Safety Report: Pearl Pointe Nursing Rehab & Care

Freeport, Illinois · Based on official CMS inspection records as of October 1, 2026.

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How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.

Official ratings

Overall★★★★★
Health inspections★★★★★
Staffing★★★★★
Quality measures★★★★★
Long-stay quality★★★★★
Short-stay quality★★★★★

Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.

Stars are calculated by CMS, not by us. We do not create our own safety score.

Serious documented violations

2Immediate jeopardy citations (severity J–L)
6Actual harm citations (severity G–I)
15Requirements cited on more than one inspection
G
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of August 28, 2026, during a complaint investigation. Facility reported correction by August 29, 2026.
Quality of Life and Care Deficiencies · Tag F689
G
Government finding: Provide safe, appropriate pain management for a resident who requires such services.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of February 18, 2026, during a complaint investigation. Facility reported correction by March 2, 2026.
Quality of Life and Care Deficiencies · Tag F697
G
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of November 19, 2025. Facility reported correction by December 1, 2025.
Quality of Life and Care Deficiencies · Tag F689
G
Government finding: Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of April 2, 2024, during a complaint investigation. Facility reported correction by April 18, 2024.
Quality of Life and Care Deficiencies · Tag F677
G
Government finding: Provide safe, appropriate pain management for a resident who requires such services.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of December 19, 2023. Facility reported correction by January 12, 2024.
Quality of Life and Care Deficiencies · Tag F697
G
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of December 19, 2023. Facility reported correction by January 12, 2024.
Quality of Life and Care Deficiencies · Tag F684
J
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of November 28, 2023, during a complaint investigation. Facility reported correction by December 18, 2023.
Quality of Life and Care Deficiencies · Tag F684
J
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of November 28, 2023, during a complaint investigation. Facility reported correction by December 18, 2023.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Citations by topic

6Abuse, neglect & exploitation
3Infection control
6Medications & pharmacy
5Accidents & supervision

Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.

Is it getting better or worse?

More citations in the most recent cycle (33) than in the cycle before (21).

Two cycles ago
5 serious
Prior cycle
none serious
Most recent cycle
3 serious

An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.

Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.

Repeat findings

These requirements were cited on more than one inspection date in the last three cycles.

RequirementTimes citedInspection dates
Provide care and assistance to perform activities of daily living for any resident who is unable. (F677)7June 30, 2026; May 6, 2026; November 19, 2025; March 14, 2025; October 1, 2024; April 2, 2024; December 19, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684)6October 16, 2025; November 14, 2024; October 1, 2024; May 7, 2024; December 19, 2023; November 28, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689)5August 28, 2026; January 29, 2026; November 19, 2025; November 14, 2024; November 2, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812)5August 28, 2026; January 20, 2026; November 19, 2025; November 14, 2024; December 19, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755)4February 18, 2026; March 14, 2025; November 14, 2024; December 19, 2023
Provide and implement an infection prevention and control program. (F880)3August 28, 2026; November 19, 2025; November 14, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (F690)3November 19, 2025; November 14, 2024; October 1, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F686)3November 19, 2025; October 1, 2024; April 2, 2024
Provide safe, appropriate pain management for a resident who requires such services. (F697)2February 18, 2026; December 19, 2023
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609)2February 18, 2026; November 24, 2025
Protect each resident from the wrongful use of the resident's belongings or money. (F602)2February 18, 2026; November 24, 2025
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (F584)2January 20, 2026; November 14, 2024
Provide safe and appropriate respiratory care for a resident when needed. (F695)2November 19, 2025; November 14, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550)2November 19, 2025; December 19, 2023
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. (F803)2February 19, 2025; November 14, 2024

Fines and enforcement

DateTypeAmount / length
February 18, 2026Fine$25,220
April 2, 2024Payment DenialPayment denial for 24 days, starting May 1, 2024
April 2, 2024Fine$64,766
November 2, 2023Payment DenialPayment denial for 21 days, starting December 22, 2023
November 2, 2023Fine$65,201

Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.

Complete inspection history

69 citations across 20 inspection dates.

