Pavilion on Main Street: Wheelchair Safety Failure - IL
Months later, that same resident ended up in a local emergency room with a head injury, a scalp abrasion, and a scalp hematoma.
Federal inspectors visited the facility on October 9, 2025, following a complaint. What they documented was straightforward: a resident at elevated fall risk was transported in a wheelchair without footrests in place, in violation of the facility's own written policy and contrary to what the Director of Nurses told inspectors was standard practice for every resident in the building.
The Director of Nurses, identified in the inspection report as V2, laid out the stakes plainly. "It is important to ensure the feet don't get tangled up underneath them," she told inspectors that afternoon. "Residents could tip forward in the chair without them. It is tiring for a resident to hold their feet up, off the ground." She said all residents require footrests when staff are pushing them, with one narrow exception: if a care plan specifically documents that the resident prefers not to use them.
The resident's care plan, initiated April 22, 2025, contained no such preference. It noted the fall risk clearly. It said nothing about footrests being optional.
The facility's own Wheelchair Use and Positioning policy, though undated, spelled out the same expectation. If a resident uses their feet to self-propel, keep the footrests up. Otherwise, lower them and help the resident place their feet properly.
This resident was not self-propelling. Staff were pushing them.
On May 19, 2025, weeks after the care plan flagged the fall risk, the resident's emergency room discharge summary listed a head injury, scalp abrasion, and scalp hematoma among the diagnoses.
The inspection report does not draw a direct causal line between the missing footrests and the ER visit. What it does show is a resident with documented instability, a facility that knew footrests were required, a care plan that never carved out an exception, and a discharge summary from a local emergency room that followed.
What the Director of Nurses described is not complicated physics. Without footrests, a resident's feet can catch on the floor while the chair moves forward. The chair stops. The resident does not. The forward pitch that follows is exactly the kind of fall that injures people whose balance is already compromised, whose gait is already unreliable, who are already, by their own care team's assessment, at high risk.
The facility received a deficiency citation under F0689, which covers the obligation to keep residents free from accidents the facility could reasonably have prevented. Inspectors classified the harm level as minimal harm or potential for actual harm, and noted few residents were affected.
That classification reflects the regulatory framework inspectors work within. It does not describe what an emergency room visit for a head injury feels like.
Pavilion on Main Street is a nursing facility in Sandwich, a small city about 65 miles southwest of Chicago. The inspection that produced this citation was a complaint survey, meaning someone raised a concern that prompted regulators to take a closer look.
The correction, if the facility follows through, is not expensive or complicated. Footrests go down before staff push a wheelchair. The resident's feet go on them. It is the kind of intervention that takes seconds and exists precisely because the alternative, a resident pitching forward out of a moving chair, is both foreseeable and preventable.
The resident identified in the report, referred to only as R1, had been flagged as high risk for falls since late April. By mid-May, they were in an emergency room. The care plan that was supposed to guide their daily care never once indicated they preferred to ride without footrests.
Nobody had checked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pavilion On Main Street, The from 2025-10-09 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 11, 2026 · Our methodology
PAVILION ON MAIN STREET, THE in SANDWICH, IL was cited for violations during a health inspection on October 9, 2025.
Months later, that same resident ended up in a local emergency room with a head injury, a scalp abrasion, and a scalp hematoma.
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.