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 resident funds were managed by the
resident/spouse per the resident/spouse wishes. This applies to 1 of 3 residents (R1) reviewed for
representative payee in a sample of 15.
Residents Affected - Few
The findings include:
Face sheet, printed 9/26/24, shows R1 was admitted to the facility on [DATE] and R1's diagnoses included
Alzheimer's disease, dementia, heart failure, severe protein-calorie malnutrition, major depression disorder,
history of thyroid neoplasm, generalized muscle weakness, anemia, and history of pulmonary embolism.
The face sheet shows V5 (Wife) listed as R1's Emergency Contact #1, POA (Power of Attorney) Care/Medical, POA - Financial, Responsible Party, and Primary [NAME] Contact.
On 9/16/24 at 1:55 PM, R1 stated his wife handled all of the finances and paperwork regarding the facility.
On 9/16/24 at 10:27 AM, V5 (Wife) stated the facility told her she had to pay $1020.00 for R1's room and
board and then applied to Social Security to become the payee of R1's Social Security checks. V5 stated
Social Security never asked her for permission to change the payee to the facility and she never gave the
facility permission to ask Social Security for R1's payments.
On 9/16/24 at 11:33 AM, V3 (Business Office Manager) stated V5 was using R1's Social Security check for
expenses outside the facility and not turning the payment over to the nursing facility to pay towards R1's
room and board per Medicaid rules. V3 stated she spoke with V5 and told her R1's income needed to be
released to the facility to pay towards his monthly balance but V5 was not paying the facility what was
owed. V3 stated V5 was keeping all of R1's income so V3 applied to become representative payee of R1's
Social Security income so the checks would come directly to the facility. V3 stated she discussed this with
V5 and V5 did not agree to allow the facility to apply to become representative payee, but V3 proceeded to
apply and told V5 that the facility could submit the application because they were not receiving their potion
of his income. V3 stated the application for representative payee could take months so V5 had time to
contest the application, but V5 did not contest the application.
On 9/16/24 at 2:58 PM, V1 (Administrator) stated she spoke with V31 (Corporate Business Office Manager)
who told V1 once the facility has exhausted all attempts to collect the resident's portion of room and board,
the facility had the legal right to apply for representative payee to obtain the payment.
(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:
145657
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
145657
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/01/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Pearl of Downers Grove
3450 Saratoga Avenue
Downers Grove, IL 60515
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 0567
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 9/16/24 at 12:22 PM, V1 (Administrator) stated that the facility should obtain permission from family
prior to applying to become a resident's representative payee.
Request To Be Selected As Payee form, signed by V5 (Business Office Manager) on 8/21/24, shows the
facility applied for representative payee status of R1's social security and provided a physician option that
R1 was incapable of managing his funds. The form shows V5 (Wife) was listed as R1's spouse and whom
we would contact. The form shows, [R1] does not owe [Facility] any money and we do not expect him to in
the future . but also shows R1 owed the facility $13,266.50 from 6/2023 to the time of the application. The
form shows, Spouse is using his income to pay mortgage, insurance, utilities and other expenses to live in
the community.
Facility Collection Policy, effective 9/1/24, shows, 9. For unpaid Patient Liability balances two days prior to
the end of the month, the Business Office Manager must review the account to assess if initiating the Rep
(Representative) Payee application is applicable. If applicable the Business Office Manager must initiate a
Rep Payee application to be completed, and signed by physician, and submitted to social security before
end of moth, or must have a signed RFMS (direct deposit software) agreement authorizing direct deposit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145657
If continuation sheet
Page 2 of 2
