Cycle 1
Health 2025-06-04 · Fire 2025-06-04
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Pontiac, IL
Accolade Healthcare Of Pontiac
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
300 West Lowell, Pontiac, IL
(815) 842-1181
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
97
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Accolade Healthcare
Operator or chain grouping
Approved since
2001-11-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.68
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.03
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.62
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.12
CMS adjusted total nurse staffing hours
Case-mix index
1.77
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,170
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.13
Baseline 21.96% · Performance 18.69% · Measure score 6.13 · Achievement 5.91 · Improvement 6.13
Healthcare-associated infections
2.56
Baseline 7.08% · Performance 7.07% · Measure score 2.56 · Achievement 2.56 · Improvement 0
Total nurse turnover
0
Baseline 55.41% · Performance 65.52% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.15
Baseline 2.09 hours · Performance 2.70 hours · Measure score 1.15 · Achievement 0 · Improvement 1.15
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.37% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 105 · Observed rate 15.24% · Lower 95% interval 8.58% |
| Discharge to community | 49.29% |
50.57%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 40.96% · Lower 95% interval 39.4% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 77 · Denominator 77 |
| Falls with major injury | 1.3% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 77 |
| Discharge self-care score | 61.82% |
53.69%
8.1 pts better
|
Numerator 34 · Denominator 55 |
| Discharge mobility score | 74.55% |
50.94%
23.6 pts better
|
Numerator 41 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 3.9% |
2.29%
1.6 pts worse
|
Numerator 3 · Denominator 77 · Adjusted rate 3.86% |
| Healthcare-associated infections requiring hospitalization | 7.07% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 56 · Observed rate 7.14% · Lower 95% interval 4.15% |
| Staff COVID-19 vaccination coverage | 21.69% |
8.2%
13.5 pts better
|
Numerator 18 · Denominator 83 |
| Staff flu vaccination coverage | 43.81% |
42%
1.8 pts better
|
Numerator 46 · Denominator 105 |
| Discharge function score | 70.91% |
56.45%
14.5 pts better
|
Numerator 39 · Denominator 55 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 9.76% |
25.2%
15.4 pts worse
|
Numerator 4 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
2.0
1.2 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.3
0.7 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
89.6%
8.8 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.4% · Q3 98.4% · Q4 96.7% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.1% |
91.6%
4.5 pts worse
|
95.5%
8.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.3%
0.5 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 3.1% · Q4 4.9% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 61.9% |
50.3%
11.6 pts worse
|
11.4%
50.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 64.0% · Q2 64.8% · Q3 63.8% · Q4 54.3% · 4Q avg 61.9% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
6.5%
1.1 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.4% · Q3 5.3% · Q4 11.5% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
18.5%
4.6 pts worse
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 22.4% · Q3 23.7% · Q4 28.1% · 4Q avg 23.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.0% |
22.8%
14.8 pts better
|
16.7%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 12.8% · Q3 0.0% · Q4 6.5% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.9% |
17.2%
0.7 pts worse
|
16.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 22.5% · Q3 15.4% · Q4 16.9% · 4Q avg 17.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
15.0%
5.7 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 28.1% · Q3 15.5% · Q4 15.8% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.1%
0.5 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 2.9% · Q4 1.5% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.0% |
21.3%
6.7 pts worse
|
19.8%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 30.1% · Q3 26.1% · Q4 23.3% · 4Q avg 28.0% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
5.2%
0.4 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.8% · Q3 4.9% · Q4 11.7% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
68.8%
28 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.8% · Q4 89.3% · 4Q avg 96.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.8% |
14.0%
1.8 pts worse
|
12.0%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 16.9% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
2.3%
1.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.9% |
63.0%
28.9 pts better
|
79.7%
12.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 39.1% |
26.2%
12.9 pts worse
|
23.9%
15.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 39.1% · Observed 45.1% · Expected 27.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-23 · Fire 2024-08-23
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Cycle 3
Health 2023-06-08 · Fire 2023-06-08
7 health deficiencies
Top issue: Infection Control (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-04
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-07-19
F · Potential for more than minimal harm
2025-06-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-18
E · Potential for more than minimal harm
2025-06-04
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-07-18
F · Potential for more than minimal harm
2024-08-23
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-18
F · Potential for more than minimal harm
2024-08-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-23
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-23
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-23
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-23
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-23
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-23
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-08-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-02
E · Potential for more than minimal harm
2024-08-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-23
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2024-09-13
F · Potential for more than minimal harm
2023-06-08
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-06-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-06-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-06-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-06-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-06-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-09
E · Potential for more than minimal harm
2025-06-04
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-18
E · Potential for more than minimal harm
2025-06-04
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-06-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-06-04
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-06-04
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-06-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-18
G · Actual harm
2024-08-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-30
F · Potential for more than minimal harm
2024-08-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-08-23
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-08-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-08-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-08-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-08-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-04-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-16
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-26
F · Potential for more than minimal harm
2023-06-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-06-08
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-06-08
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-06-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-06-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-28
F · Potential for more than minimal harm
2023-03-15
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-03-28
Penalties and ownership
What sits behind the stars
Ownership
Freedman, Moshe
5% Or Greater Direct Ownership Interest · Individual
Freedman, Moshe
Corporate Officer · Individual
Orsowy, Malerie
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Evenglow Lodge
Pontiac, IL
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Goldwater Pontiac Nursing Home
Pontiac, IL
2-star overall rating with 3-star inspections with $13,635 in total fines with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Fairview Haven
Fairbury, IL
5-star overall rating with 5-star inspections with 3 recent health deficiencies
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