Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure a residents' care provider was notified after a
resident received a Defebrilator Vest (DV) intervention (shock) which applies to 1 of 1 residents reviewed for
physician notification in a sample of 3.
The findings include:
R1's face sheet, printed on 6/3/24, showed R1 is an [AGE] year old man admitted to the facility on [DATE],
with diagnoses which include: acute on chronic (congestive) heart failure and rheumatic mitral (valve)
insufficiency.
On 6/3/24 at 10:30 AM, when asked if the defibrilator vest (DV) ever went off, R1 stated, Yes! R1 stated he
was shocked by the vest about a week ago, right here (pointed to bed). R1 stated, It felt like I got shot by a
rifle. R1 stated his pillow had some blue stuff on it. R1 then restated, It was like a shot to the chest. R1
stated one of the girls came in and went to go get the nurse. R1 stated a nurse came into his room. R1does
not remember the nurse's name, but it was a man. After the nurse left, the girl was back to clean me up.
On 6/3/24 at 3:20 PM, V7, Certified Nursing Assistant (CNA), stated she went into R1's room sometime
after dinner to round on R1 (5/26/24). The back of R1's neck and his pillow had blue gel on it. V7 stated R1
told her he had been shocked. V7 did not know what the blue gel was. V7 stated she told V5, Licensed
Practical Nurse (LPN), about the blue gel, and what R1 had said. V7 waited till V5 was done in R1's room.
V7 stated she cleaned up R1 after V5 saw the blue gel.
On 6/4/24 at 9:15 AM, V5 stated he did not initially remember R1 having blue gel on his back. After asking
V5 if he remembered a CNA coming to him about R1 having blue gel on him, V5 stated he did remember.
V5 stated he did not know what the blue gel was for at the time. V5 stated he knew the manual was at the
front desk. V5 stated he does not recall calling the physican. V5 stated he thought he called V2, Director of
Nursing (DON).
On 6/4/24 at 9:45 AM, V5 stated sometime after 9 PM (5/26/24), V7, CNA, told him R1 had some blue gel
on R1's back. V5 stated he was not sure what the blue gel was. V5 stated he went into R1's room. The DV
control box said the battery needed to be changed, so he changed the battery. V5 stated he assessed R1,
did vitals, and checked R1's orientation. V5 did not call the resident physician with an update. V5 stated the
manual for the device was available at the nurse's station.
On 6/4/24 at 10:05 AM, V5 (accomponied by V2) stated after seeing R1 (5/26/24), he did not call the
(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 6
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
06/06/2024
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)
F 0580
physican or the company about the blue gel.
Level of Harm - Minimal harm
or potential for actual harm
On 6/4/24 at 10:30 AM, V8, Cardiologist, stated he did not receive a call on 5/26/24 about R1 having blue
gel on him, or any issues with the DV possibly delivering a treatment.V8 stated if something occured with
R1's DV, he would expect a call to be updated on the resident's status.
Residents Affected - Few
On 6/4/24 at 10:45 AM, V2 stated V5 should have contacted the physician after the blue gel was found on
R1 due to the possibility a treatment has been delivered. V5 should have called the physician to see if the
provider would want to send the resident out, or give new orders.
This DV company documentation, dated 6/3/24, showed R1's vest read a treatable rhythm and delivered a
treatment (shock) on 5/26/24 at 8:16 PM.
The DV Manual, dated 5/1/22, showed the vest is to monitor the patient and deliver a treatment (shock) to
the patient if needed to regulate the patients heart rhythm. A gel is released just before a treatment is given.
If a treatment is given call you doctor's emergency number immediately to report your treatment.
The facility's change of condition policy, dated 9/20, showed attending physicians or physician on call /NP
(Nurse Practitioner) .will be notified of all changes in condition.
At the time of the survey, the facility was unable to provide a policy regarding the DV.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145403
If continuation sheet
Page 2 of 6
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
06/06/2024
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)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility neglected to identify R1 had a defibrillator vest (DV),
and failed to ensure facility staff were trained on the DV's set up, monitoring, functioning, and trouble
shooting of the device which applies to 1 of 1 residents (R1) reviewed for neglect in a sample of 3.
The findings include:
R1's medical record showed R1 was admitted to the facility on [DATE], with diagnoses which included:
acute on chronic (congestive) heart failure and rheumatic mitral (valve) insufficiency.
On 6/3/24 at 10:30 AM, R1 was in his room wearing the DV. R1 stated he got it at the hospital, and it came
with him to here (pointed at bed).
