Inspection Reports for Encore Village of Schaumburg
350 W Schaumburg Rd, Schaumburg, IL 60194, United States, IL, 60194
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 14, 2025, identified a deficiency related to the facility’s failure to have proper power of attorney documentation for a resident. Earlier inspections showed a pattern of deficiencies primarily involving medication management, resident care including wound and pressure ulcer treatment, and failure to follow policies related to resident safety and documentation. Several complaint investigations substantiated issues such as missed medication doses, improper discharge medication reconciliation, failure to protect residents from property misappropriation, and inadequate assistance with activities of daily living. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with regulatory compliance, with deficiencies continuing through the most recent inspection.
Deficiencies (last 15 years)
Deficiencies (over 15 years)
7.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
126% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 14, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to properly implement a resident's power of attorney and follow advance directive/life sustaining treatment policies.
Complaint Details
The complaint investigation revealed that the facility did not notify the resident's designated power of attorney about the resident's decline or multiple falls and incorrectly documented the power of attorney. The facility acknowledged the mistake and lack of proper documentation.
Findings
The facility failed to have power of attorney implemented for a resident (R1) and did not notify the correct power of attorney about the resident's condition and decline. The social service department was found responsible for ensuring advance directives were in place, but no documentation was found for R1's power of attorney.
Deficiencies (1)
Failed to follow advance directive/life sustaining treatment policy by not having power of attorney implemented for a resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V9 | Nurse Practitioner | Provided statement regarding decision-making by resident's daughter. |
| V7 | Social Service | Stated uncertainty about who was the power of attorney for the resident. |
| V6 | Resident's son-in-law | Identified as the resident's power of attorney and stated the facility did not inform him about the resident's condition. |
| V1 | Administrator | Acknowledged no power of attorney paperwork was received and that social service is responsible for advance directives. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 14, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to follow advance directive/life sustaining policy by not having power of attorney implemented for a resident.
Report Facts
Residents reviewed for advance directives: 3
Residents affected: 1
Date of resident death: Sep 24, 2025
Date of survey completion: Oct 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V9 | Nurse Practitioner | Provided statement about resident's daughter making decisions |
| V7 | Social Service | Interviewed regarding uncertainty about resident's POA |
| V6 | Resident's son-in-law | Claimed to be resident's POA and reported lack of notification |
| V1 | Administrator | Stated no POA paperwork was received and explained contact procedures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 20, 2025
Visit Reason
The inspection was conducted due to a complaint regarding a medication mix-up involving discharged resident medications.
Complaint Details
The complaint was substantiated. Family member V7 reported on 08/13/2025 that two medication bottles not prescribed to resident R1 were found among R1's discharge belongings, indicating a medication mix-up.
Findings
The facility failed to reconcile discharge medications for resident R1, resulting in medications intended for resident R3 being mistakenly included in R1's discharge medication bag. This failure was linked to improper medication reconciliation and handling during the discharge process.
Deficiencies (1)
Failure to reconcile a resident's discharge medications with current prescription orders prior to discharge, resulting in medication mix-up.
Report Facts
Residents reviewed for medications: 3
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V4 | Registered Nurse | Described medication handling and discharge process failures |
| V2 | Director of Nursing | Provided information on discharge procedures and nursing responsibilities |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 20, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's discharge process and medication reconciliation for residents discharged from the facility.
Complaint Details
Complaint Investigation 2517765/2591341 regarding discharge process and medication reconciliation issues.
Findings
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.
Deficiencies (1)
Failure to reconcile a resident's discharge medications with current prescription orders prior to discharge, resulting in medication mix-up between residents.
Report Facts
Date of survey completion: Aug 20, 2025
Date of resident discharge: Aug 12, 2025
Plan of Correction Completion Date: Aug 28, 2025
Frequency of QA monitoring: 3
Number of residents reviewed for medication: 3
Number of residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V4 | Registered Nurse | Reported details of medication mix-up and discharge process failures |
| V2 | Director of Nursing | Provided explanation of discharge process and medication reconciliation expectations |
Inspection Report
Deficiencies: 1
Date: Jun 24, 2025
Visit Reason
The inspection was conducted to assess pharmaceutical services and ensure residents received their scheduled medications as required by regulations.
Findings
The facility failed to ensure one resident (R1) received their scheduled tramadol medication due to the facility running out of the medication, resulting in a missed dose. The facility did not retrieve tramadol from the medication tower while waiting for pharmacy delivery.
