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Nursing HomeMedicaid Investigative

Pearl Pavilion

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

900 South Kiwanis Drive, Freeport, IL 61032109 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
2.6/5

based on 29 Google reviews

5
4
3
2
1
Pearl Pavilion Nursing Home in Freeport, IL — Street View
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6/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (1/5 stars)
  • Above-median deficiencies (23 vs median 11.0)
  • High staff turnover (58%)
  • High RN turnover (82%)

Bottom 25% in IL · Critically understaffed (RN) · Worst in SABA HEALTHCARE chain · $150,091 in fines

Source: Medicare data

What this means for your family

While some families report positive experiences, there is a recurring pattern of serious concerns regarding staffing levels, hygiene, and response times. We strongly advise visiting the facility unannounced during a weekend or evening shift to observe the actual level of care and cleanliness firsthand before making a decision.

Google Reviews

Google Reviews

29 reviews on Google
Pearl Pavilion receives highly polarized reviews, with some families praising the compassionate care and communication, while many others report severe neglect and facility maintenance issues. Critical concerns consistently include chronic understaffing, long wait times for call lights, poor hygiene, and substandard food quality. Prospective families should be aware of the significant divide between administrative-led positive feedback and recurring reports of resident neglect.

Quality Themes

Tap a score for details
Food3.0Staff4.0Clean2.0Activities5.0Meds2.0Memory5.0Comms4.0ValueN/A

Strengths

  • Compassionate individual staff members
  • Helpful administrative communication for some families
  • Positive transition experiences for specific residents

Concerns

  • Chronic understaffing leading to long call light wait times (mentioned by 5 reviewers)
  • Poor facility cleanliness and maintenance (mentioned by 4 reviewers)
  • Poor food quality and nutritional concerns (mentioned by 3 reviewers)
  • Medication management errors (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'15(1)'18(2)'20(8)'22(4)'24(6)'26(1)

Distribution · 33 analyzed

5
10
4
3
3
1
2
0
1
19

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1We've heard wonderful things about some of your individual staff members; how do you ensure that same level of compassion is consistent across all shifts?
  • 2With the recent changes in state inspections, what specific steps is the facility taking to improve maintenance and cleanliness throughout the building?
  • 3How do you manage medication administration to ensure accuracy and safety for every resident?
  • 4Could you tell us more about the dining experience and how the facility is working to improve food variety and nutritional quality?
  • 5What is the protocol for responding to call lights, and how do you ensure residents aren't waiting long periods for assistance?
  • 6In the event of a medical emergency during the night, what is the immediate process for getting care for a resident?

Personalized based on this facility's data


Key Review Excerpts

The Staff at Pearl Pavilion have always taken the best possible care of my Mother! She has memory issues so the staff does need to repeat themselves to her but they are always gracious when doing so!

Memory care family member · 2020★★★★★

Nasty and filthy. Wish I could download photos I took of the dirty walls and floors. Short staff, residents waiting half hour to hour for help. Nurses leaving pills on bedside table.

Family member · 2021☆☆☆☆

My ex husband is a current resident and he said his call light is on for hours, he's lost weight since being there, they've been aggressive with him to the point he thought they were going to hit him and they've forgotten to take him to his appointments.

Family member · 2024☆☆☆☆
Source: 29 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.28hrs
37%
Registered nurses for medical care
Total Nursing
2.84hrs
69%
All nurses + aides combined
Staff Turnover
51%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

8

measures

Worse Than Avg

7

measures

Mixed Results

2

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility77.5%
Worse than Avg
Here
77.5%
US
12.1%
IL
52.5%
Stephenson
8.2%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💉

Residents vaccinated for the flu

↑ Higher is better
This Facility83.1%
Worse than Avg
Here
83.1%
US
95.5%
IL
91.8%
Stephenson
86.5%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility26.6%
Worse than Avg
Here
26.6%
US
19.5%
IL
18.3%
Stephenson
19.6%
⚖️

Residents who lost too much weight

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
5.3%
IL
6.6%
Stephenson
7.5%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility16.1%
Mixed vs Avgs
Here
16.1%
US
15.5%
IL
21.8%
Stephenson
22.2%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility15.9%
Better than Avg
Here
15.9%
US
19.4%
IL
21.1%
Stephenson
18.7%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility18.2%
Worse than Avg
Here
18.2%
US
79.8%
IL
63.1%
Stephenson
66.8%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility31.9%
Worse than Avg
Here
31.9%
US
81.8%
IL
69.0%
Stephenson
71.0%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility3.2%
Worse than Avg
Here
3.2%
US
1.6%
IL
2.4%
Stephenson
1.7%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

25deficiencies
5penalties
Well above state avg (12.0)
33 complaint-triggered
$150,091 in fines

Pearl Pavilion has significant ongoing concerns with 80 deficiencies across 20 surveys, including 31 complaint-triggered violations where families reported problems. The facility repeatedly struggles with basic daily care assistance, medication management, and food safety, with these same issues appearing across multiple recent inspections. A serious abuse protection violation was reported in 2023, and while all deficiencies show correction dates, the persistent pattern of similar problems suggests systemic care quality challenges that families should carefully consider.

Feb 18, 2026Complaint
4
0697Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

0602Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Jan 29, 2026Complaint
2
0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0745Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Jan 20, 2026Complaint
3
0804Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0584Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

Nov 24, 2025Complaint
3
0602Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

0607Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Nov 19, 2025Routine
12
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0644Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

0578Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0645Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Oct 16, 2025Complaint
1
0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Federal Penalties

Fine

Feb 18, 2026

$38,800

Fine

Apr 2, 2024

$64,766

Payment Denial

Apr 2, 2024

24-day denial

Fine

Nov 2, 2023

$65,201

Payment Denial

Nov 2, 2023

21-day denial

Ownership & Operations

Who Operates This Facility

Owner / Operator

Pearl Pavilion

Organization Type

for profit

Chain Affiliation

Chain Name

Saba Healthcare

Chain Size

11 facilities nationwide

Chain avg rating: 1.4/5 · Rank 11 of 11 (Worst)

Ownership & Management

Owners

Blonder, Moshe

Owner

24%

Singer, Aharon

Owner

24%

Webster, Shimon

Owner

9%

Key personnel

Schofield, JennaW-2 Managing Employee
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 3 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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