Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pavilion On Main Street, The during CMS and state inspections, most recent first.
A resident requiring total staff assistance for transfers and supervision with wheelchair use was transported to an outside appointment without wheelchair footrests. After being fitted with a back brace, the resident slipped out of the wheelchair while being pushed by a staff member, resulting in a fall and head injury. Staff interviews and facility policy confirmed that footrests are necessary for safe transport unless specifically refused and care planned, but no such refusal was documented.
A resident with severe cognitive impairment, reduced mobility, and fragile skin sustained a deep leg laceration requiring hospital treatment after contact with a bed rail missing its end caps. Investigation found that multiple side rails in the facility lacked protective end caps, leaving rough metal edges exposed. Staff and maintenance confirmed the equipment was not in safe working condition at the time of the incident, and the resident had a history of skin tears and required extensive assistance for transfers.
A resident with a history of chronic pain management did not receive methadone and Lyrica for several days after admission due to missing prescriptions, resulting in multiple missed doses. Staff were unable to obtain timely scripts from the hospital, and the facility's medical director eventually provided them after a delay. Upon discharge, the resident also did not receive a prescription for a diuretic, causing further missed medication doses at home.
A resident with a history of skin tears and dependence on staff for transfers sustained a large skin tear requiring 11 stitches during a transfer from wheelchair to bed. The CNA involved noticed the injury after the transfer, and the resident was sent to the ER for treatment. The resident had experienced multiple similar injuries during previous transfers and repositioning, despite care plans and facility policies outlining the need for safe handling.
Two residents with significant weight loss did not receive their prescribed therapeutic diets, including double portions and specific supplements, as ordered by the registered dietitian. Despite clear dietary recommendations and care plans, staff provided only regular portions and omitted required items such as super cereal and ice cream during observed meals.
The facility did not follow prescribed recipes or menu requirements for pureed and mechanical soft diets, resulting in residents receiving incorrect food textures and inadequate portions. Pureed foods were prepared with unmeasured ingredients and insufficient protein, and mechanical soft diets were not properly ground as required. These failures affected all residents requiring therapeutic diets.
Surveyors observed unsanitary conditions in the kitchen and food prep areas, including overflowing garbage, dirty floors and equipment, improper storage of clean utensils, and food debris throughout. Staff failed to use required beard guards and did not follow hand hygiene protocols after handling garbage. Facility cleaning schedules and hygiene policies were not followed or enforced, affecting all residents.
Surveyors observed that several residents on pureed diets were served meals that were unappetizing, unidentifiable, and unpleasant in taste and texture. One resident voiced repeated dissatisfaction, and both surveyors and the administrator confirmed the poor quality of the pureed food after sampling. The facility's dietician acknowledged that recipes should be followed, but the meals did not meet the facility's guidelines for palatability.
Two residents were found to have significant wall damage, including heavy gouging and missing paint, behind their headboards and a recliner. The Director of Maintenance confirmed no work order had been submitted for repairs, despite facility policy requiring a safe and homelike environment.
Two residents with ADL self-care deficits did not receive scheduled showers as required. One missed a shower due to staff unavailability, with inconsistent documentation and a substantiated grievance. Another was marked as having refused a shower without proper documentation or nurse verification, and later denied refusing care. Facility policy for documenting refusals and re-attempting care was not followed.
A resident with a persistent, itchy body rash was not provided a timely dermatology consult as ordered by the physician. Despite ongoing symptoms and documentation indicating the need for referral, the scheduler was unaware of the order and no appointment was made, resulting in a delay in appropriate specialist evaluation.
Two residents experienced medication administration errors when RNs failed to follow proper procedures: one did not prime an insulin pen as required, and another gave an incorrect dose of Bumex due to a misunderstanding of tablet strength. These actions resulted in a medication error rate above the acceptable threshold.
A registered nurse used a blood glucose monitoring device on two residents consecutively without cleaning it between uses, contrary to facility policy requiring disinfection after each use. The nurse reported that the device is only cleaned after each shift. Both residents had orders for blood glucose monitoring, with one also receiving insulin therapy.
The facility did not have a certified Infection Preventionist, as the acting IP, an LPN, had not completed the required training and certification, and the previous DON with the necessary credentials was no longer employed. This failure had the potential to affect all 94 residents.
