Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pavilion Of Ottawa during CMS and state inspections, most recent first.
A resident with dementia, who is nonverbal, was observed by a CNA tapping her mouth and appearing to have lost a natural tooth, which was reported to a nurse who stated the resident would be referred to a dentist. Progress notes documented a missing right lateral tooth with no oral pain or swelling and indicated the resident’s daughter was aware, and the daughter later reported that an additional tooth was missing based on a profile picture. Despite the daughter’s repeated concerns to the Administrator and DON about how the teeth were lost, the facility did not determine what happened, did not complete a dental referral, and did not enter the concern into the grievance log or complete the required grievance investigation and follow-up communication as outlined in its grievance policy.
Cross-Contamination During Food Prep and Meal Service: A scoop was left in a container of thick-it powder, and dietary staff handled pans and condiments against their clothing while moving food. During lunch service, an aide and a cook used the same gloves to touch the steam table, meal tickets, plates, refrigerator handles, utensil handles, buns, and cheese while plating burgers, without removing gloves, washing hands, or changing gloves.
A facility failed to provide required ADL assistance for four residents. Three female residents were observed with visible facial hair and one resident was observed disheveled with unclean dentures, facial hair, and poor hygiene. Records showed care plans and MDS assessments calling for staff help with grooming, shaving, oral care, and denture care, while the DON stated grooming and shaving should be provided unless a resident refuses or is combative.
Medication containers were not properly labeled with open and discard dates. An LPN and RN observed several insulin pens with broken tamper-evident seals but missing required dating or initials, including pens for residents with active insulin orders and one pen for a resident whose insulin had already been discontinued. Two multi-dose morphine vials for hospice residents were also found without open dates or expiration dates in the narcotic box, despite staff stating that opened vials must be dated.
An LPN did not disinfect a shared glucometer according to the product label after blood sugar checks, using only brief wipe passes and returning the device to use between residents. The IP nurse and ADON stated the glucometer should remain wet for 3 minutes, and records showed 9 residents on the unit had diabetes and accu check orders. Facility policy required glucose meters to be cleaned and disinfected per manufacturer instructions and contact-time requirements.
A resident with dementia, weakness, and a history of falls was transported in a wheelchair without both footrests in place, and his foot was observed dragging on the floor during the trip. In a separate incident, another resident with dementia and moderate cognitive impairment had a prescribed nasal spray left on the bedside table within reach while he was asleep, even though he stated he could not manage his medications and staff confirmed he was not able to self-administer them.
Improper urinary catheter care and incomplete catheter orders were identified for two residents. One resident with dementia, interstitial cystitis, and urinary retention had catheter tubing left on the floor and run over during wheelchair transport, while another resident’s drainage bag was held above the bladder during a transfer and the chart lacked a diagnosis and catheter size/order details for the indwelling catheter.
Failure to Administer Ordered Oxygen: A resident with COPD, chronic respiratory failure with hypoxia, emphysema, and severe cognitive impairment was observed with a nasal cannula in place, but the oxygen tank was empty and no oxygen was being delivered despite physician orders for continuous oxygen. Staff confirmed the tank was empty and stated the resident needed oxygen running continually, while the DON stated nurses should always follow physician orders.
Two residents experienced falls and injuries due to staff not following established transfer and supervision protocols, including failure to use leg/footrests during wheelchair transport and not providing required two-person assistance or using a transfer belt during transfers. These actions were contrary to facility policy and resulted in preventable harm.
The facility failed to perform prescribed range of motion exercises and ensure the use of assistive devices for residents with functional limitations and contractures. Several residents did not receive the required exercises as per their care plans, and staff did not document any refusals. Additionally, a resident with a contracture was not provided with the necessary splint, leading to inadequate care.
A facility failed to conduct a PASARR rescreen for a resident after a new diagnosis of PTSD was added to their care plan. Despite the facility's policy requiring rescreening upon significant changes in mental health status, the Social Services Director confirmed that no rescreen was performed, highlighting a lapse in compliance with regulatory requirements.
A resident with multiple health conditions requiring assistance with ADLs was found with unshaved facial hair, contrary to the facility's grooming policy. The DON confirmed the oversight.
