Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
PAVILION ON MAIN STREET, THE
SANDWICH, IL · 113 certified beds · Last Life Safety survey October 30, 2024
CMS Certification Number 145712 · first certified March 1992
Ownership
Operated by PAVILION HEALTHCARE · For profit - Individual
- Ownership changed December 19, 2022 (change of ownership)to PAVILION ON MAIN STREET from WILLOW CREST NURSING PAVILLION, LTD.
Position within IL
25 citations — more than 74% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 9 citations; the earlier surveys in the window averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (September 2025 to December 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was October 2024. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
Get an email about PAVILION ON MAIN STREET, THE
One email when it happens. No account; stop it any time with one click.
1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
6 of the 25 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
8 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 25 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 25 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| July 28, 2022 | 5 |
| September 28, 2023 | 11 |
| October 30, 2024 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-10-30 |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 1 | 2024-10-30 |
| E-0026 | Establish roles under a Waiver declared by secretary. | 1 | 2023-09-28 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2023-09-28 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2023-09-28 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2022-07-28 |
| E-0037 | Establish staff and initial training requirements. | 1 | 2022-07-28 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2023-09-28 |
What the citations cover
- Smoke Deficiencies 8
- Emergency Preparedness Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Miscellaneous Deficiencies 3
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Emergency Preparedness Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Miscellaneous Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 30, 2024 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Waiver has been granted |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (December 13, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 13, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (December 13, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 13, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 13, 2024) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Waiver has been granted |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (December 13, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (December 13, 2024) |
September 28, 2023 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (November 3, 2023) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (November 3, 2023) |
| E-0023 | Establish policies and procedures for medical documentation. | Deficient, Provider has date of correction (November 3, 2023) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (November 3, 2023) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (November 3, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (November 3, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 3, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 3, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (November 3, 2023) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (November 22, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 3, 2023) |
July 28, 2022 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (September 12, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 12, 2022) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (September 12, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (September 12, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 12, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.