Pavilion on Main Street: Missed Pain Meds for Days - IL
The resident, identified in inspection records as R4, was admitted on August 10, 2025, transferred from a local hospital where he had been receiving methadone hydrochloride 5 mg three times daily and Lyrica 75 mg nightly. By the time his medications finally arrived at the facility, it was nearly midnight on August 13. In the roughly 50 hours between his admission and that delivery, he missed six doses of methadone and four doses of Lyrica. Ten doses total.
His family had to call the facility to find out why.
Progress notes show the facility spent August 11, 12, and 13 logging the same explanation: still waiting on pharmacy delivery for the methadone. On August 13, the Director of Nursing documented at 3:38 PM that she had received a call from R4's family asking about the missing medications. When she checked with the pharmacy, she learned the pharmacy had never received prescriptions from the doctor at all. The medications weren't delayed in transit. They hadn't been ordered.
Forty-six minutes later, the DON documented that the pharmacy called back to confirm it had now received the prescriptions and would deliver within four hours. The packing slip the facility provided to inspectors showed the methadone and Lyrica arrived at 11:47 PM.
R4's physician, who also serves as the facility's Medical Director and is identified in inspection records as V19, told inspectors on September 18 that R4 is "a challenging individual" and that the hospital should have sent two to three days' worth of methadone with him on admission, or sent a valid prescription along. "Unfortunately, this is an ongoing issue with hospitals," he said.
He acknowledged the facility had notified him to request the electronic prescription, but said he wasn't in a location where he could check a computer to see exactly when that notification came. He said the facility is "usually pretty good" at letting him know when prescriptions are needed, and that methadone and Lyrica are not medications the facility would typically keep in stock.
What the inspection report does not show is any documented attempt by facility staff, in the 50-plus hours before the family called, to escalate the missing prescriptions beyond noting in the progress record that they were waiting on the pharmacy. The facility's own medication reconciliation policy, last revised in October 2018, describes a process meant to ensure that medications a resident has been taking continue without interruption during the transfer process. It lists specific steps for resolving discrepancies: contact the nurse from the referring facility, contact the referring physician, discuss with the resident or family, contact the attending physician. It also requires that unresolved discrepancies be documented along with how they were communicated to the charge nurse, physician, pharmacy, and the next shift.
Methadone is not a medication that can be skipped for two days without consequence. It is prescribed for chronic pain management on a scheduled dosing regimen, and missed doses mean unmanaged pain, not just an inconvenience. R4 had been on it daily in the hospital immediately before his transfer.
The inspection, triggered by a complaint, was conducted on September 18, 2025. Inspectors rated the violation as causing minimal harm or potential for actual harm, and noted that few residents were affected. The facility's Medical Director placed much of the responsibility on the discharging hospital. But the facility's own records show that three days passed, the family had to intervene, and only then did anyone confirm the prescriptions had never been sent.
R4's family made the call at 3:38 in the afternoon. By midnight, the medications were there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pavilion On Main Street, The from 2025-09-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 17, 2026 · Our methodology
PAVILION ON MAIN STREET, THE in SANDWICH, IL was cited for violations during a health inspection on September 18, 2025.
By the time his medications finally arrived at the facility, it was nearly midnight on August 13.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.