Inspection Reports for Encore Village of Schaumburg

The inspection was conducted as a complaint investigation regarding the facility's failure to follow its advance directive/life sustaining policy by not having power of attorney implemented for a resident.

The facility failed to have proper power of attorney documentation for one resident (R1) out of three reviewed for advance directives. The resident's medical record lacked any paperwork designating the correct power of attorney, resulting in communication issues with the resident's legal representative.

The complaint investigation found that the facility did not have the correct power of attorney paperwork for resident R1, leading to failure in notifying the legal representative about the resident's condition and decline. The facility admitted to mistakenly documenting the son-in-law as POA when no such paperwork was on file.

The inspection was conducted as a complaint investigation regarding the facility's discharge process and medication reconciliation for residents discharged from the facility.

The facility failed to reconcile discharge medications for residents R1 and R3, resulting in medication mix-ups where medications intended for one resident were found among another resident's discharge belongings. The facility acknowledged the issue and implemented corrective actions including staff re-education and quality assurance monitoring.

Complaint Investigation 2517765/2591341 regarding discharge process and medication reconciliation issues.

The inspection was conducted as a complaint investigation (#2515606/IL194941) related to pharmacy services, specifically regarding medication administration and record-keeping.

The facility failed to ensure that one resident (R1) received a scheduled dose of tramadol due to the medication being unavailable, resulting in a missed dose. The medication records did not accurately reflect the missing dose, and the facility did not have adequate procedures to prevent this occurrence.

Complaint Investigation #2515606/IL194941 regarding pharmacy services and medication administration. The complaint was substantiated as the facility failed to provide a scheduled medication dose to a resident.

The inspection was conducted as a complaint investigation regarding the misappropriation of resident property, specifically the theft of a resident's credit card.

The facility failed to protect a resident from misappropriation of property when a credit card was stolen from the resident's room. The facility also failed to report the allegation to the state survey agency within the required timeframe and failed to thoroughly investigate the allegation. The investigation was ongoing with local police involvement, and corrective actions including staff re-education and quality assurance monitoring were implemented.

The complaint involved the theft of a resident's credit card (Resident R2). The resident's Power of Attorney (POA) discovered unauthorized charges and reported the theft to the police and the facility. The police investigation was ongoing, and the facility suspected an employee may have given the card to someone else who used it. The facility failed to report the allegation timely and did not conduct a thorough internal investigation.

The inspection was conducted as a complaint investigation regarding failure to provide timely incontinence care and nutritional assistance to residents.

The facility failed to provide timely incontinence care to 2 of 4 residents reviewed, resulting in residents being left in soiled briefs. Additionally, the facility failed to assist a resident with eating and ensure nutritional interventions were implemented, resulting in significant weight loss for one resident.

Complaint Investigation 2418769/IL179924. The complaint involved failure to provide timely incontinence care and nutritional assistance to residents.

The inspection was conducted as a complaint survey (#23110719/IL 168150) to investigate concerns related to dialysis services provided to a resident requiring peritoneal dialysis.

The facility failed to ensure that a resident's peritoneal dialysis treatments were initiated and monitored as ordered, resulting in missed treatments over several days. Documentation of treatments was incomplete, and systemic issues in verifying and carrying out dialysis orders were identified.

Complaint Survey #23110719/IL 168150 regarding dialysis services. The complaint was substantiated as the facility missed multiple peritoneal dialysis treatments for one resident, though it was stated this did not cause the resident to become unstable or require transfer.

Annual Licensure and Certification inspection conducted to assess compliance with regulatory requirements and investigate a facility reported incident from November 24, 2023.

The facility was found deficient in multiple areas including failure to implement physician-ordered wound care interventions, inadequate treatment and prevention of pressure ulcers, failure to ensure fall interventions for residents with a history of falls, incomplete pain assessments and failure to provide pain medication prior to therapy, and improper labeling and storage of medications.

Annual Licensure and Certification Survey including a Facility Reported Incident Investigation of December 7, 2022.

