Pavilion on Main Street, the
515 North Main, Sandwich, IL 60548 · De Kalb County · 113 certified beds · avg 92 residents/day · certified since Mar 1, 1992
Part of chain: PAVILION HEALTHCARE (5 facilities, chain avg rating 3.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Sep 18, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 26, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 27, 2025 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 23, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 27, 2025 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 23, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 28, 2023 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 23, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (29)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Oct 9, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 18, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 18, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Aug 27, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 27, 2025 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Aug 27, 2025 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Aug 27, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 27, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Aug 27, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Aug 27, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Aug 27, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Aug 27, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Aug 27, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 23, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jul 23, 2025 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. · from a complaint |
| Oct 30, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 30, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jun 26, 2024 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · from a complaint |
| Sep 28, 2023 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Sep 28, 2023 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Sep 28, 2023 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 28, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Sep 28, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Sep 28, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Sep 28, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Sep 28, 2023 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Sep 28, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Sep 28, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Sep 28, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 10).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 11 | 1 | G ▲ |
| 2024 | 3 | 0 | E |
| 2025 | 15 | 3 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $93,883, plus 2 Medicare payment denial periods.
| Date | Type | Amount / length |
|---|---|---|
| Aug 27, 2025 | Fine | $52,234 |
| Aug 27, 2025 | Payment Denial | 48 days from Sep 24, 2025 |
| Sep 28, 2023 | Fine | $41,649 |
| Sep 28, 2023 | Payment Denial | 9 days from Oct 25, 2023 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Illinois avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.27 | 2.99 | 3.95 | bottom 21% in Illinois; bottom 2% in the U.S. |
| Registered Nurse hours | 0.55 | 0.63 | 0.69 | top 43% in Illinois; bottom 45% in the U.S. |
| Weekend total nurse staffing | 2.07 | 2.67 | 3.50 | bottom 24% in Illinois; bottom 2% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.60 | 0.56 | 0.48 | top 31% in Illinois; top 23% in the U.S. |
| Total nursing staff turnover (%) | 34.7 | 44.5 | 45.8 | top 24% in Illinois; top 23% in the U.S. |
| RN turnover (%) | 38.5 | 41.8 | 42.9 | top 48% in Illinois; top 44% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.98, RN 0.72, weekend 2.71. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
For profit - Individual
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Goldstein, Shimon | Individual | Direct Ownership Interest | NOT APPLICABLE | 07/01/2023 |
| Graf, Marcella | Individual | Direct Ownership Interest | NOT APPLICABLE | 12/19/2022 |
| Gross, Shoshana | Individual | Direct Ownership Interest | NOT APPLICABLE | 07/01/2023 |
| Ilana D Aaron Trust C/U Maurice Aaron 2014 Family Gift Trust | Organization | 5% or Greater Direct Ownership Interest | 12% | 12/19/2022 |
| Ilana D Aaron Trust C/U Maurice Aaron 2014 Legacy Gift Trust | Organization | 5% or Greater Direct Ownership Interest | 9% | 12/19/2022 |
| Kroll, Gabriel | Individual | Direct Ownership Interest | NOT APPLICABLE | 07/01/2023 |
| Proctor, Katherine | Individual | Direct Ownership Interest | NOT APPLICABLE | 07/01/2023 |
| Ripstein, Kenneth | Individual | Direct Ownership Interest | NOT APPLICABLE | 07/01/2023 |
| Aaron, Jonathan | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/19/2022 |
| Aaron, Jonathan | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/19/2022 |
| Graf, Marcella | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/19/2022 |
| McDonald, Nancy | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/22/2024 |
| McDonald, Nancy | Individual | ADP of the SNF | NOT APPLICABLE | 04/22/2024 |
| Robin, Jason | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2023 |
| Robin, Jason | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2023 |
| Stern, Todd | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 11/10/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Sandwich Living & Rehab Center | 0.7 mi | Sandwich, IL | ★☆☆☆☆ | 1/5 | |
| Hillside Rehab & Care Center | 8.8 mi | Yorkville, IL | ★★☆☆☆ | 3/5 | |
| Pearl at the Tillers | 14.4 mi | Oswego, IL | ★★★★★ | 4/5 | |
| Pearl of Orchard Valley | 15.1 mi | Aurora, IL | ★☆☆☆☆ | 1/5 | abuse |
| Prairie Crossing LVG & Rehab | 15.5 mi | Shabbona, IL | ★★★★☆ | 4/5 | |
| La Bella of Aurora | 16.5 mi | Aurora, IL | ★☆☆☆☆ | 1/5 | abuse |
| Jennings Terrace | 17.2 mi | Aurora, IL | ★★★★☆ | 4/5 | |
| Avantara Aurora | 18.1 mi | Aurora, IL | ★★★★☆ | 4/5 | |
| Asbury Gardens Nsg & Rehab | 18.4 mi | North Aurora, IL | ★★★★☆ | 4/5 | |
| Alden Courts of Waterford | 19.1 mi | Aurora, IL | ★★★★☆ | 4/5 | |
| Alden of Waterford | 19.2 mi | Aurora, IL | ★★★☆☆ | 3/5 | |
| North Aurora Living & Rehab Ctr | 19.6 mi | North Aurora, IL | ★★★☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 145712.