Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure a resident's call light was answered in a timely
manner to meet the resident's need for one of four residents (R3) reviewed for accommodation of needs in
the sample of four.
Findings include:
The facility's Call Lights Policy, dated 8/14/21, states, Purpose: 1. To respond promptly to resident's call for
assistance. Procedure: 1. All facility personnel must be aware of call lights at all times. 2. Answer all call
lights promptly whether or not the staff person is to the resident. 3. Answer all call lights in a prompt, calm,
courteous manner; turn off the call light as soon as possible.
The Residents' Rights for People in Long Term Care Facilities, dated 11/18, documents the facility must
provide residents services to keep their physical and mental health at their highest practical level and the
facility must provide care that promotes residents' quality of life.
The facility's Certified Nursing Assistant/CNA Job Description, undated, states, Essential Duties and
Responsibilities: Answers residents' call lights promptly and courteously.
The facility's Resident Council Minutes for May 2023 states, We need more CNAs/Certified Nursing
Assistants on the floor.
R3's Facesheet documents R3 admitted to the facility on [DATE] with diagnoses to include but not limited
to: Nondisplaced Traverse Fracture of Right Patella; Morbid Obesity; Nondisplaced Fracture of Greater
Trochanter of Right Femur; Generalized Muscle Weakness; Difficulty Walking; Unsteadiness on Feet; and a
Previous Fall.
R3's Minimum Data Set/MDS Assessment, dated 5/23/23, documents the following: R3 is cognitively intact
with no memory impairments, scoring a 15 out of 15 on the Brief Interview of Mental Status (BIMS); R3 is
always continent of urine and bowel; R3 requires extensive assistance of two plus persons physical assist
for transfers, bed mobility, walking in room, and toilet use; R3 is not steady, only able to stabilize with staff
assistance for moving on and off the toilet; R3 has range of motion impairment on one side of R3's lower
extremities; and prior to R3's current illness, R3 was independent for R3's self care needs, including toilet
use.
R3's Current Care Plan at the time of R3's admission documents the following: (R3) has a deficit in
ADL/Activities of Daily Living abilities and requires staff assistance due to fall in the community
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145426
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145426
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pavilion of Ottawa
704 East Glover Street
Ottawa, IL 61350
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
with fracture of right patella. WBAT (Weight Bearing as Tolerated) to RLE (Right Lower Extremity) with
immobilizer in place at all times. (R3) is alert oriented and able to make needs known. with an intervention
of Assist with all transfers and maintain any weight bearing restrictions.; (R3) is at risk of falls due to history
of fall in the community with fracture. (R3) has impaired mobility and weakness and requires assistance
with transfers. (R3) takes medications that increase her risk of
Residents Affected - Few
falls. with an intervention of Call light in reach and answer in a timely fashion.; and Assist me with my
personal cares as needed.
On 5/31/23 at 10:26 AM, V13 (R3's Family Member) stated, On 5/23/23 shortly after 8:00 AM, I came to
visit (R3). (R3's) call light was on when I got there. I asked (R3) how long her light has been on and she
said at least a half hour. (R3) said she had to go to the bathroom badly. I took (R3) to the bathroom myself.
The nurse came in the room when we were finishing and told me to not transfer (R3) on my own. I talked to
(V2/Director of Nursing) right after that happened because I shouldn't have to be the one who helps (R3) to
the bathroom. A couple days later, (5/25/23) (R3) called me very upset that she had to go to the bathroom
so bad and had been waiting over an hour for help. (R3) ended up soiling herself because no one ever
came. (R3) knows when she has to go to the bathroom. That shouldn't have happened. I came to the facility
and went to the Administrator (V1). I let her know I wanted to take (R3) home that day with me since no one
seemed to be taking care of her there (at the facility).
On 5/31/23 at 3:19 PM, R3 stated, I wasn't at the facility for a very long time. I didn't need very much, just
help to go to the bathroom. One day (5/23/23), (V13) had to help me to the bathroom because no one was
coming in. I had already been waiting a half hour. The day I came home (5/25/23) was even worse. I waited
over an hour. I remember I saw a male nurse in the hallway. I was thinking, 'Why is no one coming in? Why
does it take that long?' I had to pee so bad that it hurt. They were giving me laxatives and I didn't know it. I
kept pushing my button over and over. I don't know if that does anything, but I really needed help, so I just
kept pushing it. I was screaming and hollering for someone to 'please, help me.' No one came. I ended up
having an accident. I had to be cleaned up of (urine and stool). I know when I have to go to the bathroom, I
shouldn't be having accidents. Before I broke my leg, I could get up and down and do everything on my
own. I can't do that right now. I ended up going home later that day. I now have a commode here in my living
room. I would rather do that and be able to go to the bathroom when I need instead of waiting hours for
help over there.
On 5/31/23 at 12:40 PM, V2 (Director of Nursing) stated that on 5/23/23, V13 came to V2's office upset with
R3's call light wait times. (V13) said that (R3) had waited over a half hour and that (V13) took (R3) to the
bathroom herself. V2 stated this occurred around 8:30 AM, which was breakfast time. V2 stated, I could see
longer (call light) wait times if it was around breakfast.
On 5/31/23 at 1:13 PM, V6 (Social Service Director) stated that V6 was aware of R3 and V13's concerns
regarding call light wait times. V6 stated R3 was offered to change rooms earlier in the week to a floor that
wasn't as heavy and R3 declined due to the rooms being smaller. V6 stated on 5/25/23, V13 was very upset
and went to V1 stating that V13 wanted to take R3 home. V6 stated R3 complained to V6 that it takes a
while for staff to get to R3. V6 stated that V6 would normally complete a grievance or complaint form for R3
and V13's concerns but V6 overlooked that. V6 stated a whole investigation was completed after V13's
concerns. V6 verified R3 discharged home the day of the 5/25/23 incident per R3's and V13's request.
On 6/1/23 at 9:57 AM, V15 (Licensed Practical Nurse) stated that V15 walked into R3's room on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145426
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145426
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pavilion of Ottawa
704 East Glover Street
Ottawa, IL 61350
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
5/23/23 as V13 was walking R3 back from the bathroom.
Level of Harm - Minimal harm
or potential for actual harm
On 6/1/23 at 10:38 AM, V14 (Certified Nursing Assistant) stated the following: R3 was alert and oriented
and able to make needs known; R3 was continent of urine and bowel; R3 required assistance to use the
bathroom; and V14 assisted R3 in being cleaned up of urine and bowel in R3's bed.
Residents Affected - Few
On 5/31/23 at 3:09 PM, V1 (Administrator) stated that is the expectation that call lights are to be answered
as soon as possible. V1 stated all staff was re-educated on 5/25/23, during the investigation into R3 and
V13's call light concerns. V1 stated that no staff member should walk past a call light without going in to
check on the resident. V1 stated that if the resident needs something that person cannot provide, the staff
member should let the resident know they will get someone to help. V1 stated, If anyone is waiting 20
minutes or more, that is too long.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145426
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
FAQ · About this visit
Common questions about this visit
What happened during the June 1, 2023 survey of PAVILION OF OTTAWA?
This was a inspection survey of PAVILION OF OTTAWA on June 1, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PAVILION OF OTTAWA on June 1, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.