The facility was found deficient in multiple areas including failure to implement abuse policies after an injury of unknown origin, failure to timely report injuries of unknown origin, failure to protect a resident with an injury of unknown origin, failure to document abnormal limb assessments and obtain daily weights for residents, and failure to properly assess, document, and treat pressure injuries.

Annual licensure and certification survey conducted to assess compliance with federal regulations including resident rights, activities of daily living, pressure ulcer prevention and treatment, accident hazards, and incontinence care.

The facility was found deficient in multiple areas including inconsistent advanced directive documentation, failure to maintain or improve residents' transfer abilities, inadequate pressure ulcer prevention and treatment, unsafe oxygen tank storage, and improper incontinence care leading to infection control concerns.

The inspection was conducted due to a complaint investigation regarding allegations of sexual abuse involving resident R1 and two female residents (R2 and R3) at Friendship Village-Schaumburg.

The facility failed to ensure residents R2 and R3 were free from non-consensual sexual contact by resident R1, who has a history of inappropriate touching of females. Immediate Jeopardy was identified beginning January 20, 2021, and removed on August 25, 2021, but noncompliance remained at a Level Two due to ongoing evaluation of staff training effectiveness. The facility implemented corrective actions including education, monitoring, and care plan amendments.

The complaint investigation substantiated that resident R1 engaged in inappropriate sexual behavior by grabbing the breasts of residents R2 and R3 on multiple occasions, including incidents on January 20, 2021 and August 11, 2021. Staff witnessed and reported these incidents, and the facility conducted an investigation confirming the abuse.

Annual Licensure and Certification Survey to assess compliance with professional standards, resident care, safety, infection control, and regulatory requirements.

The facility was found deficient in multiple areas including failure to monitor residents' weights, provide adequate incontinence and ADL care, maintain wound care and pressure injury prevention, ensure resident safety including supervision and bed positioning, maintain infection control practices especially related to COVID-19 precautions and testing, provide appropriate diets, and ensure vaccination protocols were followed.

Annual Licensure and Certification Survey to assess compliance with professional standards, resident care, safety, infection control, and regulatory requirements.

The facility was found deficient in multiple areas including failure to monitor resident weights, provide adequate incontinence and ADL care, maintain wound care and pressure injury prevention, ensure resident safety and supervision, manage catheter care, provide appropriate diets, and implement infection control measures including COVID-19 precautions and testing. Immediate Jeopardy was identified related to infection control but was removed after corrective actions.

Annual Licensure and Certification Survey including complaint investigation 2010177/IL119000 with no deficiencies found.

The facility was found deficient in multiple areas including failure to properly assess and treat pressure ulcers, inadequate perineal care leading to infection risk, failure to follow dietary recommendations for residents with weight loss, and lapses in infection prevention and control practices such as improper hand hygiene and glove use.

Complaint 2010177/IL119000 was investigated during the annual survey and no deficiencies were found related to the complaint.

The inspection was conducted in response to complaint 1919716/IL118368 regarding the facility's failure to use two staff members to safely transfer a resident with a mechanical lift, which resulted in a fracture.

The facility failed to follow its policy requiring two staff members for mechanical lift transfers, as evidenced by a CNA transferring a high-risk resident alone, resulting in a fracture. The facility acknowledged the deficiency and implemented corrective actions including staff re-training and disciplinary measures.

Complaint 1919716/IL118368 was substantiated as the facility failed to follow safe transfer protocols, increasing the resident's risk of fracture.

The inspection was conducted as a complaint investigation related to a resident fall incident where the facility allegedly failed to use a gait belt during transfer, resulting in injury.

The facility failed to safely transfer a resident by not using a gait belt, which resulted in the resident falling and sustaining a right knee fracture. The staff member involved was disciplined and ultimately terminated for repeated failure to use the gait belt. The facility implemented corrective actions including staff re-education and ongoing quality assurance monitoring.

Complaint 1914017/IL 112736 regarding failure to use gait belt during resident transfer causing a fall and injury. The complaint was substantiated as evidenced by the cited deficiency and disciplinary actions.