R1's facility referral, dated 5/22/24, showed the referral was sent to the facility's Central Intake and reviewed
on 5/21/24. R1's referral has multiple entries (8) of R1 utilizing the DV during R1's hospital admission, and
to be used until R1 was able to have an outpatient Angiogram after discharge.
On 6/4/24 at 11:10 AM, V21, Admissions Director, stated, A residents' hospital referral goes to the central
intake at our corporate level. We receive a summary from them if the resident is accepted as an admission.
Items like medical devices (wound vacs example) would be on this summary, so we know what to be
prepared for.
On 6/5/24 at 12:30 PM, V1, Administrator, stated V21 receives a referral summary (email) from Central
Intake when a resident is going to be admitting to the facility. The hospital referral information is sent to the
facility afterward and uploaded into the residents record. V21 is not expected to review the hospital
information. V21 uses the summary information provided prior to admission to be aware of anything a
resident may need with their care.
The facility's admission Summary sent on 5/21/24 to V21 showed R1's hospital location, diagnoses of
shortness of breath and weakness, payer source, needs of physical and occupational therapy, weight,
hospital social worker contact information, and patient is a [AGE] year old male with rheumatoid arthritis on
chronic steroids. admitted for SOB/weakness-Cleared for d/c. The referral summary had no information
regarding R1's (DV), which was in use at the hospital, and the need for ongoing use after hospital
discharge.
On 6/3/24 at 9:00 AM, V9, Licensed Practical Nurse (LPN), stated she was currently R1's nurse. V9 stated
she admitted R1 on 5/25/24. R1 was admitted wearing the (DV) from the hospital. V9 stated she was not
aware R1 was possibly going to have the DV until the day of his admission. V9 stated she had not had any
in-services involving the DV yet.
On 6/3/24, with multiple interviews between 9:00 AM - 11:30 AM with V10 LPN, V11 LPN, V12 LPN, and
V13, Registered Nurse (RN), stated they had not received an in-service for the DV. V10-V13 stated they do
get floated to other units and could be assigned to R1's hallway. V10 stated the DV manual was at the desk,
but he had not looked at it yet.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145403
If continuation sheet
Page 3 of 6
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
06/06/2024
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)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 6/4/24 at 9:15 AM, V5 stated he was directed to R1's room after V7, Certified Nursing Assistant, told
him about R1 having blue gel on him. V5 stated it was on Sunday (5/26/24). V5 stated he did not know what
the blue gel was for. V5 stated he knew there were 2 inservices given so far, but he had not attended one
yet.
On 6/3/24 at 3:40 PM, V6, LPN, stated on 5/29/24, she replaced the battery onto the vest pack; It went
through its initial start-up, and showed something like the 'vest needed to be serviced'. V6 stated she did
not know what was wrong, so V6 called the company. V6 stated the tech support person had to walk her
through the process of plugging in the vest's box to a phone jack. V6 stated they had not received any data
since R1 was admitted to the facility. Later that shift, the company called back to let us know the DV had
delivered a shock on 5/26/24, and they would be sending someone to come look at the DV. V6 stated V4,
Patient Service Representative (PSR), came to the facility and serviced the vest for R1.
On 6/3/24 at 9:45 AM, V4 stated she went to the facility on Wednesday (5/29/24) in the evening. V4 stated
she was called to check on R1's DV. V4 stated while at the facility, she initiated the cellular hotspot, which
was not set up to transmit data to the company. V4 stated she talked to V2, Director of Nursing, to set up
education for the DV after she was at the facility to work on R1's DV. The first DV training class V4 gave was
on 5/31/24.
On 6/4/24 at 10:15 AM, V2, Director of Nursing, stated, The referral review process is now done at
corporate through the Central Intake. They review the hospital referral and let us know if a resident has
something we need to be prepared for. We were not notified through Central Intake that (R1) had a DV, or
could possibly have it, when he got admitted . If we are notified a resident was coming with a device we
have not used before, or have not used in a long time, we could set up in-services.
The facility In-service/meeting attendance record, dated 5/31/24, was identified by V2 as the first in-service
provided for the DV (6 days after admission to the facility).
On 6/4/24 at 3:30 PM, V20, DV Legal Department/Educator, stated, The DV is usually sent with a patient to
their home, but we have patients that go to facilities with them. Part of our service is educating facility staff
which includes set up (hotspot), how the device works, and what to do after a treatment (shock) was
administered to the patient. The facility would need to contact us so we could have a representative set up
education times. V20 (while reviewing R1's chart) stated they had no record of any facility interaction before
5/29/24 when the nurse called about the DV having a problem, and a representative was sent out.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145403
If continuation sheet
Page 4 of 6
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
06/06/2024
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)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility to ensure a resident had ongoing monitoring after a
Defibrillator Vest (DV) treatment (shock) was delivered, and failed to ensure a DV hotspot was set up to
assist with remote monitoring which applies to 1 of 1 residents (R1) reviewed for quality of care in a sample
of 3.