The facility failed to ensure staff wore beard coverings while serving food, as observed during a survey. Residents raised concerns about this issue, and a dietary aide was seen serving meals without a beard covering. The dietary manager acknowledged the requirement for beard coverings and noted plans to order new ones.
A resident was found with medications left at her bedside, which she forgot to take, despite not having a self-administration order. An LPN and the DON confirmed that medications should not be left at the bedside and that nurses should ensure residents take their medications. The facility's policy requires a competency assessment for self-administration.
A facility failed to provide a bed hold notice to a resident's representative during a transfer due to safety concerns. The Social Service Director marked a form indicating the policy was given, but admitted it was not sent. The DON confirmed no documentation of the notice was provided, violating the facility's policy.
Failure to Provide Wheelchair Footrests During Transport Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of compression fracture, rheumatoid arthritis, spondylosis, and spinal stenosis, who required total staff assistance for transfers and supervision or touch assistance with wheelchair use, was transported to an outside medical appointment without wheelchair footrests. During the return from the appointment, the resident, who had just been fitted with a back brace and was sitting abnormally in the wheelchair, reported slipping out of the chair. The transport driver was unable to prevent the resident from falling forward out of the wheelchair, resulting in the resident hitting her head on the concrete sidewalk and sustaining a hematoma and scalp abrasion. The wheelchair used for transport did not have footrests, and the resident was unable to keep her feet elevated, which contributed to her slipping and falling from the chair. Interviews with facility staff confirmed that footrests are necessary for safe wheelchair transport unless specifically refused by the resident and care planned accordingly. The resident's care plan did not indicate any refusal or preference against footrest use. The facility's policy also required footrests to be used unless the resident self-propels. The lack of footrests during staff-assisted transport, combined with the resident's physical condition and recent back brace fitting, directly led to the fall and injury. There was no facility policy regarding footrest use at the time of the incident.
Failure to Maintain Safe Bed Rail Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to maintain a bed rail in a safe condition, resulting in a resident sustaining a significant injury. The resident, who had a complex medical history including severe cognitive impairment, reduced mobility, osteoporosis, repeated falls, and fragile skin, required substantial to maximal assistance for most activities of daily living and was dependent on staff for all transfers. During an attempt to transfer the resident from bed, a CNA noticed the resident was fearful and holding tightly to the side rail. As the transfer was being performed, the resident suddenly complained of leg pain, and a significant laceration with heavy bleeding was discovered on her right leg. The injury required hospital treatment and sutures. Investigation revealed that the side rail involved in the incident was missing its end caps, leaving rough, exposed metal edges. The CNA reported that the resident was not combative but was fearful and resistant to getting up, and that the injury occurred within minutes of starting the transfer. Maintenance staff later confirmed that multiple side rails throughout the facility were missing end caps, with a documented list showing over 20 side rails in need of repair or replacement of end caps. The maintenance director acknowledged that the end caps were installed and padding was added only after the incident occurred. Staff interviews and record reviews indicated that the resident had a history of multiple skin tears and wounds in recent months, and that the facility's policy required equipment to be monitored for good working condition and repairs as needed. The DON stated that staff are expected to report any equipment that might pose a safety issue and to remove it from service until repaired. The physician described the resident as extremely fragile, with a propensity for severe skin injuries, and expected that equipment used with such residents should be free of rough edges. The facility's investigation confirmed that the injury was caused by the exposed metal on the bed rail.
Failure to Provide Timely Medication Administration Due to Prescription Delays
Penalty
Summary
The facility failed to ensure that a resident's medications were available and administered as ordered upon admission. The resident, who had a history of chronic pain management with methadone and Lyrica, did not receive these medications for several days after admission due to the lack of a valid prescription. The resident's wife reported that he missed his medications for three days and expressed concern about potential withdrawal, particularly because he had been on methadone for 13 years. Nursing staff confirmed that the medications were not available and documented missed doses in the medication administration record (MAR). The delay in medication administration was attributed to the absence of signed prescriptions from the hospital at the time of admission. The facility's process required a signed script from a physician before the pharmacy could dispense the medications. Staff attempted to obtain the necessary prescriptions by contacting both the hospital and the facility's medical director. The hospital declined to provide the scripts, and the facility's medical director eventually signed them after being notified. During this period, the resident missed multiple doses of methadone and Lyrica, as documented in the MAR and progress notes. Additionally, upon discharge, the resident did not receive a prescription for a diuretic (Bumetanide), resulting in missed doses at home until a home health nurse intervened. The facility's medication reconciliation policy outlined steps to ensure continuity of medication administration during transitions, but these procedures were not effectively followed, leading to interruptions in the resident's prescribed medication regimen.
