F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure two residents (R1 and R2) were free from theft from
their personal trust fund accounts by staff. This failure applied to two of two (R1, R2) residents reviewed for
abuse.
Findings include:
R1 is an [AGE] year-old male who originally admitted to the facility on [DATE] and currently resides in the
facility. R2 was an [AGE] year-old male who originally admitted to the facility on [DATE], was sent to the
hospital on [DATE] and later expired.
Per facility reported incident dated [DATE] states in part but not limited to the following: On [DATE] a
monthly routine trust fund audit was completed and there were discrepancies and concerns found
regarding trust activity in R1 and R2's account. The facility determined that there were fraudulent checks
written from R1 and R2's trust account.
Police Incident Report dated [DATE] shows that police were called to facility for a report due to deceptive
practice and fraudulent checks. Upon arrival, we were met by V1 (Administrator) who had advised us that
two unauthorized checks for large sums were written and cashed from the trust fund accounts of R1 and
R2. V1 had reported that only two staff members have access and were authorized to write checks from
these accounts, V1 and V3 (Previous Business Office Manager Consultant). V1 advised me that someone
had to [NAME] his signature on the checks to get these checks to be authorized.
Copies of checks and Police Incident Report shows that a check for $3,600 from R1's account was written
and cashed to an unknown name through a mobile deposit. It also shows that a check for $2,770.90 was
written on [DATE] from R2's account and cashed to an unknown name on [DATE] through a currency
exchange.
On [DATE] at 11:32, V1 was interviewed regarding incident on [DATE]. V1 said on [DATE], I was auditing the
resident trust fund sheet and I noticed a discrepancy. There were two withdrawals from R1 and R2's
account and they are unable to make these withdrawals themselves. R2 expired in January of 2023 and R1
has a guardian/POA that did not make this request. The person that was handling the trust funds was V3
who was a consultant at the time. I attempted to call V3 however she refused to speak with me, ended up
resigning, and not working with the facility anymore. I have never been able to speak with her about this
incident. I did call the police the day of the incident which have an active investigation at this 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:
146078
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
146078
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ahva Care of Stickney
3900 South Oak Park Avenue
Stickney, IL 60402
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
V1 said we are responsible for the resident's trust funds. V3 was responsible for making out checks for the
residents when requested in the past. I do an audit on the trust funds every month, but we do not have a
system in place that requires documentation. This is just something that I do.
V1 said when a consultant is hired or starts working within our facility, they are trained on our policies and
procedures regarding abuse. However, there is no documentation where they sign off on this like our staff
do.
It is to be noted that V1 was asked for any documentation that V3 was trained on their abuse policy and
procedures. However, during the course of the survey, no such documentation was received.
At 12:04PM, V5 (Lead Detective) was interviewed regarding investigation of incident on [DATE]. V5 said we
were called to the facility due to two fraudulent checks that were written from the facility. V1 had told me that
only V1 and V3 were authorized to write checks out of the resident's trust fund accounts, and he had not
written these checks. My investigation showed that one of these checks was deposited via a mobile deposit
and one was cashed at a currency exchange. They were both written to unknown names and cashed under
unknown names. Unfortunately, I cannot say much more as this is still an ongoing investigation.
Facility Policy titled Resident Trust Fund Policy Notification and Authorization states in part but not limited to
the following: Residents have the right to have the facility keep their money in a trust account to safeguard
and manage personal spending money.
Facility Policy titled Policy and Guidelines on the Prevention of Abuse and Neglect dated [DATE] states in
part but not limited to the following: The facility must provide a safe resident environment and protect
residents from abuse. The residents of the facility have the right to be free from abuse, neglect,
misappropriation of resident's property and exploitation as defined in this policy. Examples of
misappropriation of resident property include but are not limited to theft of money from bank accounts. Staff
must not accept or ask a resident to borrow personal items or money, nor should they attempt to gain
access to resident's holdings, money, or personal possessions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146078
If continuation sheet
Page 2 of 2