Residents Affected - Few
The findings include:
R1's face sheet, printed on 6/3/24, showed R1 is an [AGE] year old man admitted to the facility on [DATE],
with diagnoses which include: acute on chronic (congestive) heart failure and rheumatic mitral (valve)
insufficiency.
R1's Careplan, printed on 6/3/24, showed no entries referencing R1's DV.
On 6/3/24 at 10:30 AM, R1 was in bed wearing the DV. R1 stated he started wearing the DV in the hospital
and it followed him here. When asked if the vest ever worked, R1 stated yes. R1 stated he was shocked by
the vest about a week ago right here (pointed to bed). R1 stated, It felt like I got shot by a rifle. After that
there was some blue stuff on my neck and pillow.
On 6/3/24 at 3:20 PM, V7, Certified Nursing Assistant (CNA), stated she went into R1's room sometime
after dinner to round on R1 (5/26/24). The back of R1's neck and his pillow had blue gel on it. V7 stated R1
told her he had been shocked. V7 stated she told V5, Licensed Practical Nurse (LPN), about the blue gel,
and what R1 had said. V7 waited till V5 was done in R1's room. V7 stated she cleaned up R1, and did not
see him again during her shift.
On 6/4/24 at 10:05 AM, V5, Licensed Practical Nurse (LPN), stated he was R1's nurse 5/26/24. V5 stated
some time after 9:00 (5/26/24) V7, Certified Nursing Assistant, told him R1 had some blue gel on R1's
back. V5 stated he went to the room, and R1 did have blue gel on his back. V5 stated he took some vitals
and assessed R1. V5 stated he did not contact the physician of the company after he assessed R1. R1 was
stable at the time. V5 stated he gave report to V15, LPN, at the end of his shift.
R1's Electronic Medical Record (EMR) showed no vitals were documented from 12:18 AM on 5/26/24
through 2:21 AM on 5/27/24. This medical record also had no assessment documented for this timeframe,
or progress notes reflecting any issues with R1's DV.
The DV company documentation, dated 6/3/24, showed R1's vest read a treatable rhythm and delivered a
treatment (shock) on 5/26/24 at 8:16 PM.
Comparing R1's EMR and the DV documentation showed the first recorded vitals for R1 was approximately
6 hours after R1's DV treatment was administered.
On 6/4/24 at 7:40 AM, V15 stated he had no issues with R1's DV, and had not been told about any blue gel
or DV issues when he he took report from V5 on 5/26/24.
On 6/3/24 at 3:40 PM, V6, LPN, stated on 5/29/24, she had to contact the company for an issue with R1's
DV. The person she talked to said they had not received any data on R1's DV. V6 stated they walked her
through the process to send data via telephone chord outlet. Later in the shift, the company
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145403
If continuation sheet
Page 5 of 6
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
06/06/2024
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
called and said R1 had been given a treatment (shock) by the DV on 5/26/24. V6 stated she had not been
told that in any report, and she had taken care of R1 previously in the week. V6 stated the company was
going to send out someone to look at R1's vest.
The DV documentation, dated 6/3/24, showed the first time data was transmitted after R1's admission
[DATE]) was on 5/29/24 at 6:30 PM. This documentation showed ongoing data transmitting on a daily basis
after the hotspot was set up on 5/29/24.
On 6/3/24 at 9:46 AM, V4, Patient Service Representative/PSR, stated she had been contacted by the
company to check on R1's DV. V4 stated she went to the facility on 5/29/24; she had to set up the cellular
device (hotspot) so R1's DV could upload data in a timely manner.
On 6/4/24 at 3:30 PM, V20, DV company Legal Department/Educator, stated, When the DV is set up, we
use a cellular hotspot to transmit data to the company. It transmits data once a day, usually when the
resident is sleeping. It does transmit data when a treatment is detected to ensure a patient get medical
attention if needed in a timely manner.
At the time of the survey, the facility was unable to provide a policy regarding the DV.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145403
If continuation sheet
Page 6 of 6
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the June 6, 2024 survey of ALDEN POPLAR CREEK REHAB & HCC?
This was a inspection survey of ALDEN POPLAR CREEK REHAB & HCC on June 6, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALDEN POPLAR CREEK REHAB & HCC on June 6, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.