Deficiencies (1)
Failed to ensure a resident received their scheduled medication (tramadol) causing a missed dose.
Report Facts
Residents reviewed for pharmacy services: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Provided information about medication reordering and medication tower usage |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation (#2515606/IL194941) related to pharmacy services, specifically regarding medication administration and record-keeping.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to ensure a resident received their scheduled medication (tramadol) causing a missed dose.
Report Facts
Residents reviewed for pharmacy services: 3
Missed tramadol dose: 1
Medication administration monitoring frequency: 3
Monitoring duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Provided statements regarding medication reorder procedures and medication tower usage |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 12, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of resident property, specifically the theft of a resident's credit card.
Complaint Details
The complaint involved the theft of a resident's credit card (Resident R2). The credit card was used fraudulently at a store for $500. The resident's Power of Attorney (POA) discovered the unauthorized charge and reported it to the facility and police. The facility delayed reporting to the state agency and did not conduct a thorough investigation. The police investigation is ongoing, and the facility is cooperating.
Findings
The facility failed to protect a resident from the misappropriation of property when a credit card was stolen from the resident's room. Additionally, the facility failed to timely report the allegation to the state agency, and failed to thoroughly investigate the allegation. The investigation was ongoing with law enforcement involvement.
Deficiencies (3)
Failed to protect a resident from the wrongful use of the resident's belongings or money when a credit card was stolen.
Failed to timely report suspected abuse, neglect, or theft to the state surveying agency within 24 hours.
Failed to have evidence that an allegation of misappropriation of resident property was thoroughly investigated.
Report Facts
Charge amount: 500
Dates: Oct 1, 2024
Dates: Dec 17, 2024
Dates: Dec 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V5 | Registered Nurse/Unit Manager | Reported receiving police email and involved in incident reporting |
| V6 | Executive Director | Stated theft should not occur and that administrator should ensure investigation |
| V9 | Social Services | Reported initial missing credit card to previous administrator |
| V10 | Power of Attorney/Daughter | Discovered unauthorized credit card charges and reported to facility and police |
| V11 | Assistant Director of Nursing (ADON) | Responsible for investigation but did not personally interview anyone |
| V4 | Assistant Executive Director | Signed initial incident report and commented on investigation process |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 12, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding the misappropriation of resident property, specifically the theft of a resident's credit card.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to protect a resident from misappropriation of resident property when a credit card was stolen.
Failed to report an allegation of misappropriation of resident property to the state survey agency within required timeframes.
Failed to have evidence that an allegation of misappropriation of resident property was thoroughly investigated.
Report Facts
Charge amount: 500
Deficiency completion date: Mar 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V5 | Registered Nurse/Unit Manager | Named in relation to reporting and investigation of the credit card theft |
| V4 | Assistant Executive Director | Signed the initial incident report and involved in investigation oversight |
| V11 | Assistant Director of Nursing (ADON) | Responsible for investigation of the allegation but did not personally interview staff or document interviews |
| V9 | Social Services | Reported the missing credit card to previous administrator and involved in the case |
| V6 | Executive Director | Stated the administrator should have initiated an investigation |
| Tom Robendeau | Detective | Local police detective involved in the ongoing investigation |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Nov 20, 2024
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements for nursing home care, including resident rights, advanced directives, activities of daily living, safety, nutrition, respiratory care, medication administration, and infection control.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs (wheelchair leg support), failure to discuss and implement advanced directives upon admission, inadequate assistance with activities of daily living (showers/baths), insufficient fall prevention measures, significant unaddressed weight loss in residents, improper oxygen administration, medication administration errors, unsecured medication storage, and lapses in infection prevention and control practices.
Deficiencies (10)
Failed to ensure a resident's legs were properly supported while sitting in her wheelchair.
Failed to ensure a resident's advanced directives were discussed and implemented upon admission.
Failed to ensure residents who require staff assistance with ADLs received showers/baths as scheduled.
Failed to ensure adequate supervision and fall prevention interventions after falls for residents.
Failed to monitor weights, assess significant weight loss, and implement interventions for residents with weight loss.
Failed to ensure a resident was administered oxygen using a high flow nasal cannula as ordered.
Failed to ensure staff administered medications to a resident and did not leave them on the bedside table.
Failed to ensure a resident was free from a significant medication error related to late administration of Parkinson's medication.
