Health inspection·February 21, 2025

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. 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 misappropriation of resident funds did not occur for 1 of 3 residents (R1) reviewed for misappropriation of resident funds in the sample of 9. Residents Affected - Few The findings include: R1's admission Record, provided by the facility on 2/21/25, showed she was admitted to the facility on [DATE] for aftercare following joint replacement surgery. R1's Progress Note dated 2/17/25 showed R1 was discharged home with a caregiver. R1's progress note dated 2/7/25 showed R1 had a follow up appointment with her orthopedic PA (Physician's Assistant) on 2/10/25. The note showed transportation was set up through Wheels on Wheels to take R1 to her appointment on 2/10/25. R1's 2/10/25 Progress note showed R1 went to her orthopedic appointment on 2/10/25. R1's facility assessment dated [DATE], showed she was cognitively intact and required substantial/maximal assistance from staff for dressing, toileting, and transfers. R1's care plan initiated on 1/30/25 showed she had limited physical mobility related to weakness after right hip surgery and required one staff assist with transfers. R1's care plan initiated on 2/2/25 showed she was on contact isolation related to shingles, and all services were to be provided in her room. R1's inventory list dated 1/29/25 was reviewed. No credit card was listed on the inventory list. On 2/21/25 at 10:40 AM, V1 (Administrator) said It was an odd scenario. V1 said V7 (R1's niece) claims she dropped the credit card off in a white hallmark envelope at the nurse's desk. V1 said V7 was not able to identify what the person looked like, only that it was a nurse in colorful clothing and was wearing two face masks. At 11:18 AM, V1 said she spoke with staff, and no one was aware of R1's credit card. V1 said the facility would have reimbursed R1, however, R1 said no, the credit card company was reimbursing her. On 2/21/25 at 11:23 AM, V7 (R1's niece) said she took R1 her credit card on 2/8/25. V7 said she put a piece of paper around the credit card and sealed it in a large white envelope like you would put a birthday card in. V7 said R1 was on isolation for shingles and she (V7) had a virus. V7 said she did not want R1 to get sick, so she left the envelope with R1's name and room number on it with a nurse at the second-floor rehab unit's nurse's desk. V7 said the nurse had on burgundy-colored scrubs, and two face masks. V7 said the nurse had on glasses, had her hair pulled back, and she believed the nurse was Filipino. V7 said the nurse was medium height and build, sitting at the nurse's station at a computer. V7 said the nurse took the envelope from her (V7) and set it next to her. V7 said the nurse said she would give the envelope to R1. V7 said she spoke to R1 before dropping it off and let her know that she was going to drop it off. V7 said R1 did not say anything about not getting the envelope until later. V7 said there were charges on R1's credit card that neither R1, nor her family made. V7 said after she dropped of the credit card, she left the facility. V7 said the reason she (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: 145739 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 145739 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home for the Aged 800 West Oakton Street Arlington Hts, IL 60004 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)