Inspection·September 24, 2024

F 0567 Honor the resident's right to manage his or her financial affairs. 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 that a personal mail with a gift check was given to the resident whom it was addressed to, and not deposited to the transferring account intended for payment of the resident's room and board. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for personal funds in the sample of 3. The findings include: Face sheet and Minimum Data Set (MDS) dated [DATE], shows that R1 is 83 years-old who is alert and oriented. R1 was independent to some of her activities of daily living (ADL) care and needs supervision to some. R1 was admitted to the facility on [DATE]. On September 23, 2024, at 10:17 AM, R1 said that she has been living in this facility for almost 2 years. R1 receives her husband's pension from the police department, and she has social security benefits as well. These checks go straight to the facility for payment of her room, board, and treatment. In addition, R1 usually receives a check every Christmas from the Policemen's Annuity and Benefit Fund of Chicago (PABF) for the widows and widowers of the fallen police officers. However, on December 2023, R1 did not receive a check from PABF. R1 followed up from the PABF organization and spoke to an employee from the department who manages those checks. It was a multiple back and forth follow up to the department and to the facility, until such time her contact person informed her that it was already mailed to her and cashed in. In February 2024, V2 (Former Business Office Manager) informed R1 that she found R1's check. The letter was opened, and the check deposited somewhere. V2 wrote R1 a check worth $500 to replace the missing check. R1 was informed that there was an employee in the facility who sort through residents' mails. On September 23, 2024, at 11:55 AM, V2 (Former Business Office Manager) stated that there was a check that came in for R1 (from the Policemen's Annuity and Benefit Fund of Chicago). The facility deposited it in R1's trust fund account. R1 mentioned to V2 that she (R1) was supposed to receive a check every year from that organization and has not received it yet. V2 looked and found it in R1's trust fund account. V2 also said that they can open a resident's mail depending upon the contract the resident signed with the facility. There is a special form where the residents signed giving the facility the permission to open any mail that involves a check. That check (PABF) was deposited on January 19, 2024. V2 was not sure the time that the check was released to R1. There is usually a one-week turnaround from the bank before the check is posted to the resident's account until it appears for availability of withdrawal. That particular issue was brought to V2 only one time. On September 23, 2024, at 12:26 PM, V6 (R1's Daughter/POA medical) stated that the PABF check was (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 3 Event ID: 145614 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 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)