Failure to Prevent Skin Tears During Resident Transfers
Penalty
Summary
A resident with a history of multiple skin tears and impaired skin integrity sustained a significant injury during a transfer from wheelchair to bed. The certified nursing assistant (CNA) involved reported noticing a blood stain on the resident's sock and, upon removing it, discovered a fresh wound on the left lower leg. The wound was later assessed as a large skin tear requiring 11 stitches, and the resident was transferred to the emergency room for treatment. Interviews with staff and the resident's daughter confirmed that the injury occurred during the transfer process, with the CNA unable to specify exactly how the injury happened. The resident's medical doctor and wound care nurse both confirmed the injury was sustained during the transfer. The resident's records indicate a pattern of similar incidents, including multiple previous skin tears and bruises occurring during transfers and repositioning. The care plan documented the resident's dependence on staff for transfers due to activity intolerance and dementia, requiring a two-person assist. Despite these documented needs and a policy requiring safe transfer practices, the resident continued to experience skin injuries during care, culminating in the significant laceration that required emergency intervention.
Failure to Provide Prescribed Therapeutic Diets for Residents with Significant Weight Loss
Penalty
Summary
The facility failed to implement dietary recommendations for residents with a history of significant weight loss, resulting in two residents not receiving their prescribed therapeutic diets. Observations revealed that the dietary manager prepared insufficient quantities of pureed chicken nuggets for residents on pureed diets, providing only half the required amount. Meal tickets for both affected residents indicated the need for double portions and specific supplements, but these were not provided during multiple observed meals. One resident with diagnoses including toxic encephalopathy, dysphagia, and dementia experienced significant weight loss over several months. Despite a registered dietitian's recommendation for double portions to address ongoing weight loss, the resident consistently received only regular pureed diet portions at meals. Documentation confirmed the resident's weight had decreased by over 10% in four months, and the care plan included interventions to increase meal portions, which were not followed. Another resident with major depressive disorder, complete loss of teeth, and severe underweight status was also affected. This resident's meal ticket specified a pureed diet with double portions, two bowls of super cereal at breakfast, and ice cream at lunch and dinner. Observations showed the resident did not receive the required double portions, super cereal, or ice cream during meals. The registered dietitian confirmed that these interventions were necessary to address the resident's significant weight loss, but the dietary recommendations were not implemented as ordered.
Failure to Prepare and Serve Therapeutic Diets According to Menu and Recipe Requirements
Penalty
Summary
The facility failed to properly prepare and serve pureed and mechanical soft diets according to prescribed recipes and menu requirements for all 97 residents. Specifically, for residents requiring pureed diets, the Dietary Manager did not follow the facility's pureed chicken nugget recipe, instead using unmeasured amounts of hot water and bread crumbs rather than the specified chicken broth and thickener. The Dietary Manager also failed to provide the correct portion size, pureeing only 21 chicken nuggets for 11 residents instead of the required 55, resulting in each resident receiving less than the intended amount of protein. Additionally, no pureed bread was served, despite it being listed on the menu, due to the Dietary Manager forgetting to include it. For residents requiring mechanical soft diets, the facility did not prepare the chicken nuggets according to the mechanical soft recipe, which required the nuggets to be ground with gravy. Instead, residents on mechanical soft diets were served whole chicken nuggets, not in the required texture. The Dietician confirmed that recipes and menus were not followed, and that water and bread crumbs should not have been used unless specified in the recipe. The facility's policy states that menus are to meet nutritional needs and be prepared as planned, but these procedures were not followed, resulting in residents not receiving meals consistent with their dietary requirements.
