Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 2 | 0 |
| La Salle County Nursing Home | 3.4 mi | — | 0 | 0 |
| Goldwater Care Marseilles | 5.9 mi | — | 1 | 0 |
| Parker Nursing & Rehab Center | 13.5 mi | — | 14 | 0 |
| Arc At Streator | 14.9 mi | — | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.