Pavilion on Main Street: Resident Injury, Staff Pressure - IL
She signed it. And as soon as she did, she said, she regretted it.
That moment, described by the CNA herself to a federal inspector at The Pavilion on Main Street, is at the center of a complaint inspection completed September 18, 2025, at the Sandwich, Illinois nursing home. Inspectors cited the facility for actual harm to a resident, a woman identified in the report only as R1, who left the facility in early September with a gash in her right leg that required 20 sutures.
R1 is described by her own physician, the facility's medical director, as someone who doesn't just get skin tears. "She has skin explosions," he told the inspector on September 18. He said there weren't many days between the September 2 incident and the one before it. In the three months leading up to the inspection, R1 had sustained seven skin tears. As of September 16, she had two active wounds.
The injury on September 2 happened while a certified nursing assistant, identified as V5, was getting R1 up and sitting her on the side of her bed. Fluid was coming out of R1's leg. She was sent to a local hospital, where records document a new laceration of the right lower extremity, repaired with sutures that day. She came back to the facility with 20 of them.
The facility's investigation concluded that something on the bed caused the injury, and R1's bed was padded afterward. The Director of Nursing told the inspector she expects staff to report any equipment that might cause a safety issue and to pull it from service until it's fixed. A facility list reviewed during the inspection showed more than 20 side rails across the building either had no end caps or had end caps that needed replacement.
The investigation file included staff interview statements, one of them bearing V5's name and a date of September 2, 2025, the day of the incident. That statement said R1 was resistant and kicking her legs. The facility did not provide those interview documents to the inspector until after the inspector had already spoken with V5 directly.
What V5 told the inspector was different.
On September 17, V5 said the administrator, identified as V1, and the Regional Vice President of Clinical Operations, identified as V3, pulled her aside immediately after she had spoken with the inspector the previous day. They handed her a paper. They said they had forgotten to have her sign the statement about what happened with R1's incident.
V5 said she started reading it. They told her to just sign it.
She told them she didn't recall saying anything about R1 kicking. They said she did. Just sign it.
V5 told them R1 was not kicking. She had waved her hand and told V5 to go away because she didn't want to get up. V5 said she felt pressured. She signed the form. She said she wished she hadn't.
A colleague of V5's, identified as V6, told the inspector that V5 had said she noticed fluid coming out of R1's leg while getting her up, and that R1 was resistive, not that she was kicking.
The physician's account adds a layer the facility's internal investigation did not appear to grapple with. He told the inspector he would expect staff to make sure any equipment used on a resident this fragile is smooth with no rough edges. R1's wound assessment from September 11 noted staples dry and intact, with mild episodic pain at the site. Her left lower leg still carried an open wound from a separate incident on August 25, one the facility had already been cited for during its annual survey.
The statement V5 signed, the one she said did not reflect what she told anyone, is now part of the facility's official investigation record.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 27, 2026 · Our methodology
PAVILION ON MAIN STREET, THE in SANDWICH, IL was cited for violations during a health inspection on September 18, 2025.
And as soon as she did, she said, she regretted it.
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.