Nursing Care Index

Pavilion On Main Street, The

Sandwich, De Kalb County, Illinois · CCN 145712 · For-profit (Individual) · part of Pavilion Healthcare (5 facilities, chain average 3 stars)

CMS rates Pavilion On Main Street, The 3 of 5 overall as of August 2026. 113 certified beds, 92 residents a day on average. 29 citations on record from the current inspection cycles, 4 involving actual harm; 2 fines totalling $93,883 and 2 payment denials.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★★★☆☆ 3 of 5
Health inspections★★★☆☆ 3 of 5
Staffing★★☆☆☆ 2 of 5
Quality measures★★★☆☆ 3 of 5
Quality: long-stay / short-stay4 / 3 of 5

Staffing

Total nurse staffing2.97573 hours per resident per day
Registered nurses0.7213 hours per resident per day
Weekend total2.70688 hours per resident per day
Nursing staff turnover34.7% (registered nurses 38.5%)
Administrators who left0

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2025-10-09
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-10
2025-09-18
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-09-26
2025-09-18
complaint survey
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-11
2025-08-27 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-09-23
2025-08-27 Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-09-23
2025-08-27 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.
Nutrition and Dietary Deficiencies · tag F0803
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-09-23
2025-08-27 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-09-23
2025-08-27 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies · tag F0804
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-09-23
2025-08-27 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.
Resident Rights Deficiencies · tag F0584
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-23
2025-08-27 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-23
2025-08-27 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-23
2025-08-27 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-23
2025-08-27 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-23
2025-07-23
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-08-05
2025-07-23
complaint survey
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Infection Control Deficiencies · tag F0882
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-08-05
2024-10-30 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-11-11
2024-10-30 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-11-11
2024-06-26
complaint survey
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.
Resident Rights Deficiencies · tag F0625
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-07-05
2023-09-28 Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0697
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-10-23
2023-09-28 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · tag F0725
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-10-23
2023-09-28 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-10-23
2023-09-28 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-10-23
2023-09-28 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-10-23
2023-09-28 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-10-23
2023-09-28 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · tag F0690
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-10-23
2023-09-28 Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies · tag F0694
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-10-23
2023-09-28 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-03
2023-09-28 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.
Pharmacy Service Deficiencies · tag F0761
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-10-23
2023-09-28 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-10-23

Fines and payment denials

DatePenaltyAmount
2025-08-27Payment denial for 48 days from 2025-09-24
2025-08-27Fine$52,234
2023-09-28Payment denial for 9 days from 2023-10-25
2023-09-28Fine$41,649

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Ilana D Aaron Trust C/U Maurice Aaron 2014 Family Gift Trust
Organization
5% or greater direct ownership interest12%2022-12-19
Ilana D Aaron Trust C/U Maurice Aaron 2014 Legacy Gift Trust
Organization
5% or greater direct ownership interest9%2022-12-19
Mcdonald, Nancy
Individual
adp of the snf2024-04-22
Robin, Jason
Individual
adp of the snf2023-07-01
Goldstein, Shimon
Individual
direct ownership interest2023-07-01
Graf, Marcella
Individual
direct ownership interest2022-12-19
Gross, Shoshana
Individual
direct ownership interest2023-07-01
Kroll, Gabriel
Individual
direct ownership interest2023-07-01
Proctor, Katherine
Individual
direct ownership interest2023-07-01
Ripstein, Kenneth
Individual
direct ownership interest2023-07-01
Stern, Todd
Individual
individual is an owner, partner or trustee of any adp of the snf2025-11-10
Aaron, Jonathan
Individual
managing control - governing body2022-12-19
Aaron, Jonathan
Individual
operational/managerial control2022-12-19
Graf, Marcella
Individual
operational/managerial control2022-12-19
Mcdonald, Nancy
Individual
operational/managerial control2024-04-22
Robin, Jason
Individual
operational/managerial control2023-07-01

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in De Kalb County.