Pavilion On Main Street, The
PAVILION ON MAIN STREET, THE in SANDWICH, IL — inspection on September 18, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
wished she had not signed the statement.On 9/17/2025 at 2:57 PM, V2 (Director of Nursing-DON) said
why her bed got padded. V2 said she expects staff to report any equipment might cause a safety
12:56 PM, V19 (R1's Physician/facility's Medical Director) said R1 is a very fragile individual. V19 said, She (R1) doesn't just get skin tears; she has skin explosions. V19 said there were not many days between the 9/2/2025 incident, and the one before. V19 said he would expect the facility staff to make sure the equipment used is smooth with no rough edges.The facility's investigation and QAPI plan for R1's 9/2/2025 incident showed R1 was sent to the hospital for a laceration to her right leg occurred while sitting the resident up on the side of her bed. R1 returned to the facility with 20 sutures.
The list V8 had been going over showing side rails in which there were no end caps, or the end caps needed to be replaced showed over 20 side rails either did not have end caps, or they needed to be replaced.
The facility's investigation file had staff interviews in it. V5's interview statement showed V5 said R1 was resistant and kicking her legs. V5's statement had a date up at the top of the form dated 9/2/2025. (These interviews were not provided to this surveyor until after V5 was interviewed by this surveyor).
The facility's list of residents with wounds, provided on 9/16/2025 showed R1 has had 7 skin tears in the last three months.
The facility's 9/16/2025 Wound Report for non-pressure wounds showed R1 had two active wounds as of 9/16/2025.
One to her left lower leg in the front, from a previous incident on 8/25/2025 (facility was cited for this on annual survey), and one to her right lateral lower extremity measured 4.5 centimeters (cm) in length x 6.5 cm width. R1's Wound Assessment Details Report dated 9/11/2025 showed R1 sustained a laceration and was sent to the emergency room (ER).
Staples dry and intact to site Resident with mild episodic pain to site. R1's 9/2/2025 notes from a local hospital showed New laceration of right lower extremity status post suture repair today.
The facility's undated policy and procedure titled Supplies and Equipment, Environmental Services showed Equipment shall be monitored for good working condition or any needed repairs.
145712 09/18/2025
Pavilion on Main Street, The 515 North Main Sandwich, IL 60548
available, I had the signed script sent to the pharmacy. V2 said then the facility had to wait for the
hospital should have sent 2-3 days' worth of the methadone with R4 on admission or sent a valid
notified him to request the e-script (electronic script). V19 was not in a location where he could look it up on a computer to see when the facility first notified him of the needed e-scripts. V19 said the facility is usually pretty good at letting him know when they need one. V19 said R4 should have come to facility with the prescription, or the hospital should have let me know. V19 said they are not medications that the facility would probably have at the facility. V19 said the facility should have requested 2-3 days' worth of them from hospital.R4's August 2025 Medication Administration Record (MAR) showed an order for Pregabalin (Lyrica) 150 mg.
Give 1 capsule two times a day for pain.
The MAR showed four doses were not administered (8/11/25 at 8 PM, 8/12/25 at 8:00 AM, 8/12/25at 8:00 PM, and 8/13/25 at 8:00 AM).
The MAR showed an order for Methadone Hydrochloride 5 mg.
Give 1 tablet three times a day for pain.
The MAR showed six doses were not administered as ordered. (8/11/25 at 9:00 PM, 8/12/25 at 8:00 AM, 12:00 PM, and 9:00 PM, and on 8/13/25 at 8:00 AM and 12:00 PM). R4's progress notes showed on 8/11/25, 8/12/25, and 8/13/25 the facility was awaiting delivery from pharmacy for the methadone.
The 8/13/25 notes showed the facility was waiting on R1's Lyrica to be delivered from pharmacy.
The 8/13/25 notes showed V2 (DON) documented at 3:38 PM that she received a call from R4's family regarding his missing medications.
The notes showed the pharmacy informed her they had not received prescriptions from the doctor. 8/13/25 at 4:34 PM, V2 documented the pharmacy called and verified they received the prescriptions, and the medications would be delivered within four hours.R4's referral notes from the local hospital dated 8/10/2025 showed he was receiving methadone 5 mg three times daily and Lyrica 75 mg nightly in the hospital.The facility provided the pharmacy's packing slip showing the methadone and Lyrica were delivered to the facility on 8/13/2025 at 11:47 PM.The facility's policy and procedure titled Reconciliation of Medications, with a revision date of October 2018, showed, Gather the information needed to reconcile the medication list: a.
Approved mediation reconciliation form. b.
Discharge summary from referring facility. c. admission order sheet. d.
All prescription and supplement information obtained from the resident/family during the medication history. e.
Most recent electronic medication administration record, if this is a readmission.
The policy showed, General Guidelines: 1.
Medication reconciliation is the process of generating a master list of the resident's current medications. 2.
Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. 6. If there is a discrepancy or conflict in medications, dose, route, or frequency, determine the most appropriate action to resolve the discrepancy.
For example: a.
Contact the nurse from the referring facility; b.
Contact the physician from the referring facility; c.
Discuss with the resident or family; d.
Contact the resident's primary physician in the community.Contact the admitting and/or attending physician . 7.
Document findings and actions in the resident's electronic medical record.
Documentation.If the discrepancy was unresolved, document how the discrepancy was communicated to the charge nurse, physician, pharmacy, and/or next shift.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.