Cycle 1
Health 2025-08-28 · Fire 2024-10-24
8 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Ottawa, IL
Pavilion Of Ottawa
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
704 East Glover Street, Ottawa, IL
(815) 434-7144
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
135
Certified beds
Average residents
124
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pavilion Healthcare
Operator or chain grouping
Approved since
1981-06-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
0.78
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.37
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.64
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.16
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.37
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.02
CMS adjusted total nurse staffing hours
Case-mix index
1.72
Higher values indicate more complex resident acuity
RN turnover
19%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,615
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9892
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 16.85% · Performance 21.55% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.87
Baseline 7.29% · Performance 6.08% · Measure score 5.87 · Achievement 5.87 · Improvement 4.78
Total nurse turnover
8.18
Baseline 37.78% · Performance 30.25% · Measure score 8.18 · Achievement 8.18 · Improvement 5.32
Adjusted total nurse staffing
0.17
Baseline 2.78 hours · Performance 2.98 hours · Measure score 0.17 · Achievement 0 · Improvement 0.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.04% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 218 · Observed rate 8.72% · Lower 95% interval 7.35% |
| Discharge to community | 55.91% |
50.57%
5.3 pts better
|
No Different than the National Rate · Eligible stays 193 · Observed rate 55.44% · Lower 95% interval 48.4% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.06% |
95.27%
2.8 pts better
|
Numerator 101 · Denominator 103 |
| Falls with major injury | 1.94% |
0.77%
1.2 pts worse
|
Numerator 2 · Denominator 103 |
| Discharge self-care score | 25.97% |
53.69%
27.7 pts worse
|
Numerator 20 · Denominator 77 |
| Discharge mobility score | 29.87% |
50.94%
21.1 pts worse
|
Numerator 23 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 5.83% |
2.29%
3.5 pts worse
|
Numerator 6 · Denominator 103 · Adjusted rate 4.9% |
| Healthcare-associated infections requiring hospitalization | 6.08% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 109 · Observed rate 3.67% · Lower 95% interval 3.06% |
| Staff COVID-19 vaccination coverage | 7.69% |
8.2%
0.5 pts worse
|
Numerator 15 · Denominator 195 |
| Staff flu vaccination coverage | 49.25% |
42%
7.2 pts better
|
Numerator 98 · Denominator 199 |
| Discharge function score | 31.17% |
56.45%
25.3 pts worse
|
Numerator 24 · Denominator 77 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 95.12% |
96.28%
1.2 pts worse
|
Numerator 39 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 36.96% |
25.2%
11.8 pts better
|
Numerator 17 · Denominator 46 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.0
0.1 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.3
0.2 pts better
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.6%
10.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.3%
1.8 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 2.6% · Q4 1.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 60.7% |
50.3%
10.4 pts worse
|
11.4%
49.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 55.8% · Q2 60.7% · Q3 60.4% · Q4 66.3% · 4Q avg 60.7% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
6.5%
2.4 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.2% · Q3 3.4% · Q4 3.5% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.7% |
18.5%
0.8 pts better
|
19.6%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 20.8% · Q3 14.4% · Q4 19.5% · 4Q avg 17.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
22.8%
13.9 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 9.0% · Q3 7.8% · Q4 10.7% · 4Q avg 8.9% · 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 | 8.4% |
17.2%
8.8 pts better
|
16.3%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 5.2% · Q3 7.3% · Q4 11.8% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.5% |
15.0%
9.5 pts better
|
14.9%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.5% · Q3 4.5% · Q4 5.8% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.1%
0.6 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.7% · Q4 0.8% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.7%
1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.6% |
21.3%
7.3 pts worse
|
19.8%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.5% · Q2 32.3% · Q3 25.0% · Q4 28.2% · 4Q avg 28.6% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.2%
2.5 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.4% · Q3 1.9% · Q4 1.2% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.5% |
68.8%
17.7 pts better
|
81.7%
4.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.3% · Q2 90.1% · Q3 83.9% · Q4 82.6% · 4Q avg 86.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
14.0%
5.2 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 8.4% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
2.3%
1.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 1.7% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.3% |
63.0%
23.3 pts better
|
79.7%
6.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
26.2%
3.5 pts better
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 21.5% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-24 · Fire 2023-09-29
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-09-29 · Fire 2022-04-14
6 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-24
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-11-15
E · Potential for more than minimal harm
2023-09-29
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-10-11
E · Potential for more than minimal harm
2023-09-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-10-11
E · Potential for more than minimal harm
2023-09-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-10-12
C · Minimal harm
2023-09-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-11
F · Potential for more than minimal harm
2022-04-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-06
F · Potential for more than minimal harm
2022-04-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-05-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-28
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 2025-09-09
E · Potential for more than minimal harm
2025-08-28
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 2025-09-09
E · Potential for more than minimal harm
2025-08-28
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 2025-09-09
E · Potential for more than minimal harm
2025-08-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-28
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 2025-09-09
D · Potential for more than minimal harm
2025-08-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-09
G · Actual harm
2025-04-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-14
E · Potential for more than minimal harm
2024-10-24
F688 · Quality of Life and Care Deficiencies
Health
Provide 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.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-24
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-24
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 2024-11-13
F · Potential for more than minimal harm
2023-09-29
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 2023-10-10
E · Potential for more than minimal harm
2023-09-29
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 2023-10-11
D · Potential for more than minimal harm
2023-09-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-09-29
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2023-10-11
F · Potential for more than minimal harm
2023-07-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-02
D · Potential for more than minimal harm
2023-06-01
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 2023-06-09
Penalties and ownership
What sits behind the stars
Ownership
Aaron, Jonathan
5% Or Greater Direct Ownership Interest · Individual
Stern Family Investment Tr
5% Or Greater Direct Ownership Interest · Organization
Todd A Stern 2015 Irrv Ins Tr
5% Or Greater Direct Ownership Interest · Organization
Ilana D Aaron Trust C/U Maurice Aaron 2014 Family Gift Trust
5% Or Greater Direct Ownership Interest · Organization
Ripstein, Kenneth
5% Or Greater Indirect Ownership Interest · Individual
Ilana D Aaron Trust C/U Maurice Aaron 2014 Legacy Gift Trust
5% Or Greater Direct Ownership Interest · Organization
Stern, Raphaela
5% Or Greater Indirect Ownership Interest · Individual
Stern, Todd
5% Or Greater Indirect Ownership Interest · Individual
Graf, Marcella
Corporate Officer · Individual
Graf, Marcella
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Pleasant View Luther Home
Ottawa, IL
4-star overall rating with 3-star inspections with $87,819 in total fines with 18 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
La Salle County Nursing Home
Ottawa, IL
5-star overall rating with 3-star inspections with $146,063 in total fines with 10 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Goldwater Care Marseilles
Marseilles, IL
1-star overall rating with 2-star inspections with abuse icon flag with $271,252 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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