Pearl Pointe Nursing Rehab & Care

F 0602

Protect each resident from the wrongful use of the resident's belongings or money.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review the facility failed to ensure a resident was free from misappropriation for 1 of 3 residents (Resident R1) reviewed for theft in the sample of 5. The findings include:On 11/24/25 at 9:30 AM, Resident R1 was sitting at the bedside in her room. Resident R1 said she woke up one morning and her ring was missing. Resident R1 pointed to her left hand, ring finger. Resident R1's left hand ring finger had a visible indentation of where a ring had been worn. Resident R1's skin in this area was lighter in color. Resident R1 said it was a tight-fitting ring and it just wouldn't slide off. Resident R1 said she was very upset and told the first person that came in the room when she noticed. Resident R1 said she never took the ring off. Resident R1 said it was a large ring and went from her knuckle to the base of her finger. Resident R1 said it had numerous diamonds with two large diamonds and it was yellow gold. Resident R1 stated I miss it a lot. Resident R2 (Resident R1's room mate) said Resident R1 always wore the ring and both herself and Resident R3 sat with Resident R1 at meals saw Resident R1's ring. Resident R2 said Resident R1 came to breakfast one day and told herself and Resident R3 that the ring was missing. Resident R2 said Resident R1's ring fit snuggly. On 11/24/25 at 10:00 AM, Resident R3 said Resident R1 wore a wedding band

on her left hand that she always had on. Resident R3 said Resident R1 told them one morning at breakfast that she lost her ring. Resident R3 said Resident R1 was very upset and said V4 Housekeeping was looking for it.On 11/24/25 at 11:25 AM, V9 (Resident R1's Power of Attorney/sister) said Resident R1 had a ring when she came to the facility from the hospital. V9 said Resident R1's daughter visited Resident R1 at the facility on 10/13/25 and confirmed that Resident R1 had her ring on her finger.Resident R1's Inventory of Personal Effects dated 9/25/25 shows Jewelry-1 ring.Resident R2's Minimum Data Set, dated [DATE REDACTED] shows Resident R2 is cognitively intact.Resident R3's MDS dated [DATE REDACTED] shows Resident R3 is cognitively intact.The facility's Abuse Prevention Policy dated 1/24 shows Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment.

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:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl Pavilion

900 South Kiwanis Drive Freeport, IL 61032

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 0607

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review the facility failed to follow their Abuse Policy when a resident reported missing property for 1 of 3 residents (Resident R1) reviewed for abuse in the sample of 5. The findings include:On 11/24/25 at 9:30 AM, Resident R1 was sitting at the bedside in her room. Resident R1 said she woke up one morning and her ring was missing. Resident R1 pointed to her left hand, ring finger. Resident R1's left hand ring finger had

a visible indentation of where a ring had been worn. Resident R1's skin in this area was lighter in color. Resident R1 said it was

a tight-fitting ring and just wouldn't slide off. Resident R1 said she was very upset and told the first person that came

in the room when she noticed. Resident R1 said she never took the ring off. Resident R1 said it was a large ring and went from her knuckle to the base of her finger. Resident R1 said it had numerous diamonds with two large diamonds and it was yellow gold. Resident R1 stated I miss it a lot. Resident R2 (Resident R1's roommate) said Resident R1 always wore the ring and both herself and Resident R3 sat with Resident R1 at meals saw Resident R1's ring. Resident R1 said some staff had helped her look for it. Resident R2 said Resident R1 came to breakfast one day and told herself and Resident R3 that the ring was missing. On 11/24/25 at 10:00 AM, Resident R3 said Resident R1 wore a wedding band on her left hand, that she always had on. Resident R3 said Resident R1 told them one morning at breakfast that she lost her ring. Resident R3 said Resident R1 was very upset and said V4 Housekeeping was looking for it.On 11/24/25 at 10:09 AM, V4 Housekeeping Manager said she was in Resident R1's room one morning and Resident R1 told her she was missing her ring and was very upset about it. V4 said she looked under Resident R1's bed,

