Pavilion On Main Street, The
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
resistive. V6 said V5 said she was getting Resident R1 up and noticed fluid coming out of leg. On 9/17/2025 at 2:10 PM, V5 CNA said V1 (Administrator) and V3 (Regional VP of Clinical Operations) met with her right after
she talked with this surveyor the previous day. V5 said they asked her what this surveyor was talking with her about, then they handed her a paper and said we forgot to have you sign the statement about what happened with Resident R1's incident. V5 said she started reading it and was told to just sign it. V5 said she told them she was going to read it first. V5 said she told them she did not recall saying anything about Resident R1 kicking. V5 said V1 and V3 said You did, just sign it. V5 said she told them Resident R1 was not kicking, she just waved her hand and told me to go away because she did not want to get up. V5 said she felt pressured into signing the form and just signed it. V5 said as soon as she did, she regretted it, and wished she had not signed the statement.On 9/17/2025 at 2:57 PM, V2 (Director of Nursing-DON) said they determined something happened with the metal on the bed caused Resident R1's injury. V2 said that is why her bed got padded.
V2 said she expects staff to report any equipment might cause a safety issue for residents, and to take the equipment out of service until it can be repaired.On 9/18/2025 at 12:56 PM, V19 (Resident R1's Physician/facility's Medical Director) said Resident R1 is a very fragile individual. V19 said, She (Resident 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 Resident R1's 9/2/2025 incident showed Resident 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. Resident 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 Resident 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 Resident R1 has had 7 skin tears in the last three months. The facility's 9/16/2025 Wound Report for non-pressure wounds showed Resident 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. Resident R1's Wound Assessment Details Report dated 9/11/2025 showed Resident 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. Resident 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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pavilion on Main Street, The
515 North Main Sandwich, IL 60548
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0755
Federal health inspectors cited PAVILION ON MAIN STREET, THE in SANDWICH, IL for a deficiency under regulatory tag F-F0755 during a complaint investigation conducted on 2025-09-18.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 2 deficiencies cited during this inspection of PAVILION ON MAIN STREET, THE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-11.
PAVILION ON MAIN STREET, THE in SANDWICH, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SANDWICH, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PAVILION ON MAIN STREET, THE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.