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Pearl Pavillion Ratings & Violations

Many nursing facilities are overcrowded and understaffed with an insufficient number of Registered Nurses, Certified Nursing Assistants, and Licensed Practical Nurses. Because of that, the health and well-being of many patients are often compromised, especially residents who require a high level of ongoing assistance and monitoring. A lack of supervision could cause hazardous environments where residents without the ability to provide their own care will ask other residents for assistance. Rosenfeld Injury Lawyers LLC have provided legal representation to many Illinois nursing home residents who have been injured in skilled nursing homes like Pearl Pavilion due to a lack of sufficient monitoring and care.

Pearl Pavilion

This Center is a ‘for profit’ 109-certified-bed Home providing nursing services to residents of Freeport and Stephenson County, Illinois. The Medicaid/Medicare-accepted Nursing Facility is located at:

900 South Kiwanis Drive
Freeport, IL 61032
(815) 235-6196

Freeport Nursing Home Resident Safety Concerns

Both the state of Illinois and the federal government regularly update their nursing home database systems to reflect all safety concerns, health violations, filed complaints and opened investigations. This data can be found on numerous websites including

Currently, Pearl Pavilion maintains an overall one out of five available star rating in the nationwide Medicare comparison analysis system. This includes four out of five stars for quality measures, two out of five stars for health inspections and one out of five stars for staffing issues. The Stephenson County nursing home neglect attorneys at Rosenfeld Injury Lawyers LLC have located various safety concerns, violations and deficiencies at this nursing facility that include:

  • Failure to Provide Every Resident Environment Free of Accident Hazards and Provide Adequate Supervision to Avoid Injury

    In a summary statement of deficiencies dated 09/02/2016, a state surveying agency opened a formal complaint against the nursing home for its failure to “ensure a cognitively impaired resident with a history of falls was supervised and safely transferred.” The deficient practice also involved a failure “to ensure the safety of residents by making sure medications were packaged and secured.” These failures involved five residents “reviewed for safety and supervision.”

    One incident involved a review of a resident’s 05/25/2016 MDS (Minimum Data Set) revealing that the resident “is cognitively impaired and requires extensive staff assistance with bed mobility, transfers, dressing, and hygiene.” In addition, the MDS also revealed that the resident’s “balance is unsteady with standing and moving from seated to standing position [...and the resident] has a history of falls.”

    The resident’s Care Plan revealed that the resident fell on numerous occasions including on “May 18, May 31, June 3, June 18, June 19, July 2, July 20, and August 25,” which is eight incidents in three months. The Care Plan also states that the resident “should have a bed alarm and chair alarm.”

    An observation was made of the resident at 4:32 AM on 09/01/2016 when the resident “was sitting in a hardback facility chair in the lounge in front of the nurse station.” At that time, the resident “was leaning forward and then moving backward in the chair.” The resident’s “wheelchair was approximately 4 to 5 feet from her with the chair alarm in place, not connected to [the resident].” At that time, the resident “was not in view of facility staff, who were in [other residents’ rooms] providing care.”

    On 09/01/2016 at 5:01 AM, the resident “was sitting in the lounge in her wheelchair, out of view of the staff that was in other resident’s rooms.” The resident “was asking [another resident] to help her get into the chair (facility chair).” The other resident “was attempting to help [the resident] stand, and [the resident’s] wheelchair was unlocked and sliding backwards.” During the observation, the resident’s “bottom was off the edge of the chair seat, and [the resident’s] chair was rolling as she attempted to stand.” The surveyor asked the assisting resident “to wait for help and not help [the resident] to the chair.”

    The surveyor noted that the actions of the nursing staff failed to follow the facility’s March 2015 Supervision and Safety Policy that reads in part:

    “Resident supervision is a core component to resident safety… Socialization between residents will be encouraged daily in public areas for increased supervision.”

    In addition, the facility’s Charge Nurse stated at 12:30 PM that same day that the resident “is a very high risk for falls.” During an interview with the facility’s Director of Nursing, it was verified that the assisting resident “should not be transferring residents.”

Freeport Illinois Nursing Home Abuse Lawyers

If you and your family suspect that your loved one was the victim of abuse, neglect or mistreatment by visitors, caregivers, employees or other residents while a patient at Pearl Pavilion, contact Rosenfeld Injury Lawyers LLC now. Our skilled Freeport attorneys can file and successfully resolve your victim case involving mistreatment, neglect or abuse and hold those who caused your loved one harm financially accountable.

We encourage you to contact our Stephenson County elder abuse law offices by calling (888) 424-5757 today to schedule your free, comprehensive case evaluation. No upfront fees are necessary because our law firm accepts every personal injury case, wrongful death lawsuit, and nursing home abuse/neglect claim for compensation through a contingency fee agreement.


Disclaimer: The above inspection findings are take from public sources including the State Department of Health and from Medicare inspection conducted at the facility at least every fifteen months. Rosenfeld Injury Lawyers LLC cannot confirm that the content on this site is the most recent information related to the facilities mentions.

The inspection findings published are not complete. You may find the most up to date information here: or

The deficiencies/citations listed on this page may have been corrected or substantially corrected after the date of the inspection and date of publishing this material. This page is a legal advertisement and a resource of information for visitors. This material is not endorsed by the facility noted or by any governmental agency. Rosenfeld Injury Lawyers LLC does not have any affiliation with the facility.

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