Pearl Pavilion Violations & Ratings

Pearl Pavilion in Freeport, IL, is a large nursing home that offers long-term and short-term skilled nursing to individuals who cannot be cared for within the community. 

This nursing home has been cited for numerous violations relating to a lack of appropriate treatment, failure to employ sufficient staff for adequate supervision of residents, offering substandard nutrition service, and depriving residents of their right to a dignified existence.

If your loved one has been deprived of his or her rights at Pearl Pavilion, acting swiftly to ensure they receive the appropriate care is essential. Contact our Illinois nursing home abuse attorneys today; we’ll guide you through the steps necessary to hold facilities accountable for their failures to uphold professional standards. 

Quick Overview

• Facility Name: Pearl Pavilion
• Address: 900 South Kiwanis Drive, Freeport, IL 61032
• CMS Overall Rating: 1 out of 5 stars 
• CMS Health Inspection Rating: 1 out of 5 stars 
• CMS Staffing Rating: 1 out of 5 stars 
• CMS Quality Measures Rating:  1 out of 5 stars 
• Federal Fines in Last 3 Years: 6 fines totaling $130,824
• Payment Denials by Medicare in the Last 3 Years: 2 denials
• Consumer Alert: Yes, flagged for abuse citation
• Total Bed Capacity: 109 beds
• Ownership Type: For-Profit Corporation [1]

Facility Overview

Located in Freeport, Illinois, Pearl Pavilion provides 24-hour care and rehabilitation services to short-term and long-term residents. Staff can help residents safely perform activities of daily living, including dressing, bathing, grooming, toileting, and eating. 

Pearl Pavilion has struggled to retain enough nursing staff, which imperils their ability to care for every resident. This nursing home has a consumer alert due to allegations of abuse and neglect; many violations resulted in actual harm to residents, putting their lives and health at risk. It is not associated with a local hospital or retirement community.

CMS Ratings and Performance

The Centers for Medicare and Medicaid Services (CMS) grades nursing homes and other facilities on their ability to provide safe and competent treatment to their patients, including such services as pressure ulcer care, pharmaceutical services, and other appropriate competencies. 

This is rated out of 5 stars, with three subsections looking at more specific areas. Three stars are considered satisfactory, while 1 star demonstrates serious deficiencies. The CMS may also flag a nursing home with a consumer alert if they have been accused of abuse.

Pearl Pavilion has a 1-star overall rating and a consumer alert because of severe risks to resident health. It also has a 1-star rating on the three subsections: health inspections, staffing, and quality measures.[1]

This nursing home has received 6 fines totaling $130,824 since 2021, and Medicare reimbursement was denied twice.

In the second quarter of 2023, the Illinois Department of Public Health also fined Pearl Pavilion a combined $30,400 for five violations, including those that posed a significant risk to nursing home residents. 

Services Provided

This nursing home offers assistance with activities of daily living and amenities such as TV, a beauty salon, transportation, housekeeping, a library, and the internet. 

Services provided at Pearl Pavilion include:

• Food and nutrition service
• Feeding tube care
• Catheter care
• IV therapy
• Physical therapy
• Occupational therapy
• Speech therapy

There is very high staff turnover and individuals at this nursing home receive fewer registered nurse staff hours per day than the national average. 

Violations and Citations

ProPublica notes that Pearl Pavilion has been cited for 82 deficiencies, including 6 infection-related deficiencies, in the last three years. This nursing home does not adhere to currently accepted professional principles, putting residents at risk of severe distress and actual harm. 

Specific Violations

Specific violations noted at Pearl Pavilion in Freeport, Illinois, include the following. 

Resident Rights: The nursing home has failed to implement policies and training that respect a patient’s right to self-determination, including helping them fill out an advance directive or explaining their options for participating in experimental research. It has also not provided a homelike environment free of accident hazards.

Care Deficiencies: A May 2024 inspection cited the nursing home for failing to respect residents’ preferences in treatment, including forcing a resident to change his own wound dressings. Pearl Pavilion has also been cited multiple times for failing to provide appropriate pressure ulcer or catheter care. 

Lack of Infection Prevention: The nursing home has a poor track record with its infection control program, including failing to prevent urinary tract infections. A low percentage of staff have received pneumonia vaccinations. 

Nutrition and Dietary Deficiencies: Multiple citations note that the organization does not serve food at a safe and appetizing temperature for all individuals. As of March 2023, there was no qualified dietician on staff, which may mean that the nursing home did not procure food from sources approved by the IDPH or ensure menus met every resident’s needs. 

Medication Errors: The nursing home does not provide pharmaceutical services in line with professional standards, such as having a licensed pharmacist on staff to ensure drugs are handled appropriately. Medicine was not kept in separately locked compartments. 

Impact on Residents

Pearl Pavilion’s inability to prevent accidents and ensure safety has significantly impacted resident well-being. 

Health and Safety Concerns

Many residents in the long-term nursing home area experienced deteriorating conditions that required greater assistance with everyday needs, which suggests that the nursing home has failed to provide activities that improve a resident’s physical health. Numerous patients developed new ulcers while at Pearl Pavilion.

Emotional and Psychological Impact

There are serious concerns that residents are not receiving treatment that meets their physical, emotional, and nutritional needs. A high percentage of long-term residents received controlled drugs like antipsychotics, which may not have been prescribed for a medical reason.

Case Examples

In December 2023, a double amputee complained that a nurse aide mocked him for having an uncontrolled bowel movement, making him feel “subhuman.” The resident also stated that more than one staff member had suggested he have a bowel movement in his pants so they do not have to provide him with as much assistance.

In November 2023, one patient with a wound vac bled to death after pulling out his dressings. The licensed nurse on hand did not provide emergency care and did not provide patient details to EMS that arrived on the scene. 

Part of providing appropriate treatment is inserting feeding tubes when necessary and when the resident agrees to ensure food intake. In March 2023, one resident did not receive a feeding tube as needed and lost 28 pounds in three months. 

A December 2022 report showed that a resident who required IV fluids had his port removed, putting him at risk of malnutrition or dehydration. 

Legal Rights and Actions

The Illinois Department of Public Health states that all nursing home residents have a right to a dignified existence and self-determination. 

When these rights are violated, families can complain to the long-term care ombudsman or the Centers for Medicare and Medicaid Services. They can also file a lawsuit with the help of the Nursing Home Law Center. 

Our lawyers’ investigative skills set us apart from other law firms. We will thoroughly investigate all concerns and guide you through your legal options. Contact us today for a free consultation about your rights.

[1] Medicare