Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0602
Protect each resident from the wrongful use of the resident's belongings or money.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to keep a resident free from misappropriation of property
related to a staff member's use of a resident's money, for 1 of 3 residents (R3) reviewed for
misappropriation in a sample of 8. This failure resulted in R3 having money stolen from bank account and
feeling unsafe, like a fool, stupid and like a target. This past non-compliance occurred on 7/9/24 to
7/17/2024.
Residents Affected - Few
Findings include:
R3's Minimal Data Set, dated 5/30/2024, documents that R3 is cognitively intact.
The facility's investigation documents On 7/16/2024, resident (R3), notified her bank of inconsistencies with
her bank account. She filed a report with the bank. The bank did an investigation and determined that two
staff members made several transactions using (R3's) (mobile payment application). The bank notified
(Local) Police Department (PD) (report #) (Local) PD notified the facility. Upon receiving the initial concern
on 7/17/2024, we initiated an internal investigation in accordance with our protocols. Our investigation
involved interviewing residents, interviewing staff, reviewing the evidence and consulting our
interdisciplinary team to ensure a thorough investigation. The findings of our investigation are as follows: 1.
On 7/16/2024 (R3) reported to her bank that she had multiple charges to her account. The bank then
reviewed the transactions with (R3) and they determined that these were fraudulent charges. The bank then
notified (Local) Police Department of this incident. (Local) Police Department came to facility on 7/17/2024
and reported that the fraudulent charges were made by CNA (Certified Nursing Aid) (V9) and former
employee (V8) (CNA). 2. Statements were collected from the staff that were working that night. a. (V9)
(CNA) reports that (R3) had asked her to order pizza. V9 saved (R3's) card to her phone so she could place
the order. She reports that she forgot to delete the card and that her cell phone made the debit card her
default card. She reports that she didn't realize that it wasn't her card but when she did, she notified (R3)
and they called the bank together. When questioned about (V8) charge, she reported that she sent him
$100 because he asked her for $100 and that she gives him money all the time. 3. (R3) reports that she
asked (V9) (CNA) to order pizza for the hall. R3 states she took her debit card out and laid it on her bedside
table and then she thinks she must have fallen asleep. When she awoke, she changed her mind and
decided it would cost too much to order pizza for the entire hall. It also documents 4. At the conclusion of
our investigation, it was determined that the allegation of abuse was substantiated due to the evidence
provided to both the resident and staff. We will be submitting a past non-compliance for misappropriation of
resident's property. All information was taken into Consideration during this investigation.
R3's bank Statement documents Current & Previous Cycle documents: multiple transfers from R3's
(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 4
Event ID:
145454
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
145454
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carlinville Rehab & Hcc
751 North Oak Street
Carlinville, IL 62626
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
Account to V9 (mobile payment application) totaling $678.70, $100 to V8 (mobile payment application) and
additional store charges for total of $750.
Level of Harm - Actual harm
Residents Affected - Few
R3's Police Report, dated 7/17/2024, documents Initial Report Debit Card Fraud On 07/17/24 I (V13) was
requested to (Local) Bank to speak with Branch Manager (V10). (V10) said she had a customer named
(R3) with fraudulent activity on her account. R3 is currently living at (facility). (V10) had started the fraud
dispute paperwork and she provided copies of the suspected transactions. (V10) said the suspects were
(V8, CNA) and (V9, CNA). I then went to (facility). I spoke to (V14) and (V2, DON). They did confirm (V8)
was a former employee with (facility) and (V9) is a current employee. I then went and spoke to (R3). (R3)
said she did not give permission for (V8) or (V9) to use her debit card. (R3) said she did speak to one of the
employees about buying pizza for some of the residents but the pizzas were never delivered. (R3) could not
remember who she spoke to about the pizzas. (R3) was able to show me her debit card. Whoever obtained
the debit card information would have had to have access to R3's room. I was able to review the paperwork
provided to me by (V10). The debit showed multiple transfers to the financial application (mobile payment
application) with the name (V9). On 07/14/24 a $50.00 dollar transfer was made to (V9). On 07/12/24 $350
was transferred to the (mobile payment application) under the name (V9). On 07/11/24 $449.86 was
transferred through the (mobile payment application) to (V9). On 07/09/24 $300.00 was transferred to (V9)
through the (mobile payment application). The total amount transferred to (V9) ls $1099.86. Charges were
also made to (online retail store) on 07/09/24, 7/10/24, and 07/12/24 for a total of $283.05. On 07/09/24
$100.00 was transferred through the (mobile payment application) to (V8). It is believed Lock is short for
(V8).
On 8/21/2024 at 11:39 AM, R3 stated that some staff are rude, and others are nice. R3 stated that she has
had an incident where she felt wronged. R3 stated that she wanted a debit card and with the help of the
staff she was able to go to the bank and get a debit card. R3 stated that she had the card on her over bed
table. R3 stated that (V9), was caring for her that day and had taken care of R3 for a long time. R3 stated
that she informed (V9) that she wanted to buy pizza for the other residents on the hall. R3 stated that (V9)
informed her that it would be close to $200. R3 stated that this was to much for her and did not want to do it
and told (V9) this. R3 stated that later she was informed that (V9) had used R3's debit card, transferred
money, made purchases and even given money to other people. R3 stated that she took at least $600. R3
stated that she did not given (V9) permission to use her card or save R3's information in her phone. R3
stated that she is not sure how (V9) got it. (V9) must have taken a picture. R3 stated that she feels sad and
like a fool. R3 looking down and eyes [NAME] with water. I feel so stupid. I trusted her. How? Why would
she do that to me? R3 stated that she does not feel safe and that she feels like she is being looked at as a
target.
