Pavilion On Main Street, The
PAVILION ON MAIN STREET, THE in SANDWICH, IL — inspection on October 9, 2025.
Found 1 citation. 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
wheelchair while being pushed. On 10/9/25 at 2:01 PM, V2 (Director of Nurses) stated residents need wheelchair footrests when being pushed by staff. V2 said, It is important to ensure the feet don't get tangled up underneath them.
Residents could tip forward in the chair without them. It is tiring for a resident to hold their feet up, off the ground.
All residents need footrests when staff are pushing them, unless it is care planned that the resident prefers not to have them. R1's care plan showed a focus area initiated 4/22/25 for a high risk for falls related to deconditioning, gait, and balance problems.
The care plan did not show any indication R1 preferred not to have wheelchair footrests. R1's local emergency room discharge summary report dated 5/19/25 showed diagnoses of a head injury, scalp abrasion, and scalp hematoma.
The facility's undated Wheelchair Use and Positioning policy states: If the resident uses their feet to self-propel keep the footrests up otherwise lower the footrests and assist the resident to place their feet on the footrest placing legs and feet in proper alignment if possible.
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