Health inspection·August 12, 2024

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to release a resident's trust funds after discharge for 1 of 3 residents (R1) reviewed for trust funds in the sample of 3. Residents Affected - Few The findings include: R1's Face Sheet, dated 8/12/24, shows R1 was discharged from the facility on 3/10/24. On 8/12/24 at 10:54 AM, V1, Administrator, said, When a resident discharges, any money remaining in the trust fund after all bills have been paid, is returned to the resident or to the resident's Power of Attorney (POA). (V3, Director of Financial Service) at the corporate office sends out the resident funds. On 8/12/24 at 10:35 AM, V2, Business Office Manager, said she didn't recall any concerns with R1's trust fund or speaking to R1's family or R1's new facility about it. On 8/12/24 at 11:58 AM, V3 said R1 discharged from the facility on 3/10/24, and R1's remaining balance was sent to another facility in two checks. V3 said, The first check for $5288.14 was dated 4/15/24 (36 days after discharge), and as of today shows that it wasn't cashed, and the second check was sent 4/18/24 (39 days after discharge) for $1685. 00 and shows that it was cashed. V3 said since the first check wasn't cashed, she had V4, Financial Coordinator, void the original check and re-issue it today. V3 said she did not know why this was not done until today, or why no one followed up when the check had not been cashed. V3 said she reached out to V4 and the email correspondence between V4 and V5 (Business Office Manager at R1's new facility) has been going on since April 2024. On 8/12/24 at 1:01 PM, V5 said R1's son and herself have been trying to get R1's funds sent over since R1 moved to the facility. V5 said they received a check for $1685.00, but never received a second check. V5 said her last correspondence with V4 was in May, and she was told it could take 2-3 weeks for the check to be received. V5 said as of today (22 weeks after R1 was discharged ), R1 has not yet received the second check for $5288.14 from her previous facility. The facility's email from V3, dated 8/12/24, shows (R1) was discharged on 3/10/24 per the notes the son informed the facility resident NOT returning. On 4/11/24 the financial coordinator at the new facility requested refund of R1's money. 4/15/24 refund of $5288.14 sent. As of today not cashed and has been voided. 4/18/24 refund for April income sent $1685.00 8/12/24 reissuance of check for $5288.14. The included email threads shows numerous communications between V2 and V5, including the last one on 5/14/24, V5 to V2 shows they have not received the second check and V2 responds it usually takes 4-6 weeks from date requested, please allow additional time. (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: 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 08/12/2024 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)