Pearl Pointe Nursing Rehab & Care
Inspection Findings
F-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to appropriately assess a resident experiencing a change in condition. This applies to 1 of 3 residents reviewed for quality of care and the sample of 3. The findings include:Resident R1's admission Record showed he was admitted to the facility on [DATE REDACTED] with diagnoses to include but not limited to Chronic Obstructive Pulmonary Disorder (COPD, chronic lung disease); Dementia, atrial fibrillation (irregular, rapid heartbeat); Heart Failure; and Diabetes;. Resident R1's 9/19/25 Alert Note from 12:00 PM (Authored by V7 Licensed Practical Nurse, LPN) showed Resident R1 was more lethargic than usual; however, the note showed V7 believed this was due to Resident R1's urinary tract infection, which Resident R1 was being treated for. The note does not document any vital signs, blood sugar, or complete head-to-toe assessment. The note showed Resident R1 was sent out via 911.Resident R1's 9/19/25 at 2:26 PM, Narrative note showed vital signs transcribed from 9/18/25 at 5:34 PM. The note did not show a blood sugar was checked or a complete head-to-toe assessment was completed.Resident R1's Hospital Transfer assessment from 9/19/25 showed he was being sent to
a local area hospital for a change in condition. The assessment showed vital signs Most Recent blood pressure, pulse, respirations, and temperature were from 9/18/25 at 5:34 PM. On 10/15/25 at 11:53 AM, V7 (LPN) stated she did not take vitals for Resident R1; however, she believed another staff member may have. V7 said if vitals were taken, they would be documented in Resident R1's medical record. V7 said Resident R1's assessment would also be documented in Resident R1's electronic health record. V7 said she does not know if Resident R1's blood sugar was checked.On 10/15/25 at 12:25 PM, V9 Certified Nursing Assistant (CNA) stated she believed Resident R1's vitals were taken, and they were normal. V9 stated the vitals would have been given to the nurse. V9 said CNAs cannot check blood sugars and must be done by nursing staff.On 10/16/25 at 9:15 AM, V2 (DON/Director of Nursing) stated Resident R1 is diabetic. V2 stated signs of low or high blood sugar could be lethargy and can be a serious condition. V2 stated, if a resident is experiencing increased lethargy and they are diabetic, the nurse should check the residents blood sugar as a part of their assessment. V2 said, in addition to blood sugar, the nurse should do a head-to-toe assessment checking for cognition, swelling, lung sounds, heart sounds, swelling, etc and this should be documented in the resident's electronic health record. Resident R1's Vitals Electronic Health Record showed his last documented blood sugar measurement was on 9/14/25. The facility's Change in Resident's Condition policy (dated 11/2023) showed, .Appropriate assessment and documentation will be completed based on the resident's change in condition or indication.
Residents Affected - Few
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
Event ID:
Pearl Pointe Nursing Rehab & Care in FREEPORT, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FREEPORT, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Pearl Pointe Nursing Rehab & Care or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.