Complaint Investigation

Pavilion On Main Street, The

October 9, 2025 · Sandwich, IL · 515 North Main

Citations 1

CMS Rating 3/5

Beds 113

Provider ID 145712

Healthcare Facility

Pavilion On Main Street, The

Sandwich, IL · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

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

FF0689

Quality of Life and Care Deficiencies

Potential for More Than Minimal Harm

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.

Facility ID:

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.

More Reports

About This Inspection Report

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.