August 28, 2026 — 4 citations (includes serious) · complaint investigation
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected August 29, 2026
F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
No actual harm, but potential for more than minimal harm · Widespread · Environmental Deficiencies · F925 · complaint · corrected September 3, 2026
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · complaint · corrected August 31, 2026
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected August 28, 2026
June 30, 2026 — 2 citations · complaint investigation
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · complaint · corrected July 7, 2026
D
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F558 · complaint · corrected July 7, 2026
May 18, 2026 — 1 citation · complaint investigation
F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F725 · complaint · corrected May 22, 2026
May 6, 2026 — 1 citation · complaint investigation
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · complaint · corrected May 15, 2026
February 18, 2026 — 4 citations (includes serious) · complaint investigation
G
Provide safe, appropriate pain management for a resident who requires such services.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F697 · complaint · corrected March 2, 2026
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · complaint · corrected March 2, 2026
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected March 2, 2026
D
Protect each resident from the wrongful use of the resident's belongings or money.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F602 · complaint · corrected March 2, 2026
January 29, 2026 — 2 citations · complaint investigation
D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F745 · complaint · corrected February 5, 2026
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected February 5, 2026
January 20, 2026 — 3 citations · complaint investigation
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · complaint · corrected January 23, 2026
F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F804 · complaint · corrected January 23, 2026
D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · complaint · corrected January 23, 2026
November 24, 2025 — 3 citations · complaint investigation
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected December 2, 2025
D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · complaint · corrected December 2, 2025
D
Protect each resident from the wrongful use of the resident's belongings or money.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F602 · complaint · corrected December 2, 2025
November 19, 2025 — 12 citations (includes serious)
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F689 · corrected December 1, 2025
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected December 1, 2025
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected December 1, 2025
E
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F644 · corrected December 1, 2025
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected December 1, 2025
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · corrected December 1, 2025
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · corrected December 10, 2025
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · corrected December 10, 2025
D
PASARR screening for Mental disorders or Intellectual Disabilities
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F645 · corrected December 1, 2025
D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F578 · corrected December 1, 2025
D
Allow residents to self-administer drugs if determined clinically appropriate.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F554 · corrected December 10, 2025
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected December 1, 2025
October 16, 2025 — 1 citation · complaint investigation
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected October 18, 2025
March 14, 2025 — 2 citations · complaint investigation
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · complaint · corrected March 20, 2025
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · complaint · corrected March 20, 2025
February 19, 2025 — 1 citation · complaint investigation
F
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F803 · complaint · corrected February 26, 2025
November 14, 2024 — 14 citations
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected November 23, 2024
F
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F803 · corrected November 23, 2024
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected November 23, 2024
E
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F808 · corrected November 23, 2024
E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · corrected November 23, 2024
D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · corrected November 23, 2024
D
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F759 · corrected November 23, 2024
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · corrected November 23, 2024
D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F698 · corrected November 23, 2024
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected November 23, 2024
D
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F692 · corrected November 23, 2024
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · corrected November 23, 2024
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected November 23, 2024
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected November 23, 2024
October 1, 2024 — 4 citations · complaint investigation
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · complaint · corrected October 5, 2024
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · complaint · corrected October 5, 2024
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected October 5, 2024
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · complaint · corrected October 5, 2024
May 24, 2024 — 1 citation · complaint investigation
D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F582 · complaint · corrected May 25, 2024
May 7, 2024 — 1 citation · complaint investigation
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected May 22, 2024
April 2, 2024 — 2 citations (includes serious) · complaint investigation
G
Provide care and assistance to perform activities of daily living for any resident who is unable.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F677 · complaint · corrected April 18, 2024
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · complaint · corrected April 18, 2024
December 19, 2023 — 8 citations (includes serious)
G
Provide safe, appropriate pain management for a resident who requires such services.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F697 · corrected January 12, 2024
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F684 · corrected January 12, 2024
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected January 12, 2024
D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F921 · corrected January 12, 2024
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · corrected January 12, 2024
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · corrected January 12, 2024
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected January 12, 2024
C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
No actual harm, potential for minimal harm · Widespread · Resident Rights Deficiencies · F577 · corrected January 12, 2024
November 28, 2023 — 2 citations (includes serious) · complaint investigation
J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected December 18, 2023
J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected December 18, 2023
November 2, 2023 — 1 citation · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected November 17, 2023

Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare

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