025 |
| Sep 18, 2025 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755, Pharmacy Service, Complaint inspection | Potential for harm, isolated | Corrected by Nov 11, 2025 |
| Aug 27, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Standard inspection | Actual harm, isolated | Corrected by Sep 23, 2025 |
| Aug 27, 2025 | Provide enough food/fluids to maintain a resident's health. F0692, Quality of Life and Care, Standard inspection | Actual harm, isolated | Corrected by Sep 23, 2025 |
| Aug 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. F0803, Nutrition and Dietary, Standard inspection | Potential for harm, widespread | Corrected by Sep 23, 2025 |
| Aug 27, 2025 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, widespread | Corrected by Sep 23, 2025 |
| Aug 27, 2025 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. F0804, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Sep 23, 2025 |
| Aug 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. F0584, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Sep 23, 2025 |
| Aug 27, 2025 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Sep 23, 2025 |
| Aug 27, 2025 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Sep 23, 2025 |
| Aug 27, 2025 | Ensure medication error rates are not 5 percent or greater. F0759, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Sep 23, 2025 |
| Aug 27, 2025 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Sep 23, 2025 |
| Jul 23, 2025 | Provide and implement an infection prevention and control program. F0880, Infection Control, Complaint inspection | Potential for harm, widespread | Corrected by Aug 5, 2025 |
| Jul 23, 2025 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. F0882, Infection Control, Complaint inspection | Potential for harm, widespread | Corrected by Aug 5, 2025 |
| Oct 30, 2024 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Nov 11, 2024 |
| Oct 30, 2024 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Nov 11, 2024 |
| Jun 26, 2024 | 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. F0625, Resident Rights, Complaint inspection | Potential for harm, isolated | Corrected by Jul 5, 2024 |
| Sep 28, 2023 | Provide safe, appropriate pain management for a resident who requires such services. F0697, Quality of Life and Care, Standard inspection | Actual harm, isolated | Corrected by Oct 23, 2023 |
| Sep 28, 2023 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. F0725, Nursing and Physician Services, Standard inspection | Potential for harm, widespread | Corrected by Oct 23, 2023 |
| Sep 28, 2023 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Standard inspection | Potential for harm, pattern | Corrected by Oct 23, 2023 |
| Sep 28, 2023 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Oct 23, 2023 |
| Sep 28, 2023 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Oct 23, 2023 |
| Sep 28, 2023 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Oct 23, 2023 |
| Sep 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. F0690, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Oct 23, 2023 |
| Sep 28, 2023 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. F0694, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Oct 23, 2023 |
| Sep 28, 2023 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Nov 3, 2023 |
| Sep 28, 2023 | 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Oct 23, 2023 |
| Sep 28, 2023 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Oct 23, 2023 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.59 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 5.86 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.19 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 0.3 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 94.55 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.78 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.38 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 17.47 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.82 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.03 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.08 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.51 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 23.81 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 5.38 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.41 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 16.28 | 15.38 |
Sandwich Living & Rehab Center Location: 902 East Arnold Street, Sandwich, Illinois 60548 Phone: (815) 786-8409 |