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Complaint Investigation

Pearl Pointe Nursing Rehab & Care

January 29, 2026 · Freeport, IL · 900 South Kiwanis Drive
Citations 2
CMS Rating 1/5
Beds 109
Provider ID 145234
Healthcare Facility
Pearl Pointe Nursing Rehab & Care
Freeport, IL  ·  View full profile →
Inspection Summary

Pearl Pointe Nursing Rehab & Care in FREEPORT, IL — inspection on January 29, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies

dated January 2026 shows orders dated 12/1/25 for a urine drug screen. R2's nurses note dated

urinate. R2's EHR (electronic health record) shows the urine drug screen was not collected. R2's

  • On 1/29/26 at 9:30 AM, R2 was in his room; he said he goes out to the community independently.
  • R2 admitted to consuming alcohol on occasion when he is out because he has problems sleeping. R2 said he can leave the facility when he pleases and denied using substances while at the facility. On 1/28/26 at 9:19 AM, V7 (Certified Nursing Assistant) said R2 does his own thing, he just does whatever he wants. R2 does not have any restrictions, he can leave the facility by himself. On 1/28/26 at 12:38 PM, V5 (RN) said R2 is young male resident, refuses some of his medications and leaves the facility when he wants. V5 said she has heard R2 goes out to the bars and drinks. On 1/28/26 at 1023 AM, V2 (DON) said R2 is independent, goes out on pass and does not need to be supervised. R2 does his own thing.

Denies R2 having behaviors, she was not aware of R2 refusing medications or having any concerns with using substances at the facility. On 1/28/26 at 12:05 PM, V4 (Social Services) said she does the community assessment to determine if a resident is safe to go out on pass independently. If a resident violates the pass privileges, they should not be able to go out independently. R2 can leave the facility interpedently and she is not aware of R2 using substances while at the facility.On 1/29/26 at 1:34 PM, V8 (Psych Nurse Practitioner) said R2 has a history of alcohol abuse and confirmed he refused to be drug tested. V8 said she has shared her concerns with R2's use of substances with the facility. R2's Psychiatry Note dated 1/12/26 shows he is frustrated about insomnia. R2 is currently using illicit substances such as ETOH (Alcohol) and possibly cocaine.

He has been refusing to provide a urine sample for drug screening.staff report he is exhibiting odd behaviors and been verbally aggressive towards staff. R2's Psychiatry Note dated 12/15/25 shows he is frustrated because he is still not sleeping well at night. R2 refusing his antipsychotic because he is not sure why it was ordered.

The urine drug screen that was ordered since last visit due to refusal. It is possible that he has been using substances such as ETOH, cocaine and marijuana during community passes. R2's Community Survival Skills assessment dated [DATE] shows he is capable of outside pass privileges.

The facility's Community Pass Policy states, A resident has the right to community overnight access with the consent of the facility and the resident's cooperation with the standards described within. If the resident refuses to adhere to the standards, he or she may be discharged from the facility in accordance with the Involuntary Discharge or Against Medical Advice Policy.Residents will be informed and educated about rules and expectations while in the community, including, but not limited to.Using alcohol or any illicit substance and/or bringing these items into the facility is prohibited and may result in forfeiture of pass privilege.Consenting to be checked at the discretion of supervisory personnel upon return if reasonable suspicion of contraband exists.

Contraband is defined as any non-prescribed medication, substance or object that is not part of the treatment plan, is not ordered by the physician and has the likelihood of causing the individual or other persons direct or indirect harm.The facility reserves the right to revoke the community pass privilege of a person assessed by the IDT or physician or Social Services as a threat to him/herself or others to assure the safety of the individual resident and the neighboring community.

145234 01/29/2026

Pearl Pointe Nursing Rehab & Care 900 South Kiwanis Drive Freeport, IL 61032

requested from November 2025 to January 2026 shows no documentation for discharge planning. R2's

long term care setting. R2's preference is not to be asked about discharge planning.

The facility's

active discharge planning, to facilitate the transition to a less structured environment/or resident/decision-maker transfer requests to another facility of choice and to coordinate adequate supportive community care services.To assure the involvement of the Social Work staff in assessing discharge potential, transfer requests, documenting significant information related to discharge and coordinating community health care services.

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.


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