Health inspection·October 9, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident safety during transportation to an outside appointment for 1 of 3 residents (R1) reviewed for safety in the sample of 4. The findings include:R1's face sheet printed on 10/9/25 showed diagnoses including but not limited to compression fracture of fifth vertebra (at admission), rheumatoid arthritis, spondylosis of the cervical region and lumbar region, and spinal stenosis. R1's facility assessment dated [DATE] showed no cognitive impairment and total staff assisted needed for transfers. The same assessment showed R1 needed staff supervision or touch assistance with wheelchair use. R1's progress note dated 5/19/25 at 1:30 PM, stated the resident returned to the facility following an orthopedic appointment. Nurse on duty was notified that resident fell from her wheelchair outside of the physician's office. A full assessment was done, and a hematoma (collection of blood trapped under the skin/bruise) was observed on the right side of her forehead. An order to send R1 to the local emergency room was received. On 10/9/25 at 10:56 AM, V4 (Receptionist/Transport Driver) stated she was responsible for R1's transport appointment at a neighboring hospital on 5/19/25. V4 said she went into the exam room with R1, per the resident's request. R1 was fitted with a back brace at that appointment. V4 stated she was wheeling R1 out of the building and pushing the wheelchair in a normal fashion. V4 said R1 suddenly said, I am slipping out, and firmly set her feet down on the ground. R1 fell forward out of the wheelchair and hit her head on the concrete sidewalk. V4 said she tried to hold R1 upright in the chair but just could not do it. V4 stated the wheelchair did not have footrests on it. V4 said hospital staff did respond to the situation and R1 refused any medical care from them. V4 said she called the subject facility and asked what to do. V4 was told to transport R1 back to the facility. V4 said R1 was alert, was not bleeding, but had a reddened area on her forehead. V4 said R1 was assessed by the nurse on duty when she returned to the facility and eventually sent to the local emergency room. V4 said R1 needed footrests for sure! R1 was complaining about the back brace making her sit abnormally in the wheelchair. R1 was trying to hold her feet upright but it was too hard for her. V4 said there was no facility policy regarding footrest use at that time. V4 said now the rule is nobody gets moved to the transport van unless they have wheelchair footrests. The nurse on duty when R1 returned to the facility on 5/19/25 was attempted to be reached for interview but did not respond during the survey. On 10/9/25 at 12:45 PM, V7 (Certified Nurse Aide) stated she did care for R1 frequently and was familiar with R1's needs. V7 said R1 had back issues at admission and used a wheelchair. V7 said R1 did not always sit in the wheelchair the right way. R1 would sit on the edge of the seat a lot. V7 said she had heard R1 fell out of the wheelchair while out of the facility at a doctor's appointment. On 10/9/25 at 1:25 PM, V1 (Administrator) stated resident wheelchairs should always have footrests, unless the resident refuses which is their right. Footrests are needed to elevate legs and keep them off the ground, so they don't drag. Footrests help keep the resident properly positioned in the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145712 Printed: 05/15/2026 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 145712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2025 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)