Pearl Pointe Nursing Rehab & Care

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Drug Screen dated 1/14/25 shows she tested positive for cannabis. Resident R1's current care plan does not include

she has a history of substance abuse. Resident R2's face sheet shows he has diagnoses including unspecified cirrhosis of liver, alcohol abuse, restless leg, insomnia, and major depressive disorders.Resident R2's Physician Order Sheets dated January 2026 shows orders dated 12/1/25 for a urine drug screen. Resident R2's nurses note dated 12/15/25 documents on multiple occasions (Resident R2) was asked to provide a urine specimen for ordered urine drug screen. (Resident R2) would either be out of the building or stated each time he was not able to urinate. Resident R2's EHR (electronic health record) shows the urine drug screen was not collected. Resident R2's Community Survival Skills assessment dated [DATE REDACTED] shows he is capable of outside pass privileges. 2. On 1/29/26 at 9:30 AM, Resident R2 was in his room; he said he goes out to the community independently. Resident R2 admitted to consuming alcohol on occasion when he is out because he has problems sleeping. Resident 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 Resident R2 does his own thing, he just does whatever he wants. Resident R2 does not have any restrictions, he can leave the facility by himself. On 1/28/26 at 12:38 PM, V5 (RN) said Resident R2 is young male resident, refuses some of his medications and leaves the facility when he wants. V5 said she has heard Resident R2 goes out to the bars and drinks. On 1/28/26 at 1023 AM, V2 (DON) said Resident R2 is independent, goes out on pass and does not need to be supervised. Resident R2 does his own thing. Denies Resident R2 having behaviors, she was not aware of Resident 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. Resident R2 can leave the facility interpedently and she is not aware of Resident R2 using substances while at the facility.On 1/29/26 at 1:34 PM, V8 (Psych Nurse Practitioner) said Resident R2 has a history of alcohol abuse and confirmed he refused to be drug tested. V8 said she has shared her concerns with Resident R2's use of substances with the facility. Resident R2's Psychiatry Note dated 1/12/26 shows he is frustrated about insomnia. Resident 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. Resident R2's Psychiatry Note dated 12/15/25 shows he is frustrated because he is still not sleeping well at night. Resident 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. Resident R2's Community Survival Skills assessment dated [DATE REDACTED] 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.

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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

01/29/2026

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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

planning or attempts to find alternative placement. Resident R2's Social Service note dated 11/9/25 documents, he is alert and oriented, able to communicate verbally his needs, ambulated independently using a walker, is a smoker, goes out of the facility has an independent community pass. Resident R2's Social Service notes requested from November 2025 to January 2026 shows no documentation for discharge planning. Resident R2's current care plan shows he is here for short term rehab; he makes his own decisions and is independent with activities. Resident R2 discharge care plan shows he has extensive care needs and requires long term care setting. Resident R2's preference is not to be asked about discharge planning. The facility's Discharge Planning dated January 2020, states, To identify appropriate candidates for inclusion in 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.

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