Failure to Investigate and Resolve Grievance Regarding Resident’s Missing Teeth
Penalty
Summary
The facility failed to honor a resident’s right to voice grievances and have them promptly investigated and resolved when the resident’s daughter reported concerns about the resident’s missing natural teeth. The daughter stated that about a month prior she had raised concerns to staff, including the Administrator and DON, about how the resident lost at least one tooth and questioned whether it had come off in the resident’s mouth and what caused it to fall out. As of the survey date, she reported that no one at the facility had provided her with an explanation of what happened. A CNA reported that a couple of weeks earlier she observed the resident, who has dementia and is nonverbal, tapping her mouth and appearing to have lost a tooth, and that she reported this to a nurse who said the resident would be referred to a dentist. Progress notes dated 1/27/26 documented an oral visual check with no pain, discomfort, redness, or swelling of the gums, and noted one right lateral tooth missing, with the daughter aware. The DON stated that an email was sent to the daughter on 1/27/26 indicating the facility was looking into how the tooth became missing, and that on 1/30/26 the daughter reported additional missing teeth based on the resident’s profile picture, for a total of two missing teeth. As of the survey date, the DON acknowledged there had been no update to the daughter because no one knew what had happened to the missing tooth, and the resident had not been referred to a dentist. Review of the facility’s grievance log showed that the daughter’s concerns about the missing tooth were not entered, and both the Administrator and DON confirmed the concern should have been logged with a resolution, contrary to the facility’s grievance policy requiring investigation and communication of findings within specified time frames.
Cross-Contamination During Food Preparation and Meal Service
Penalty
Summary
The facility failed to ensure food was prepared, stored, and served in a manner to prevent cross-contamination. During kitchen observation, a scoop was left inside a large container of thick-it powder, with the scoop handle touching the powder. The DON stated the facility did not have any residents with a feeding tube. The dietary manager later stated the scoops should not be in dried food containers because that is cross-contamination and should be placed in a bag on top of the container. During lunch preparation and service, a cook prepared pureed hamburger patties and separated them into small pans for different halls, then carried pans and condiments against her clothing while placing them in the hot box or refrigerator. During meal service, dietary staff on the 200-hall and 800-hall used the same gloves while touching the steam table, meal tickets, Styrofoam plates, refrigerator door handles, utensil handles, buns, and slices of cheese while plating burgers. They did not remove gloves, wash hands, or change gloves during the observation. The dietary manager stated staff should not touch refrigerator door handles, steam tables, utensil handles, or ready-to-eat items like buns or cheese with gloved hands, and tongs should be used for buns and ready-to-eat foods.
Failure to Provide Required Grooming, Shaving, and Denture Care
Penalty
Summary
The facility failed to provide assistance with shaving facial hair for three female residents and failed to provide grooming, shaving, and denture care for one resident. During observations, R48 was seen seated in a wheelchair with thick, coarse facial hair on the chin area, and R57 was observed with visible facial hair on the upper lip, lower lip, and chin area. R65 was observed seated in her wheelchair with facial hair on the chin area, uncombed hair, and an overall disheveled appearance. Each of these residents had care plans that included staff assistance with ADLs, grooming, and hygiene, and their MDS assessments indicated they required varying levels of assistance with personal hygiene, including shaving and grooming. The record review for these residents showed no documentation of refusals of care, except for one documented refusal for R65 involving an agency staff member. R131 was observed lying in bed wearing a gown with thick, coarse facial hair on the cheeks, mouth, and chin area. His dentures were unclean with visible food debris between the teeth and throughout the top denture. He stated that he had not been washed up yet and had not taken out his dentures for a few days. On a later observation, he was still wearing a hospital gown, did not recall whether he had been washed up, and said he had not had a shower since admission. He also stated that an aide had told him she would shave him but never returned. He indicated he needed to be shaved and could probably shave himself with an electric razor if he were positioned in front of a mirror. The residents’ records reflected admission diagnoses and care needs including dementia, muscle weakness, morbid obesity, anxiety, impaired mobility, arthritis, and, for R131, infection of the right knee prosthesis and history of spinal fusion. The facility’s DON stated that female residents should not have visible facial hair and that resident grooming typically includes shaving and trimming fingernails on shower days, with oral and denture care provided daily. The facility’s ADL care policy included grooming, denture care, shaving, hair care, fingernail care, partial baths, and dressing assistance. Despite these documented care needs and policies, the observations and record review showed that the identified residents did not receive the expected grooming, shaving, and denture care.
