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PAVILION OF OTTAWA Inspection Report, Violations & Safety Grade (OTTAWA, Illinois)

704 EAST GLOVER STREET, OTTAWA, Illinois 61350

Phone: 8154347144

CMS Overall:4/5

Overview & Bed Count

Certified Beds
135
Avg Residents/Day
125.9
Ownership
For profit - Individual
Provider Type
Medicare and Medicaid
County
La Salle
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall4/5
Health4/5
Staffing3/5
Quality4/5

Nurse Staffing Check

MetricThis FacilityIllinois AvgDifference
RN Hours per Resident per Day0.810.71+0.10
Total Nurse Hours per Resident per Day3.643.47+0.17
CMS Staffing Rating3/52.2/5-
Nursing Staff Turnover27.7%43.7%-

Health Citation History

16 health citations on record

DateCategoryDescriptionSeverity
2026-02-20Resident Rights DeficienciesHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.D – Moderate Harm Potential
2025-08-28Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2025-08-28Quality of Life and Care DeficienciesProvide care and assistance to perform activities of daily living for any resident who is unable.E – Moderate Harm Potential
2025-08-28Pharmacy Service DeficienciesEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.E – Moderate Harm Potential
2025-08-28Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2025-08-28Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2025-08-28Quality of Life and Care DeficienciesProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.D – Moderate Harm Potential
2025-08-28Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2025-04-02Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G – Actual Harm
2024-10-24Quality of Life and Care DeficienciesProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.E – Moderate Harm Potential
2024-10-24Resident Assessment and Care Planning DeficienciesCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.D – Moderate Harm Potential
2024-10-24Quality of Life and Care DeficienciesProvide care and assistance to perform activities of daily living for any resident who is unable.D – Moderate Harm Potential
2023-09-29Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2023-09-29Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.E – Moderate Harm Potential
2023-09-29Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2023-09-29Pharmacy Service DeficienciesImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.D – Moderate Harm Potential

Fire Safety Citation History

9 fire safety citations on record

DateCategoryDescriptionSeverity
2024-10-24Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.F – Moderate Harm Potential
2024-10-24Egress DeficienciesHave stairways and smokeproof enclosures used as exits that meet safety requirements.E – Moderate Harm Potential
2023-09-29Egress DeficienciesHave exits that are accessible at all times.E – Moderate Harm Potential
2023-09-29Smoke DeficienciesInstall an approved automatic sprinkler system.E – Moderate Harm Potential
2023-09-29Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.E – Moderate Harm Potential
2023-09-29Smoke DeficienciesInstall smoke barrier doors that can resist smoke for at least 20 minutes.E – Moderate Harm Potential
2023-09-29Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.C – Minimal Harm Potential
2022-04-14Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2022-04-14Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.F – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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