Pavilion on Main Street, the
515 North Main, Sandwich, IL 60548
Pavilion on Main Street, the is a nursing home in Sandwich, Illinois. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 3 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (815) 786-8426
- Last standard health inspection
- August 27, 2025 (1 year ago)
- Certified beds
- 113
- Residents per day, on average
- 91.3
- Ownership type
- For profit - Individual
- Legal business name
- Pavilion on Main Street LLC
- Chain
- Pavilion Healthcare
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Illinois average (29 vs 38).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 8, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Fine
CMS changed the fine from August 27, 2025 from $80,360 to $52,234.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of April 29, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of December 15, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
1 citation
Health inspection on October 9, 2025
CMS lists this as a complaint inspection.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on October 10, 2025.
CMS has cited this home for F0689 4 times since 2023.
Payment stopped
September 24, 2025 (1 year ago)
CMS stopped payment for new admissions from September 24, 2025, for 48 days.
2 citations
Health inspection on September 18, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
362 of 664 Illinois homes (55%) got a citation at the actual harm level in 2025.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 26, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on November 11, 2025.
CMS has cited this home for F0755 3 times since 2023.
10 citations
Health inspection on August 27, 2025
CMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
362 of 664 Illinois homes (55%) got a citation at the actual harm level in 2025.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 23, 2025.
Citation F0692. Severity G: actual harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on September 23, 2025.
Citation F0803. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on September 23, 2025.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 23, 2025.
CMS has cited this home for F0812 2 times since 2024.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on September 23, 2025.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 23, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on September 23, 2025.
CMS has cited this home for F0677 2 times since 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on September 23, 2025.
CMS has cited this home for F0684 2 times since 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on September 23, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 23, 2025.
CMS has cited this home for F0880 3 times since 2023.
Fine
August 27, 2025 (1 year ago)
CMS fine of $52,234 on August 27, 2025.
2 citations
Health inspection on July 23, 2025
CMS lists this as a complaint inspection.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on August 5, 2025.
Citation F0882. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on August 5, 2025.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
2 citations
Health inspection on October 30, 2024
CMS lists this as a standard inspection.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 11, 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on November 11, 2024.
9 citations
Fire safety inspection on October 30, 2024
CMS lists this as a standard inspection.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on December 13, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 13, 2024.
CMS has cited this home for K0353 2 times since 2022.
Citation K0919. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on December 13, 2024.
Citation K0225. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Citation K0281. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install proper backup exit lighting.
CMS lists it as corrected on December 13, 2024.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on December 13, 2024.
Citation K0341. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on December 13, 2024.
Citation K0531. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have elevators that firefighters can control in the event of a fire.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on December 13, 2024.
CMS update of August 29, 2024
Fine
CMS changed the fine from July 28, 2022 from $21,670 to $22,192.
Fine
CMS changed the fine from August 12, 2022 from $18,196 to $18,597.
Fine
CMS changed the fine from September 28, 2023 from $40,879 to $41,649.
1 citation
Health inspection on June 26, 2024
CMS lists this as a complaint inspection.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 5, 2024.
CMS update of June 26, 2024
Fine
CMS changed the fine from August 12, 2022 from $16,965 to $18,196.
CMS update of May 29, 2024
Fine
CMS changed the fine from July 28, 2022 from $20,000 to $21,670.
Fine
CMS changed the fine from September 28, 2023 from $62,890 to $40,879.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of February 29, 2024
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of January 31, 2024
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
CMS update of December 21, 2023
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
11 citations
Health inspection on September 28, 2023
CMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
212 of 664 Illinois homes (32%) got a citation at the actual harm level in 2023.
Citation F0697. Severity G: actual harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on October 23, 2023.
Citation F0725. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on October 23, 2023.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on October 23, 2023.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on October 23, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on October 23, 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on October 23, 2023.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on October 23, 2023.
Citation F0694. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
CMS lists it as corrected on October 23, 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on November 3, 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 23, 2023.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 23, 2023.
11 citations
Fire safety inspection on September 28, 2023
CMS lists this as a standard inspection.
Citation E0015. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Address subsistence needs for staff and patients.
CMS lists it as corrected on November 3, 2023.
Citation E0022. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures for sheltering.
CMS lists it as corrected on November 3, 2023.
Citation E0023. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures for medical documentation.
CMS lists it as corrected on November 3, 2023.
Citation E0026. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish roles under a Waiver declared by secretary.
CMS lists it as corrected on November 3, 2023.
Citation E0041. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on November 3, 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on November 3, 2023.
Citation K0916. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a battery powered remote alarm panel in a location accessible by operating personnel.
CMS lists it as corrected on November 22, 2023.
Citation K0351. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on November 3, 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on November 3, 2023.
Citation K0741. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on November 3, 2023.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on November 3, 2023.
5 citations
Fire safety inspection on July 28, 2022
CMS lists this as a standard inspection.
Citation E0037. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish staff and initial training requirements.
CMS lists it as corrected on September 12, 2022.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on September 12, 2022.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on September 12, 2022.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on September 12, 2022.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on September 12, 2022.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- ILANA D AARON TRUST C/U MAURICE AARON 2014 FAMILY GIFT TRUST5% or greater direct ownership interest · 12% · since 12/19/2022
- ILANA D AARON TRUST C/U MAURICE AARON 2014 LEGACY GIFT TRUST5% or greater direct ownership interest · 9% · since 12/19/2022
- GOLDSTEIN, SHIMONDirect ownership interest · not applicable · since 07/01/2023
- GRAF, MARCELLADirect ownership interest · not applicable · since 12/19/2022
- GROSS, SHOSHANADirect ownership interest · not applicable · since 07/01/2023
- KROLL, GABRIELDirect ownership interest · not applicable · since 07/01/2023
- PROCTOR, KATHERINEDirect ownership interest · not applicable · since 07/01/2023
- RIPSTEIN, KENNETHDirect ownership interest · not applicable · since 07/01/2023
- AARON, JONATHANOperational/managerial control · not applicable · since 12/19/2022
- GRAF, MARCELLAOperational/managerial control · not applicable · since 12/19/2022
- MCDONALD, NANCYOperational/managerial control · not applicable · since 04/22/2024
- ROBIN, JASONOperational/managerial control · not applicable · since 07/01/2023
Questions
When was Pavilion on Main Street, the last inspected?
CMS lists August 27, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Pavilion on Main Street, the have?
CMS lists 29 health citations since September 28, 2023. CMS also calls these deficiencies.
Has Pavilion on Main Street, the been fined?
CMS lists 1 fine in the past three years, $52,234 in total.
What is the CMS star rating of Pavilion on Main Street, the?
Its CMS overall star rating is 3 of 5.
Is Pavilion on Main Street, the a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.