Medication containers were not properly dated
Penalty
Summary
The facility failed to ensure multiple insulin pens and a vial of liquid morphine were properly labeled with an open date and discard date in accordance with professional standards. During observation on 8/27/2025, R94’s long-acting prefilled insulin pen had a yellow sticker for documenting the date opened, date expired, and initials, but it was blank even though the cap had tamper-resistant red tape indicating the pen had been opened. An LPN stated the pen had already been previously opened and used before that morning. On the 800 unit, two glargine insulin pens for R82 and one glargine insulin pen for R5 were observed with broken red tamper-evident tape and no open date or discard date. Another glargine insulin pen for R8 had broken red tape and an open date of 08/22/2025, but no discard date or staff initials. The RN stated she would add a discard date to R8’s pen and used a spreadsheet with insulin expiration dates to determine the discard date. The RN also stated that R8 and R82 had both received insulin that morning and that she labels insulin pens upon opening with the date opened, discard date, and her initials. The 500-unit medication cart contained two multi-dose vials of liquid morphine for R41 and R74 in the narcotic box, and neither vial was dated with an open date or expiration date. The corresponding count sheets showed R41’s morphine had first been administered on 7/24/25 and R74’s on 6/13/25. The LPN stated both vials should be dated to show when they were opened and that expired medications may be less effective. R5 had a history of type 2 diabetes and no current insulin glargine order, with the insulin discontinued on 06/30/2025, yet the insulin pen remained in storage. R8 and R82 both had active insulin glargine orders and received doses on the day of observation, and R41 and R74 were hospice residents receiving morphine for pain or shortness of breath.
Improper Disinfection of Shared Glucometer
Penalty
Summary
The facility failed to ensure the glucometer used to check residents’ blood sugar levels was disinfected according to the manufacturer’s instructions for 9 of 9 residents reviewed for glucose checks on the 200-hall. On 8/26/2025, an LPN performed a blood glucose test on one resident before lunch, wiped the glucometer once with a micro-kill disinfectant wipe, and placed it on a tissue on the medication cart. The same glucometer was then used for another resident’s blood sugar check, placed on a windowsill in the resident’s room, and later wiped again for 5 seconds before being placed back on the same tissue and returned to the medication cart when dry. On 8/27/2025, the LPN/Infection Prevention nurse and the ADON identified the residents on the 200-hall who received blood glucose checks. They stated the nurses should disinfect glucometers with Clorox wipes from the medication carts and keep the glucometer wet with the wipe for at least 3 minutes. They also stated that if a nurse is doing another glucose check, there should be another glucometer ready to go, and that the glucometer should be cleaned according to the manufacturer’s instructions so it is sanitized and does not cross-contaminate another resident. The residents identified as receiving blood glucose checks were R3, R10, R13, R20, R34, R40, R75, R107, and R127. Record review showed all 9 residents had diagnoses of diabetes mellitus and orders for accu checks. The facility’s policy required reusable resident-care equipment, including glucose monitoring devices, to be cleaned and disinfected according to CDC recommendations, OSHA Bloodborne Pathogens standards, and manufacturer instructions. The policy for blood glucose meters stated shared meters must be cleaned of visible soil, disinfected with the product used according to manufacturer directions, and allowed the required drying/contact time. The micro-kill wipe instructions provided by the Administrator stated the surface must remain visibly wet for the full contact time required by the product label, and the label indicated a 3-minute wet contact time.