Failed to ensure medications were securely stored and not left unsecured on a resident's bedside table.
Failed to ensure staff washed hands and changed gloves appropriately and donned all applicable Personal Protective Equipment for residents on Enhanced Barrier Precautions.
Report Facts
Residents reviewed: 26
Weight loss: 12.6
Weight loss: 10.2
Weight loss: 16.8
Medication administration delay: 3
Oxygen flow rate: 7
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V20 | Therapy Director | Provided expert opinion on proper wheelchair positioning for resident R57. |
| V2 | Director of Nursing | Provided multiple interviews regarding advanced directives, ADL assistance, medication administration, and infection control. |
| V7 | Certified Nursing Assistant | Reported on shower assistance issues for resident R58 and feeding assistance for resident R231. |
| V14 | Restorative Registered Nurse | Reported on fall incidents and interventions for resident R110. |
| V19 | Certified Nursing Assistant | Reported on shower charting and gait belt use. |
| V21 | Respiratory Therapist | Provided expert opinion on oxygen cannula type for resident R281. |
| V6 | Licensed Practical Nurse (Agency) | Reported on medication administration timing for resident R58. |
| V22 | Licensed Practical Nurse | Reported on medication storage practices for resident R121. |
| V15 | Licensed Practical Nurse | Reported on medication storage and security concerns. |
| V9 | Certified Nursing Assistant | Observed providing incontinence care to resident R20. |
| V10 | Certified Nursing Assistant | Observed providing incontinence care to resident R20 with infection control lapses. |
| V12 | Wound Nurse | Observed not wearing gown during wound care for resident R12. |
| V11 | Registered Nurse | Commented on hand hygiene practices. |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 31, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living, nutritional support, and incontinence care for residents at Encore Village nursing home.
Findings
The facility failed to provide timely incontinence care to two residents requiring assistance, and failed to assist a resident with eating and ensure nutritional interventions were implemented, resulting in significant weight loss for one resident. These deficiencies were noted through observations, interviews, and record reviews.
Deficiencies (2)
Failure to ensure residents requiring assistance with Activities of Daily Living (ADLs) received timely incontinence care.
Failure to assist a resident with eating and failure to ensure a nutritional intervention was implemented for a resident with significant weight loss.
Report Facts
Weight loss percentage: 6.2
Weight loss percentage: 13.3
Weight loss percentage: 14.8
Weight loss in pounds: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V5 | Certified Nursing Assistant | Named in finding related to failure to provide timely incontinence care to resident R2 |
| V6 | Certified Nursing Assistant | Named in finding related to failure to provide timely incontinence care to resident R1 |
| V7 | Licensed Practical Nurse | Provided statement on toileting and incontinence care frequency |
| V8 | Registered Nurse | Clarified nutritional intervention for resident R4 |
| V9 | Certified Nursing Assistant | Reported resident R4 did not eat breakfast |
| V16 | Dietary Director | Confirmed failure to provide nutritional shakes to resident R4 |
| V4 | Assistant Director of Nursing | Reported resident R4's continued weight loss |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 31, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding failure to provide timely incontinence care and nutritional assistance to residents.
Complaint Details
Complaint Investigation 2418769/IL179924. The complaint involved failure to provide timely incontinence care and nutritional assistance to residents.
Findings
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.
Deficiencies (2)
Failure to ensure residents who required staff assistance with Activities of Daily Living (ADLs) received timely incontinence care.
Failure to assist a resident with eating and failure to ensure a nutritional intervention was implemented for a resident with significant weight loss.
Report Facts
Residents reviewed for ADLs: 4
Residents reviewed for weight loss: 4
Weight loss percentage: 6.2
Weight loss percentage: 13.3
Weight loss percentage: 14.8
Weight loss in pounds: 3
Weight loss in pounds: 6.2
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 26, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's failure to properly monitor and manage psychotropic medications for a resident (R1), which resulted in adverse effects and hospitalization.
Complaint Details
The investigation was complaint-related, focusing on the failure to monitor and manage psychotropic medications for resident R1, resulting in actual harm and hospitalization. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to report adverse side effects immediately, failed to monitor psychotropic medication use, and failed to hold medication orders for a resident showing signs of excessive drowsiness, resulting in hospitalization for stroke-like symptoms. Documentation and communication regarding medication holds and physician notifications were inadequate.
