Pavilion on Main Street: Bed Rail Injury, 20 Sutures - IL
The facility's own investigation concluded that metal on the bed caused the injury. The Director of Nursing told inspectors that is why the bed was padded afterward. She said she expects staff to report any equipment that might pose a safety risk and pull it from use until it can be repaired.
The resident's physician, who also serves as the facility's Medical Director, described her in terms that made the stakes plain. "She doesn't just get skin tears," he said. "She has skin explosions." He said he would expect staff to ensure any equipment used on her is smooth with no rough edges.
The facility's own wound tracking showed she had suffered seven skin tears in the three months before the inspection. As of September 16, she had two active wounds, including the sutured laceration to her right lower leg and a separate wound to her left lower leg from an incident on August 25, one the facility had already been cited for during an annual survey.
When inspectors examined the facility's bed rail inventory, they found a list of more than 20 side rails that either had no end caps at all or had end caps that needed to be replaced.
The staff interview from the September 2 incident was dated that same day, but the facility did not provide it to the inspector until after the inspector had already interviewed the staff member herself.
The resident returned from the hospital with staples in her right leg. Nine days later, on September 11, a wound assessment noted mild episodic pain at the site.
Her physician said there were not many days between the September 2 incident and the one before it.
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.
Download the official CMS inspection PDF from Medicare.gov
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 23, 2026 · Our methodology
PAVILION ON MAIN STREET, THE in SANDWICH, IL was cited for violations during a health inspection on September 18, 2025.
The facility's own investigation concluded that metal on the bed caused the injury.
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.