Wheelchair Footrest Missing During Transport and Medication Left Within Resident Reach
Penalty
Summary
The facility failed to ensure a wheelchair footrest was in place during transport for a resident with Alzheimer’s disease, muscle weakness, osteoarthritis, a history of falling, osteoporosis, and weakness. The resident’s care plan identified her as a mechanical lift transfer, and her MDS showed she required partial/moderate assistance for wheelchair transport of 50 feet and was totally dependent on staff for transport of 150 feet. During observation, a CNA transported the resident in her wheelchair to the dining area without both footrests in place, and the resident’s right foot was dragging and skipping along the floor during the transport. The DON stated that because the resident’s foot was dragging, a footrest should have been used, and the facility policy stated that any resident transported in a wheelchair off the assigned unit should have footrests. The facility also failed to ensure a resident’s medication was secured. The resident had diagnoses including dementia, heart disease, kidney disease, anxiety disorder, and cataracts, and the facility assessment showed moderate cognitive impairment with staff assistance needed for eating and supervision for oral hygiene. A physician order was in place for fluticasone propionate nasal suspension, but the medication bottle was observed sitting on the resident’s bedside table within reach while the resident was asleep in bed and no staff were present in the room or immediate area. The resident stated he did not know how to take his medications and that nurses gave him all medications. An LPN stated the resident was not able to take medications on his own and needed help with nasal sprays, and the DON stated there was no assessment for self-administration and that medications should not be left in resident rooms.
Improper urinary catheter care and incomplete catheter orders
Penalty
Summary
Appropriate catheter care and infection prevention were not provided for two residents with indwelling urinary catheters. One resident had diagnoses including dementia, interstitial cystitis, and urinary retention, and was identified in the care plan as having a UTI and being at risk for recurrent UTIs. During observation, the resident was sitting in a wheelchair with catheter tubing exiting the lower pant leg and draining into a bag suspended under the seat, with at least 18 inches of tubing laying on the floor. During transport in the wheelchair, the tubing was rolled over twice by the wheelchair wheel and dragged along the floor. The DON stated the tubing should not be on the floor, dragged along the floor, or run over with a wheelchair because this is to prevent UTIs. A second resident had orders for a urinary drainage bag change, urinary output monitoring, and enhanced barrier protection due to an indwelling urinary catheter, but the orders did not include a diagnosis for the catheter or the catheter size, and the care plan did not list a reason or diagnosis for the catheter. During observation, the resident’s drainage bag was removed from under the wheelchair and held well above the level of the bladder while the resident was being transferred from the wheelchair to the bed. The DON stated the orders should include when to change the catheter, the size, and a diagnosis, and stated the drainage bag should always remain below the level of the bladder so urine does not back up in the tubing.
Failure to Administer Ordered Oxygen
Penalty
Summary
The facility failed to ensure oxygen was administered at the physician-prescribed rate for one resident with COPD, acute and chronic respiratory failure with hypoxia, emphysema, cerebral atherosclerosis, and dependence on supplemental oxygen. The resident’s order summary showed oxygen at three liters via nasal cannula every shift for dyspnea, and the care plan addressed the risk of acute exacerbation of COPD and directed oxygen at two liters per continuous nasal cannula per physician orders. The resident also had severe cognitive impairment documented on the facility assessment. During observation, the resident was seated in a high-back wheelchair in her room with an oxygen tank attached to the back of the wheelchair and tubing in place via nasal cannula. The oxygen tank setting showed the needle in the red, empty zone, and no oxygen was being administered even though the setting was at three. The resident removed the nasal cannula and stated she did not feel any air coming through the tubing. A CNA observed the tank and stated the resident needs oxygen every day, 24/7. An RN later verified the tank was empty and stated the resident needs oxygen running continually due to COPD and could become short of breath or have trouble breathing if it was not running as ordered. The DON stated nurses should always be following physician orders, and an RN stated resident care plans should match physician orders.