Deficiencies (3)
Failure to implement gradual dose reductions and non-pharmacological interventions prior to or instead of continuing psychotropic medication; failure to limit PRN psychotropic medication use.
Failure to report adverse side effects immediately and failure to monitor psychotropic medication use.
Failure to carry out orders to hold medication for a resident showing signs of adverse effects of excessive drowsiness.
Report Facts
Psychotropic medications scheduled: 3
Medication doses: 375
Medication doses: 100
Medication doses: 0.5
Sample size: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V7 | Registered Nurse | RN who assisted R1 and reported behaviors and medication monitoring issues. |
| V9 | Certified Nursing Assistant | Provided care to R1 including incontinence care and transfers. |
| V10 | Certified Nursing Assistant | Provided care to R1 including incontinence care and transfers. |
| V5 | Unit Manager | Reported on R1's condition and medication issues on 8/26/24. |
| V4 | Registered Nurse (Agency) | Agency nurse caring for R1 on 8/15/24 who administered medications and reported concerns. |
| V2 | Director of Nursing | Confirmed medication monitoring and notification failures. |
| V15 | Psych Nurse Practitioner | Assessed R1 and ordered to hold psychotropic medications if lethargic. |
| V14 | Psych Nurse Practitioner | Provided new orders for R1 on 8/14/24. |
| V16 | Nurse Practitioner | R1's daughter and also noted in clinical context; assessed R1 on 8/15/24. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 24, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's property, specifically the theft of pain medication by a staff member.
Complaint Details
The complaint investigation was substantiated. The Licensed Practical Nurse (V4 LPN) admitted to taking the resident's Norco medication due to personal financial and health issues. The facility involved police and state agency following the incident.
Findings
The facility failed to protect a resident's right to be free from misappropriation of property when a Licensed Practical Nurse (V4 LPN) admitted to taking 30 tablets of Norco pain medication prescribed to Resident 1. The nurse initially denied the theft but later confessed due to financial hardship and lack of insurance. The facility notified police and the state agency.
Deficiencies (1)
Failure to protect a resident from misappropriation of property (theft of pain medication by staff).
Report Facts
Tablets missing: 30
Medication dosage: 7.5
Medication dosage: 325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | V5 Unit Manager involved in investigation and communication with staff and doctor | |
| Licensed Practical Nurse | V4 LPN admitted to taking resident's medication |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 27, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure a resident's peritoneal dialysis treatments were initiated and monitored properly.
Complaint Details
The complaint investigation found that the resident missed three peritoneal dialysis treatments (12/23, 12/24, 12/25) after hospital discharge. The facility did not verify hospital orders promptly, and documentation of treatments was incomplete. The resident did not become unstable or require transfer due to missed treatments.
Findings
The facility failed to ensure that peritoneal dialysis treatments were initiated and monitored for one resident (R1), who missed three treatments after hospital readmission. Documentation of treatments and related clinical data was incomplete, though the resident did not become unstable or require transfer due to missed treatments.
Deficiencies (1)
Failure to ensure a resident's peritoneal dialysis treatments were initiated and monitored as ordered.
Report Facts
Missed peritoneal dialysis treatments: 3
Resident age: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Stated R1 is the only peritoneal dialysis resident | |
| 3rd party Dialysis Nurse | Provided treatment history on R1's PD cycler | |
| Registered Nurse | Discussed documentation of PD treatments | |
| Nephrology Nurse Practitioner | Assessed resident and PD orders, confirmed missed treatments | |
| Nursing Manager | Called Nephrology Nurse Practitioner regarding PD orders |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 27, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to ensure a resident's peritoneal dialysis treatments were initiated and monitored as ordered.
Report Facts
Missed dialysis treatments: 3
Dialysis treatments documented: 1
Sample size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Stated resident was the only peritoneal dialysis resident in the facility. | |
| 3rd party Dialysis Nurse | Showed treatment history on resident's PD cycler. | |
| Registered Nurse | Entered resident's room and described documentation process for PD treatments. | |
| Nephrology Nurse Practitioner | Discussed missed treatments and clinical impact. | |
| Nursing Manager | Called Nephrology Nurse Practitioner regarding PD orders. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Dec 6, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, medication management, and wound care at Encore Village nursing home.
Findings
The facility was found deficient in multiple areas including failure to implement physician-ordered wound interventions, inadequate pressure ulcer care and prevention, insufficient fall prevention measures, failure to assess and manage resident pain appropriately, and improper medication labeling and storage practices.