in Resident R1's wheelchair, and shook out Resident R1's pajama pants. V4 said she told another housekeeper that when Resident R1 got up for breakfast to strip Resident R1's bed and look in the covers. V4 said Resident R2 reported to her that Resident R1's ring was missing, and she told Resident R2 that she was looking for it. V4 said she did not report Resident R1's missing ring to anyone, but she should have. On 11/24/25 at 12:43 PM, V12 Certified Nursing Assistant (CNA) said Resident R1 told her about her ring missing awhile back when Resident R1 was on the south hallway. V12 said she told the nurse on duty at that time and talked about it with V13 CNA. On 11/24/25 at 12:01 PM, V1 Administrator said she became aware of Resident R1's missing ring on 11/17/25 when Resident R1's POA and nephew came into the facility and reported it to her. V1 said staff are to report a resident's missing item right away to the administrator of supervisor according to their abuse policy.The facility's Abuse Prevention Program Policy dated 1/24 shows Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl Pavilion

900 South Kiwanis Drive Freeport, IL 61032

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review the facility failed to ensure an allegation of misappropriation of resident property was reported immediately for 1 of 3 residents (Resident R1) reviewed for theft in the sample of 5.The findings include: On 11/24/25 at 9:30 AM, Resident R1 was sitting at the bedside in her room. Resident R1 said she woke up one morning and her ring was missing. Resident R1 pointed to her left hand, ring finger. Resident R1's left hand ring finger had a visible indentation of where a ring had been worn. Resident R1's skin in this area was lighter in color. Resident R1 said it was a tight-fitting ring and just wouldn't slide off. Resident R1 said she was very upset and told the first person that came in the room when she noticed. Resident R1 said she never took the ring off. Resident R1 said it was a large ring and went from her knuckle to the base of her finger. Resident R1 said it had numerous diamonds with two large diamonds and it was yellow gold. Resident R1 stated I miss it a lot. Resident R2 (Resident R1's roommate) said Resident R1 always wore the ring and both herself and Resident R3 sat with Resident R1 at meals saw Resident R1's ring. Resident R1 said some staff had helped her look for it. Resident R2 said Resident R1 came to breakfast one day and told herself and Resident R3 that the ring was missing. Resident R2 said Resident R1's ring fit snuggly and Resident R1 always had it on. On 11/24/25 at 10:00 AM, Resident R3 said Resident R1 wore a wedding band on her left hand, that she always had on. Resident R3 said Resident R1 told them one morning at breakfast that she lost her ring. Resident R3 said Resident R1 was very upset and said V4 Housekeeping was looking for it.On 11/24/25 at 10:09 AM, V4 Housekeeping Manager said she was in Resident R1's room one morning and Resident R1 told her she was missing her ring and was very upset about it. V4 said she looked under Resident R1's bed, in Resident R1's wheelchair, and shook out Resident R1's pajama pants. V4 said she told another housekeeper that when Resident R1 got up for breakfast to strip Resident R1's bed and look in the covers. V4 said Resident R2 reported to her that Resident R1's ring was missing, and she told Resident R2 that she was looking for it. V4 said she did not report Resident R1's missing ring to anyone, but she should have. V4 said this occurred when Resident R1 was in a room on the south hall.On 11/24/25 at 12:43 PM, V12 Certified Nursing Assistant (CNA) said Resident R1 told her about her ring missing awhile back when Resident R1 was on the south hallway.

V12 said she told the nurse on duty at that time and talked about it with V13 CNA. V12 said Resident R1 was upset and had her things on her floor looking for the ring. V12 said she helped Resident R1 look for her ring and put Resident R1's things back in order. On 11/24/25 at 1:21 PM, V13 CNA said Resident R1 told her that her ring was missing at breakfast one morning. V13 said V12 had reported it. On 11/24/25 at 12:01 PM, V1 Administrator said she became aware of Resident R1's missing ring on 11/17/25 when Resident R1's POA and nephew came into the facility and reported it to her. V1 said staff are to report a resident's missing item right away to the administrator of supervisor. Resident R1's Census list shows Resident R1 resided in the south hallway room (Room Number) from admission

on [DATE REDACTED] to 11/11/25, when she was moved to room (Room Number)The facility's Abuse Prevention Program Policy dated 1/24 shows Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator.

Event ID:

Facility ID:

If continuation sheet