Failure to Maintain Sanitary Food Service Practices and Proper Staff Hygiene
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen and food preparation areas, as evidenced by multiple observations during a survey. The kitchen was found with an overflowing garbage container under the handwashing sink, sticky floors, and food and liquid debris present in several areas, including the sides and front of the oven and food processor. Clean utensils such as large spoons and metal scoops were stored on a dirty drainage mat contaminated with food debris and a sticky white liquid. The Dietary Manager acknowledged the unsanitary storage of utensils and was unsure when the kitchen was last cleaned, stating it had likely not been cleaned in over a week. In the walk-in freezer and dry storage room, food items and packets were scattered on the floor among opened boxes and debris. Additionally, two dietary aides with full beards were observed working in the kitchen without facial hair coverings, contrary to facility policy. Further unsanitary conditions were noted in the first-floor kitchenette, where the coffee machine was dirty, and the sink contained a soiled spoon, wet washcloth, cup, empty pitcher, and food debris, including scrambled eggs, with flies present. The floor was sticky and littered with food debris, and the steam table had spilled food with flies crawling on it. During food preparation, the Dietary Manager handled garbage and then prepared food without washing hands. Facility policies required daily cleaning schedules and the use of hair restraints and beard guards, but these were not followed or enforced, as confirmed by staff interviews and observations.
Unappetizing and Unpalatable Pureed Meals Served to Residents
Penalty
Summary
Surveyors found that the facility failed to ensure that residents on pureed diets received appetizing and flavorful meals. One resident, who required a pureed diet, repeatedly expressed dissatisfaction with the taste and appearance of his meals, stating he could not eat most of the food provided. Observations revealed that his trays often contained unidentifiable or unappetizing items, such as pureed pancakes and eggs with an unpleasant taste and consistency. Surveyors and the facility administrator sampled the pureed eggs and found them to be milky white, with a thin pudding-like consistency and an unpleasant, watery, powdery taste. Pureed chicken nuggets and carrots were also sampled and found to be very thick, sticking to the roof of the mouth, and unpalatable. The facility's dietician acknowledged that kitchen staff should be following recipes, but the meals served did not meet the guidelines for palatability and appetizing presentation. The deficiency affected at least four residents on pureed diets, including those with cognitive impairments who could not be interviewed. The facility's own guidelines require food to be prepared and served in a manner that is both safe and appetizing, but observations and interviews confirmed that this standard was not met for residents receiving pureed meals.
Failure to Maintain Homelike Environment Due to Wall Damage
Penalty
Summary
The facility failed to provide a homelike environment for two residents, as evidenced by heavy gouging and missing paint on the walls behind both residents' headboards and behind one resident's recliner. The damaged areas measured approximately 2-3 feet by 2-3 feet. During an interview, the Director of Maintenance confirmed that there was no work order submitted for the room and stated that resident rooms should not have wall damage or holes. Facility policy requires that residents be provided with a safe, clean, comfortable, and homelike environment.
Failure to Provide Scheduled Bathing and Proper Documentation for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled bathing assistance for two residents who required staff support for activities of daily living (ADLs). One resident, with a documented self-care deficit and a care plan indicating the need for staff assistance with bathing, was scheduled to receive showers twice weekly. However, records showed a significant gap between showers, and documentation was inconsistent between the shower sheets and the electronic medical record. The resident reported missing a scheduled shower due to staff being unavailable, and a grievance filed by the resident's son was substantiated, confirming the missed care. Another resident, also with an ADL self-care deficit and scheduled for twice-weekly showers, was documented as having refused a shower on a scheduled day. However, the documentation lacked a reason for the refusal, the name of the staff member who recorded it, and a nurse's signature, as required by facility policy. The resident later denied refusing the shower, stating he was waiting for it. Staff interviews confirmed that refusals should be documented with a nurse's involvement and that re-attempts should be made, but these steps were not followed.
Failure to Follow Physician's Orders for Dermatology Consult
Penalty
Summary
The facility failed to follow physician's orders for a dermatology consult for a resident with a persistent body rash that had been ongoing since July 2025. The resident was observed with a red, scabby rash covering his arms, abdomen, and inner thighs, and reported ongoing itching and discomfort. Despite being treated with Permethrin Cream for suspected scabies in July, the rash persisted. Progress notes from early August indicated a referral to dermatology was needed and that the resident's power of attorney agreed with this plan. However, the facility scheduler was unaware of the need for the appointment and had not scheduled it, resulting in a significant delay in obtaining the dermatology consult as ordered by the physician.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 6.67%, which exceeds the acceptable threshold of 5%. In one instance, a registered nurse (RN) administered Insulin Degludec to a resident without priming the needle as required by the manufacturer's guidelines. The nurse incorrectly believed that priming was only necessary for the first dose from the pen, despite instructions specifying that the pen should be primed before each injection to ensure proper dosing. In another case, a different RN administered only one tablet of Bumex (bumetanide) to a resident instead of the prescribed two tablets. The nurse misinterpreted the dosage, believing the tablets were 2 mg each when they were actually 1 mg, as indicated on the medication administration record and the medication card. This resulted in the resident receiving less medication than ordered by the physician. Both incidents demonstrate a failure to follow physician orders and established medication administration policies.