Deficiencies (5)
Failed to implement physician ordered wound interventions for 1 of 24 residents (R93) reviewed for non-pressure wounds.
Failed to ensure a soiled dressing was changed, failed to reposition residents with pressure injuries, and failed to have pressure relieving interventions in place for 2 of 5 residents (R40, R81) reviewed for pressure injuries.
Failed to ensure fall interventions were in place for a resident (R51) with a history of falls.
Failed to assess a resident's pain every shift and provide pain medication prior to therapy for 1 of 24 residents (R23) reviewed for pain.
Failed to ensure a resident's insulin vial was disposed of after 28 days of opening and failed to ensure a medication vial for anti-anxiety was dated and labeled upon opening for 2 of 6 residents (R80 and R37) reviewed for medication storage.
Report Facts
Residents reviewed for non-pressure wounds: 24
Residents reviewed for pressure injuries: 24
Residents reviewed for pressure injuries: 5
Residents reviewed for safety: 24
Residents reviewed for pain: 24
Residents reviewed for medication storage: 6
Missing pain assessments: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V6 Unit Manager | Provided information about resident R93's wound care and AFO boots | |
| V7 Wound Care Nurse | Provided wound care details for residents R40 and R81 | |
| V12 CNA | Certified Nursing Assistant | Assisted resident R40 and provided information about dressing |
| V13 CNA | Certified Nursing Assistant | Assisted resident R40 |
| V10 CNA | Certified Nursing Assistant | Provided incontinent care to resident R81 and discussed air mattress use |
| V5 | Registered Nurse | Provided information about fall risk and medication storage |
| V8 | Physical Therapy Assistant | Provided therapy details for resident R23 |
| V9 | Registered Nurse/Unit Manager | Discussed pain medication administration prior to therapy for resident R23 |
| V11 | RN-Agency | Reported not having seen resident R23 on the morning of 12/5/2023 |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Dec 6, 2023
Visit Reason
Annual Licensure and Certification inspection conducted to assess compliance with regulatory requirements and investigate a facility reported incident from November 24, 2023.
Findings
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.
Deficiencies (5)
Failed to implement physician ordered wound interventions for 1 of 24 residents (R93) reviewed for non-pressure wounds.
Failed to ensure soiled dressing was changed, failed to reposition residents with pressure injuries, and failed to have pressure relieving interventions in place for 2 of 5 residents (R40, R81) reviewed for pressure injuries.
Failed to ensure fall interventions were in place for a resident (R51) with a history of falls.
Failed to assess a resident's (R23) pain every shift and provide pain medication prior to therapy.
Failed to ensure a resident's insulin vial was disposed of after 28 days of opening and failed to ensure a medication vial for anti-anxiety was dated and labeled upon opening (Residents R80 and R37).
Report Facts
Residents reviewed: 24
Residents reviewed for pressure injuries: 5
Residents reviewed for medication storage: 6
Missing pain assessments: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V6 Unit Manager | Provided information about resident R93's wound care and resident R81's wound history | |
| V7 Wound Care Nurse | Provided wound care details and assessment for residents R40 and R81 | |
| V10 CNA | Certified Nursing Assistant | Provided care and observations related to resident R81 |
| V5 RN | Registered Nurse | Provided information about resident R51's fall risk and observations |
| V8 Physical Therapy Assistant | Physical Therapy Assistant | Provided therapy details for resident R23 |
| V9 Registered Nurse/Unit Manager | Registered Nurse/Unit Manager | Provided information about pain medication administration and therapy for resident R23 |
| V11 RN | Registered Nurse | Agency nurse who had not seen resident R23 on the morning of observation |
| R5 Registered Nurse | Registered Nurse | Provided information about medication storage and labeling for residents R80 and R37 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 5, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to document an abnormal limb assessment and failure to obtain daily weights and notify a physician of weight gains for two residents, as well as failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for another resident.
Complaint Details
The complaint investigation revealed failures in nursing care related to limb assessment and weight monitoring for residents R6 and R75, and failures in pressure ulcer care for resident R100. The investigation included interviews with nursing staff and review of medical records and policies.
Findings
The facility failed to document an abnormal limb assessment and notify a physician of significant weight gains for two residents, resulting in potential harm. Additionally, the facility failed to revise and implement appropriate care plans for pressure injuries, conduct initial and weekly wound assessments, leading to the development of multiple pressure injuries in one resident.