The inspection was conducted in response to complaint 1914017/IL 112736 concerning the facility's failure to safely transfer a resident, resulting in a fall and injury.

The facility failed to use a gait belt during the transfer of a resident, which led to the resident falling and sustaining a right knee fracture. The staff member responsible was disciplined and eventually terminated for repeated failure to use the gait belt. The facility implemented corrective actions including staff re-education and ongoing quality assurance monitoring.

Complaint 1914017/IL 112736 regarding failure to use a gait belt during resident transfer, resulting in a fall and injury. The complaint was substantiated as evidenced by interviews, record reviews, and disciplinary actions.

This document is a Plan of Correction submitted by Friendship Village of Schaumburg in response to deficiencies cited during an annual health and complaint survey conducted on February 6, 2019.

The plan addresses a deficiency related to residents self-administering medications in a clinically appropriate manner, specifically the improper storage of mupirocin ointment at a resident's bedside. Corrective actions include removal of the medication, inspection of all resident rooms, staff in-service training, and ongoing quality assurance audits.

This Plan of Correction is submitted as a written allegation of compliance for deficiencies cited related to hazards, supervision, and devices following a complaint investigation.

The facility identified deficiencies related to fall risks and care plan updates for residents affected. Corrective actions include reassessment of residents, staff re-education, root cause analysis development, and ongoing audits by the Director of Nursing or designee to ensure compliance and prevention of recurrence.

Complaint number 1793157/IL94295 is referenced, indicating the Plan of Correction is in response to a complaint.

This document is a Plan of Correction submitted by Friendship Village in response to complaints numbered 1790067/IL90865 and 1791626/IL92621, addressing deficiencies cited related to resident safety and supervision.

The plan addresses deficiencies related to free of accident hazards, supervision, and use of assistive devices during resident transfers. It outlines corrective actions including re-education of direct care staff and ongoing monitoring by the Director of Nursing or designee.

This Plan of Correction responds to complaints 1790067/IL90865 and 1791626/IL92621. The document does not state substantiation status.

This Plan of Correction is submitted as a written allegation of compliance for deficiencies cited during the inspection conducted on 3/24/17.

The facility addressed a deficiency related to dignity and respect of individuality, specifically involving the removal and termination of an employee (E3) and re-education of staff on dignity policy and resident rights.

This document is a Plan of Correction (POC) submitted by Friendship Village of Schaumburg to address deficiencies identified during a regulatory inspection.

The facility identified multiple deficiencies related to call light accessibility, housekeeping and maintenance, accident hazards, and food procurement and sanitation. Corrective actions included staff re-education, removal of hazards, proper labeling and storage of personal care items, and monitoring by designated staff until 100% compliance is achieved.

This document is a Plan of Correction submitted by Friendship Village in response to deficiencies cited during a complaint survey (Complaint Survey 1695829/IL89113) conducted on November 11, 2016.

The plan addresses deficiencies related to treatment and services to improve/maintain ADLs, ADL care for dependent residents, treatment care for special needs, and sufficient 24-hour nursing staff per care plans. Corrective actions include reassessment of residents' needs, re-education of staff, increased staffing levels, individualized interventions, and monitoring through Quality Assurance Plans.

This Plan of Correction is in response to a complaint survey identified as Complaint Survey 1695829/IL89113.

This document is a Plan of Correction submitted by the facility to address deficiencies identified during a prior survey. It outlines corrective actions, monitoring plans, and completion dates for various issues related to medication administration, infection control, and resident transfers.

The Plan of Correction details re-education of nursing staff on documentation, medication administration, infection control, and transfer policies. It includes monitoring procedures by the Director of Nursing to ensure compliance until 100% adherence is achieved over a three-month period.

This document is a plan of correction submitted by Friendship Village of Schaumburg to address deficiencies related to accident hazards, supervision, devices, and treatment/care for special needs identified during a prior inspection.

