Health inspection·October 4, 2023

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Based on interview and record review, the facility failed to ensure residents received a quarterly statement of their monthly Social Security stipend for five of five residents (R5, R28, R44, R81, R102) reviewed for Personal Funds in the sample of 26. The findings include: On 10/02/23 at 9:39 AM, R44 said, The person on the first floor that handles the resident's money never answers the phone. The first person would come around and ask if I needed any money, the new lady is hard to get to. If I wanted to get a couple of dollars I would have to wait for my son. On 10/03/23 at 2:17 PM, V14, Business Office Manager, said, I do not send out quarterly statements to the residents. I give the resident their balance when they make a withdrawl. Residents are the only ones that have access to their accounts. On 10/04/23 at 9:05AM, R81 said, I do not get quarterly statements. On 10/04/23 at 9:12 AM, R102 said, I think it started in November 2022. I have asked twice for a statement regarding the balance of my funds; no one has given me one. I have no idea how much money I have in my account. I have no idea how to get my money. I asked about it, I was told they would look into it; I have not heard back. I have been asking for a couple of months now to get ahold of the finance department, no one has contacted me. I do not want to get anyone in trouble, but I have questions and want answers. On 10/04/23 at 9:26 AM, R5 said, If the facility sent me a quarterly statement, I would know the balance in my account. I like to buy my own toothpaste. On 10/04/23 at 9:30 AM, R28 said, I would like to know my balance. It would be nice to give my friend some money to go out and buy a few items for me. On 10/04/23 at 10:00 AM, R44 said, I am not always able to go down to the bank or (V14's) office. It is difficult for me to get out of bed. I do not get quarterly statements telling me what my balance is. The facility's Resident Fund Trial Balance, dated 10/03/23 at 3:28PM, shows multiple residents including R5, R28, R44, R81, and R102. On 10/04/23 the facility did not provide a policy for Resident Personal Funds. 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 4 Event ID: 145403 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 145403 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Poplar Creek Rehab & Hcc 1545 Barrington Road Hoffman Estates, IL 60169 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)