Deficiencies (2)
Failed to document an abnormal limb assessment and failed to obtain daily weights and notify a physician of weight gains for two residents.
Failed to revise/update a plan of care after new pressure injuries were identified, failed to implement a plan of care for a resident with pressure injuries, failed to do initial wound assessments, and failed to do weekly wound assessments.
Report Facts
Residents reviewed: 32
Weight gain: 17.1
Weight measurements: 5
Pressure injuries: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V5 | Registered Nurse (RN) | Reported abnormal limb condition and hospital transfer for resident R6 |
| V12 | Certified Nursing Assistant (CNA) | Reported daily weights done but unaware of resident R75's need for daily weighing |
| V11 | Registered Nurse (RN) | Confirmed resident R75 needed daily weights and instructed staff accordingly |
| V2 | Director of Nursing | Confirmed importance of daily weights for resident R75 and wound care expectations |
| V3 | Wound Nurse | Described wound assessment procedures and noted failures in wound care for resident R100 |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jan 5, 2023
Visit Reason
Annual Licensure and Certification Survey including a Facility Reported Incident Investigation of December 7, 2022.
Findings
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.
Deficiencies (5)
Failed to implement abuse policies after an injury of unknown origin for one resident (R6).
Failed to report immediately and timely to the Administrator and state agency an injury of unknown origin for one resident (R6).
Failed to protect a resident (R6) when an injury of unknown origin was identified.
Failed to document an abnormal limb assessment and failed to obtain daily weights and notify a physician of weight gains for two residents (R6, R75).
Failed to revise/update plan of care, implement plan of care, perform initial and weekly wound assessments for one resident (R100) with pressure injuries.
Report Facts
Sample size: 32
Resident age: 98
Resident age: 91
Weight gain: 17.1
Weight measurements: 172.5
Weight measurements: 175.3
Weight measurements: 178.9
Weight measurements: 188.8
Weight measurements: 189.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V1 | Administrator | Facility abuse coordinator who did not initiate abuse investigation for R6. |
| V2 | Director of Nursing | Notified of R6's fractured leg and involved in investigation and reporting. |
| V5 | Registered Nurse | Notified supervisor of R6's injury and involved in investigation. |
| V6 | Certified Nursing Assistant | Transferred resident R6 and involved in injury incident. |
| V7 | Certified Nursing Assistant | Reported R6's injury and assisted in care. |
| V3 | Wound Nurse | Responsible for wound assessments and treatment for resident R100. |
| V11 | Registered Nurse | Acknowledged daily weight order for resident R75 and instructed staff accordingly. |
| V12 | Certified Nursing Assistant | Performed weights and was unaware of daily weight order for resident R75. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Mar 24, 2022
Visit Reason
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.
Findings
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.
Deficiencies (5)
Failed to have consistent advanced directive information for residents R5 and R93.
Failed to ensure a resident's transfer status did not deteriorate (R36).
Failed to implement pressure ulcer prevention and treatment measures for residents R28, R31, R36, and R98.
Failed to ensure oxygen tank was stored safely for resident R4.
Failed to provide incontinence care in a manner to prevent urinary tract infections for resident R31.
Report Facts
Residents reviewed for advanced directives: 27
Residents reviewed for pressure ulcers: 8
Residents reviewed for incontinence care: 27
Wound assessments performed for R31: 3
Wound care order revision interval for R36: 28
Wound assessment gap for R36: 16
Audit frequency for advanced directives: 5
Audit frequency for transfer status: 3
Audit frequency for pressure injuries: 5
Audit frequency for oxygen cylinder storage: 5
Audit frequency for perineal care observations: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V13 | Certified Nursing Assistant | Named in advanced directive deficiency related to code status wristbands |
| V14 | Registered Nurse | Named in advanced directive deficiency related to code status wristbands |
| V15 | RN Unit Manager | Named in advanced directive deficiency related to code status wristbands |
| V2 | Director of Nursing | Provided statements on advanced directives, transfer status, wound care, and oxygen safety |
| V3 | Wound Care Nurse | Provided statements and assessments related to pressure ulcer deficiencies |
| V4 | Restorative Nurse | Provided statements related to transfer status and wound care |
| V5 | Registered Nurse | Provided statements related to advanced directive wristbands |
| V6 | Restorative Aide | Observed providing incontinence care with infection control issues |
| V7 | Certified Nursing Assistant | Observed assisting with transfers |
| V8 | Agency Certified Nursing Assistant | Observed providing improper incontinence care; identified as not returning to facility |
| V9 | Certified Nursing Assistant | Provided statements on oxygen tank safety |
| V10 | Registered Nurse | Provided statements on oxygen tank safety |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 25, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Facility failed to prevent non-consensual sexual contact by resident R1 towards residents R2 and R3.