On 8/19/2024 at 2:28 PM, V9, CNA stated that (R3) told her that she wanted to buy pizza for the residents.
V9 stated that she was going to order it online. V9 stated that she entered (R3's) card information into her
phone. V9 stated that she left the room and went to help other residents. V9 stated that when she returned
(R3) was sleep. V9 stated that she did send money to her (mobile payment application), made purchases,
and sent money to other people. V9 stated that she was not aware that she was using (R3's) card. V9
stated that the information must have gone to her electronic wallet. V9 stated that when (R3) told her this
she and (R3) called the bank and tried to fix it. V9 stated that she has not returned the money. V9 stated
that she does not know how much it is. V9 stated that she is waiting on the States's Attorney's office to
contact her and tell her what she needs to pay. V9 stated that she thought she was using her own money
but when she found out she did not tell the facility and that's her fault. V9 stated that she did use (R3's)
money and when she found out she should have said something to her boss but she didn't and takes
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145454
If continuation sheet
Page 2 of 4
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
145454
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carlinville Rehab & Hcc
751 North Oak Street
Carlinville, IL 62626
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
responsibility for what she did.
Level of Harm - Actual harm
On 8/22/2024 at 3:26 PM V10, Local Bank Manager, stated that the bank noticed that there were some
fraudulent charges on (R3's) account. V10 stated that the bank investigated it and found the charges and
transfer of cash was not authorized by the account holder. V10 stated at that time she notified the police.
V10 stated that they were able to identify (V9) as the unauthorized user and this was notified to the police.
V10 stated that the bank card was closed, and the account holder was notified.
Residents Affected - Few
The facility's Abuse, Prevention and Prohibition Policy, dated 01/24, documents STATEMENT OF INTENT:
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 of other agencies serving the resident, family members or legal
guardians, friends, or other individuals. POLICY: This facility prohibits mistreatment, neglect, or abuse of
residents. This also includes the deprivation by an individual, including a caretaker, of goods or services
that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that
all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish.
The facility also prohibits misappropriation of resident property. The residents must not be subjected to
abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of
the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. Annually,
the Administrator will contact local law enforcement to review the requirements for reporting to law
enforcement. It also documents 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. Mistreatment Means inappropriate treatment or exploitation of a resident.
Willful as defined in the definition of abuse, and means the individual must have acted deliberately, not that
the individual must have intended to inflict injury or harm.
The deficiency practice that began on 7/09/24 was corrected on 7/17/24 after the facility took the following
actions to correct the noncompliance prior to the start of current survey:
1.
Social Service Director provided residents with emotional support and reassurance. The Social Service
Director provided Trauma Assessment
2.
AD HOC QAPI meeting was held to discuss the investigations and theft of resident items. It was also
determined that the facility would develop a past non-compliance to address the issue.
3.
The Director of Nursing notified the Medical Director of the investigations and theft of resident monies. He
was additionally notified that the facility would develop a past non-compliance to address the issue.
4.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145454
If continuation sheet
Page 3 of 4
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
145454
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carlinville Rehab & Hcc
751 North Oak Street
Carlinville, IL 62626
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
R3 was offered a lock box for their room to keep their valuables.
Level of Harm - Actual harm
5.
Residents Affected - Few
V9 and V8 employee files was reviewed. It was noted that pre-employee screening was done including
reference checks and background checks. At the time the report was made, V8 was not employed at the
facility. V9 employment was terminated following the outcome to the investigation.
6.
AD HOC QAPI was held to discuss the conclusion of the investigation. The past non-compliance was also
discussed, and it was determined that the facility would allege compliance on 7/17 /24 the Medical Director
was updated as well.
7.
The resident was notified by the financial institution that the money would be reimbursed to the account.
8.
The Director of Nursing initiated all staff education on the Abuse policy with special focus on theft of
resident items. All staff receive an education prior to working.
9.
In servicing is ongoing with all staff on not using resident personal property. They need to report to the
abuse coordinator if the resident is unable to keep personal items so we can supply a lockbox or give it to
family for safekeeping.
10.
Audits are in place related to the abuse deficiencies cited during the annual survey. The facility will continue
to audit through the plan of correction and address any issues identified.
11.
Compliance Achieved 07/17/2024.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145454
If continuation sheet
Page 4 of 4
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Back to topCitations
1 citation 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.
F602 - The resident has the right to be free from abuse, neglect, misappropriation of re
Protect each resident from the wrongful use of the resident's belongings or money.
FAQ · About this visit
Common questions about this visit
What happened during the September 3, 2024 survey of CARLINVILLE REHAB & HCC?
This was a inspection survey of CARLINVILLE REHAB & HCC on September 3, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CARLINVILLE REHAB & HCC on September 3, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from the wrongful use of the resident's belongings or money."
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.