The plan outlines corrective actions taken to remove accident hazards such as unsecured oxygen cylinders and wheelchair leg rests, and to replace and properly store medical equipment like oxygen nasal cannulas, spirometers, and nebulizer masks. It also describes ongoing monitoring and quality assurance plans to ensure compliance and prevent recurrence.

This document is a Plan of Correction submitted by Friendship Village of Schaumburg in response to deficiencies identified during a prior inspection.

The plan addresses multiple deficiencies related to dignity and respect of individuality, activity participation, pharmacy services, medical supply management, resident chart security, and emergency procedures/drills. Corrective actions include new seating arrangements, activity program adjustments, removal of expired supplies, securing resident charts, and staff re-education on emergency preparedness.

This document is a Plan of Correction submitted by Friendship Village in response to deficiencies identified during a survey conducted on January 18, 2012.

The plan addresses multiple deficiencies related to care plans, food procurement and safety, accident hazards, drug records, and infection control. Corrective actions include staff in-service training, policy reviews, audits, and quality assurance monitoring to ensure compliance and prevent recurrence.

This document is a Plan of Correction submitted by Friendship Village of Schaumburg following an annual survey conducted on March 10, 2011.

The Plan of Correction addresses deficiencies related to comprehensive assessments and infection control, detailing corrective actions, monitoring plans, and timelines to ensure compliance and prevent recurrence.

The document is a plan of correction responding to deficiencies identified by surveyors related to dignity, comprehensive care plans, accidents and supervision, medication errors, menus and nutritional adequacy, and sanitary conditions.

The facility identified deficiencies in resident dignity, medication management, accident prevention, nutritional adequacy, and sanitary conditions. Corrective actions include staff in-services, committee formation, chart audits, education, policy updates, and quality assurance monitoring to ensure compliance and prevent recurrence.

The inspection was conducted as a complaint investigation based on complaints #0993825 and #0994273 regarding care plan errors and quality of care issues at Friendship Village of Schaumburg.

The facility was found to have deficiencies related to comprehensive care plans and quality of care, including medication administration errors and feeding order inaccuracies. Corrective actions were implemented, including staff in-services, policy revisions, and quality assurance monitoring to prevent recurrence.

Complaint investigation based on complaints #0993825 and #0994273. The report includes corrective actions taken and monitoring plans. Substantiation status is not explicitly stated.

This document is a plan of correction addressing deficiencies related to infection prevention and control at Friendship Village of Schaumburg.

The facility identified deficiencies in hand washing and hand hygiene during medication administration and outlined corrective actions including re-education of nurses and ongoing monitoring by the Director of Nursing.

This document is a Plan of Correction related to Complaint #1093569/IL50463 & IL 50357 addressing deficiencies cited in notifications of changes and provision of care/services for highest well-being.

The facility identified deficiencies related to notification of changes in residents' conditions and prompt efforts to resolve grievances. Corrective actions include staff reminders, in-service training, and quality assurance monitoring plans to ensure issues are corrected and do not recur.

Complaint #1093569/IL50463 & IL 50357. Resident identified in report had already been discharged. No other residents found to be affected. Complaint substantiation status not explicitly stated.

This document is a Plan of Correction responding to complaints identified by complaint numbers #1091464/IL46933, #1091888/IL47435, and IRI of 4/8/10/IL47283.

The plan addresses a deficiency related to resident R9 not being put to bed at the requested time due to medication pass, staff breaks, and attending other residents. Staff were in-serviced to attend residents timely, adjust break times, and communicate break coverage. No resident injury resulted from the deficient practice.

The document references complaints #1091464/IL46933, #1091888/IL47435, and IRI of 4/8/10/IL47283 but does not state substantiation status.

This document is a Plan of Correction submitted by Friendship Village of Schaumburg addressing deficiencies identified during a prior inspection related to medication storage, infection control, and medical record security.

The plan outlines corrective actions including removal of expired supplies, re-education of staff on infection control and medication handling, securing resident charts, and ongoing quality assurance monitoring to ensure compliance and prevent recurrence.