Failure to Clean Glucose Monitoring Device Between Resident Uses
Penalty
Summary
The facility failed to ensure proper cleaning of the blood glucose monitoring machine after each resident use, as observed during a survey. On the morning of 8/26/2025, a registered nurse used the glucose monitoring device to check the blood sugar of one resident and, without cleaning the machine, proceeded to use it on a second resident. The nurse then placed the uncleaned device back into the medication cart. When questioned, the nurse stated that the machine is cleaned after each shift with disinfectant wipes, rather than after each resident use. Both residents involved had physician orders for blood glucose monitoring, with one also receiving insulin aspart per sliding scale. The facility's policy requires cleaning and disinfecting of blood glucose meters between patient uses to prevent transmission of pathogens.
Lack of Certified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified Infection Preventionist (IP) who had successfully completed the required infection preventionist training and certification. The acting IP, an LPN, had been serving in this role for over a year but had not passed the test portion of the infection preventionist course and therefore had not received certification. The previous DON, who held the necessary IP certification, was no longer employed at the facility. The facility administrator confirmed that there was currently no certified IP on staff, despite the facility's job description requiring such certification for the position. This deficiency had the potential to affect all 94 residents in the facility, as noted in the facility data sheet.
Failure to Ensure Beard Coverings During Meal Service
Penalty
Summary
The facility failed to ensure that staff wore beard coverings while serving food, as observed during a survey. During a resident council meeting, residents expressed concerns about staff not wearing beard coverings when serving meals. This issue was observed firsthand when a dietary aide with a beard was seen serving food without a beard covering during meal service on both the first and second floors. Despite being reminded by another staff member to wear a face mask, the dietary aide initially did not comply. The dietary manager acknowledged that staff with beards should wear at least a face mask to cover their facial hair when serving or plating food. The manager also noted that some staff members were dissatisfied with the current beard coverings provided by the facility and mentioned plans to order new ones. The facility's policy on hair restraints, revised in 2017, requires food and nutrition employees to wear hair restraints and beard guards, which was not adhered to in this instance.
Failure to Monitor Medication Administration
Penalty
Summary
The facility failed to monitor a resident during medication administration, which was observed during a survey. A resident was found with medications left in a pill cup on her bedside table, which she had forgotten to take. The resident confirmed that the medications were left by a nurse about an hour prior, despite not having a self-administration order for medications. A Licensed Practical Nurse (LPN) stated that the resident did not have a self-administration order and that medications should not be left at the bedside. The Director of Nursing (DON) also confirmed that medications should not be left at the bedside and that nurses should ensure residents take their medications. The facility's policy requires that residents may only self-administer medications if they have been deemed competent to do so by the Attending Physician and the Interdisciplinary Care Planning Team.
Failure to Provide Bed Hold Notice During Resident Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to a resident's representative at the time of transfer, which is a violation of resident rights. The incident involved a resident who was transferred out of the facility due to safety concerns. The Notice of Involuntary Transfer or Discharge form, dated 5/21/24, indicated that a copy of the facility's bed hold policy was given to the resident or their responsible party. However, the Social Service Director admitted that she did not actually send a copy of the bed hold policy at that time, despite marking the form to indicate that it had been provided. The Director of Nurses confirmed that there was no documentation of a bed hold notice being sent with the resident at the time of transfer. The facility's policy requires that information concerning the bed-hold policy be provided upon admission and when a resident is transferred for hospitalization or therapeutic leave.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Sandwich
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sandwich Living & Rehab Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Hillside Rehab & Care Center | 8.8 mi | ★★★★★ | 9 | 0 |
| Pearl At The Tillers | 14.4 mi | ★★★★★ | 2 | 0 |
| Pearl Of Orchard Valley | 15.1 mi | ★★★★★ | 7 | 2 |
| Prairie Crossing Lvg & Rehab | 15.5 mi | ★★★★★ | 0 | 0 |
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