F 0602
Protect each resident from the wrongful use of the resident's belongings or money.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review the facility failed to ensure a resident was free from misappropriation. This
applies to 1 of 4 residents (R1) reviewed for misappropriation in the sample of 4.
Residents Affected - Few
The findings include:
R1's Minimum Data Set, dated [DATE] shows R1 scored a 15 out of 15 on her brief interview for mental
status test indicating R1 is cognitively intact.
On 2/24/25 at 10:00 AM, R1 said during the week of February 10th through February 15th, V4 (R1's Family
Member) visited and gave R1 two twenty-dollar bills. R1 said she placed the two bills with the rest of R1's
money in the side pocket of her purse that uses a drawstring to close.
On 2/24/25 at 11:53 AM, V4 said after giving R1 the money, R1 and V4 counted the money together and V4
watched R1 put the money into the side pocket of the purse and closed the drawstring closure.
Facility sign-in sheet for visitors shows that V4 visited R1 on 2/11/25 and again on 2/14/25.
On 2/24/25 at 10:00 AM, R1 said on the morning of 2/15/25, R1 asked V5 (Agency Certified Nursing
Assistant- Agency CNA) to grab R1's purse from the floor to give money to V5 to go to the vending machine
for R1 and purchase a water and a package of cookies. When V5 gave R1 her purse, R1 opened the side
pocket with the drawstring and immediately noticed the two twenty-dollar bills were not in the pocket. V5
said V5 helped R1 search R1's purse and immediate surrounding in R1's room, but the money could not be
found.
On 2/24/25 at 11:27 AM, V6 (RN Supervisor) said V5 reported the missing money to V6 and V6
immediately notified V2 (Assistant Administrator) who was working as the manager on duty for the
weekend. V2 along with V1 (Administrator) notified the local police and state agency of the incident and
conducted an investigation thereafter.
On 2/24/25 at 10:40 AM, V1 said after discussing the incident with R1, R1 believed V5 stole R1's money,
but could not determine when. V1 said V5 was immediately suspended pending the investigation and V3
(Director of Nursing) placed V5 on the Do Not Return list with V5's staffing agency. V1 reimbursed R1 the
missing forty dollars and R1 was appreciative.
On 2/24/25 at 11:37 AM, V5 denied taking R1's money but corroborated helping R1 search R1's purse and
room for the missing money.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145257
Printed: 05/15/2026
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
145257
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Pines Rehab & Hcc
335 North Illinois Avenue
Crystal Lake, IL 60014
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 0602
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility Abuse, Prevention, & Prohibition Policy dated 12/2024 states, Each resident has the right to be free
from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by
anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other
agencies serving the resident, family members or legal guardians, friends, or other individuals .
Misappropriation of Resident Property is defined as the deliberate misplacement, exploitation, or wrongful,
temporary, or permanent use of a resident's belongings or money without the resident's consent.
Event ID:
Facility ID:
145257
If continuation sheet
Page 2 of 2