Failure to Prevent Falls Due to Noncompliance with Transfer and Supervision Policies
Penalty
Summary
The facility failed to identify fall risks and follow established policies and procedures to prevent falls for two of three residents reviewed for falls. One resident, who had a history of hemiplegia, hemiparesis, and other neurological deficits, was being transported in a wheelchair without leg/footrests at his request. During transport up an inclined hallway, the resident became fatigued, dropped his feet, and was propelled forward out of the wheelchair, resulting in a facial injury, nasal fracture, and hospital visit. Staff statements indicated that the CNA did not insist on the use of leg rests, and the nurse was not notified of the resident's refusal, contrary to facility policy. The root cause analysis identified the absence of leg rests during transport as a contributing factor. Another resident, with a history of falls, morbid obesity, and multiple orthopedic and neurological conditions, experienced two incidents where she was lowered to the floor during transfers. After the first incident, her care plan was updated to require two staff for transfers and the use of a transfer belt. Despite this, a CNA transferred the resident alone and without a transfer belt, resulting in the resident sliding to her knees and sustaining bruising. Both the resident and staff confirmed that the transfer was not performed according to the updated care plan and facility policy, which mandates two-person assistance and the use of a transfer belt for all transfers. The facility's own policies require comprehensive assessment of fall risks, implementation of individualized interventions, and strict adherence to transfer safety protocols, including the use of transfer belts and appropriate staff assistance. In both cases, staff failed to follow these protocols, leading to preventable falls and injuries. Documentation and interviews confirmed that these lapses in supervision and failure to implement required safety measures directly contributed to the residents' accidents.
Failure to Implement Range of Motion Exercises and Use Assistive Devices
Penalty
Summary
The facility failed to implement range of motion (ROM) exercises for residents with functional limitations and did not ensure the use of assistive devices for residents with contractures. This deficiency was observed in four residents, each requiring specific ROM interventions as part of their care plans. For instance, one resident required active assistive range of motion (AAROM) exercises twice daily, but records showed that these exercises were not completed on 43 occasions over a specified period. Another resident, diagnosed with hemiplegia, was supposed to receive passive ROM exercises twice daily, but these were not initiated until much later than planned, and were only completed six times over a week. The report also highlights that staff failed to document any refusals of ROM exercises by residents, which was confirmed by the restorative nurse. The Director of Nursing verified that the ROM exercises were not being performed as care planned for the residents. Additionally, one resident's son expressed concern about the lack of consistent exercises to maintain his mother's mobility, especially in her legs, which was corroborated by the facility's documentation showing missed ROM sessions. Furthermore, another resident with a contracture was not provided with the prescribed carrot splint, which was supposed to be in place to prevent further limitations. Instead, a washcloth was used, and the resident's daughter confirmed that the splint was rarely applied. The resident herself stated that she had to attempt to exercise her arm independently, as staff did not assist her with the ROM exercises as required. This lack of adherence to care plans and failure to provide necessary assistive devices contributed to the deficiency identified in the facility's care practices.
Failure to Conduct PASARR Rescreen for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to perform a PASARR rescreen for a resident after the emergence of a newly diagnosed severe mental illness. The facility's policy on Preadmission Screening and Annual Resident Review (PASARR) requires a rescreen upon significant changes in a resident's mental health status. The resident, identified as R103, was admitted with diagnoses of Depression and Anxiety Disorder. The resident's care plan, dated November 23, 2022, noted a risk of abuse/neglect and included a diagnosis of PTSD added on December 15, 2023. However, the Social Services Director confirmed that a PASARR rescreen was not conducted following this new diagnosis, indicating a failure to adhere to the facility's policy and regulatory requirements.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to provide grooming assistance to a resident who required help with activities of daily living (ADL). The facility's policy on ADL care, dated November 2015, mandates staff to meet the grooming and hygiene needs of residents with dignity and privacy. The resident in question, identified as R12, has multiple diagnoses including vascular dementia, osteoporosis, and rheumatoid arthritis, and requires moderate to total assistance from staff due to generalized weakness and impaired mobility. Despite these needs, on October 21, 2024, R12 was observed with half-inch long facial hair on her chin, indicating a lack of grooming assistance. The Director of Nursing confirmed the presence of the facial hair and acknowledged that R12 should have been shaved.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ottawa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant View Luther Home | 0.8 mi | ★★★★★ | 3 | 0 |
| La Salle County Nursing Home | 3.4 mi | ★★★★★ | 0 | 0 |
| Goldwater Care Marseilles | 5.9 mi | ★★★★★ | 12 | 0 |
| Parker Nursing & Rehab Center | 13.5 mi | ★★★★★ | 14 | 0 |
| Arc At Streator | 14.9 mi | ★★★★★ | 6 | 0 |
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