Noncompliance remained at Level Two after removal of Immediate Jeopardy due to need for further evaluation of training effectiveness.
Report Facts
Deficiency completion date: 2021
Education completion date: 2021
Audit frequency: 10
Audit duration: 8
Audit compliance period: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V4 RN | Registered Nurse | Witnessed incident of R1 grabbing R3's breast on August 11, 2021 |
| V10 CNA | Certified Nursing Assistant | Witnessed R1 grabbing breasts of residents R2 and R3 on August 11, 2021 |
| V5 RN | Registered Nurse | Primary nurse who responded to incident and reported history of R1's inappropriate behavior |
| V3 ADON | Assistant Director of Nursing | Notified of incidents and discussed staff response to R1's behavior |
| Director of Nursing | Director of Nursing | Provided education to nursing and CNA staff regarding abuse identification and prevention |
| Facility Administrator | Facility Administrator | Reviewed facility policies and participated in corrective action planning |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Jun 16, 2021
Visit Reason
Annual Licensure and Certification Survey to assess compliance with professional standards, resident care, safety, infection control, and regulatory requirements.
Findings
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.
Deficiencies (11)
Failed to monitor and obtain residents' weights as ordered for three residents.
Failed to perform incontinence care and ADL assistance for five residents.
Failed to provide necessary care and services for treatment of leg wound, excoriated perineal area, and failed to monitor daily weights for a resident with CHF.
Failed to prevent pressure ulcers, maintain pressure wound dressings, and assess and measure pressure wounds for four residents, contributing to worsening wounds and infection.
Failed to ensure supervision of residents with dysphagia during eating and safe bed positioning for four residents.
Failed to keep urinary catheter bag and tubing off the floor to prevent infections for one resident.
Failed to maintain resident's upright position during tube feeding infusion for one resident.
Failed to ensure a resident received a mechanically altered diet as ordered.
Failed to follow CDC guidelines for PPE use and isolation for residents under investigation for COVID-19, resulting in Immediate Jeopardy.
Failed to provide pneumococcal 23 vaccine to two residents as required.
Failed to immediately perform COVID-19 testing on residents with signs and symptoms of COVID-19, resulting in Immediate Jeopardy.
Report Facts
Residents reviewed: 28
Resident census: 141
Staff not vaccinated: 28
Residents not vaccinated: 6
N95 masks supply: 9000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Provided information on PPE use, COVID-19 testing, and vaccination |
| V3 | Infection Control Nurse | Provided information on catheter care and COVID-19 testing |
| V4 | Registered Nurse | Provided information on resident isolation and PPE use |
| V5 | Certified Nursing Assistant | Observed not using PPE in isolation room |
| V6 | Certified Nursing Assistant | Observed providing care without proper PPE and involved in weight and incontinence care deficiencies |
| V8 | Purchasing | Provided information on PPE supply |
| V9 | Certified Nursing Assistant | Provided information on PPE requirements |
| V10 | Certified Nursing Assistant | Observed not using PPE in isolation room |
| V11 | Speech Therapist | Provided information on resident swallowing precautions |
| V22 | Wound Care Nurse | Provided wound care assessments and education |
| V25 | Registered Nurse | Involved in wound care, weight monitoring, and resident safety |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Jun 16, 2021
Visit Reason
Annual Licensure and Certification Survey to assess compliance with professional standards, resident care, safety, infection control, and regulatory requirements.
Findings
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.
Deficiencies (11)
Failed to monitor and obtain residents weights as ordered for three residents.
Failed to perform incontinence care and ADL assistance for dependent residents.
Failed to provide necessary care and services for treatment of wounds and failed to monitor daily weights for a resident with CHF.
Failed to prevent pressure ulcers, maintain pressure wound dressings, and assess and measure pressure wounds for residents.
Failed to ensure supervision during eating for a resident with dysphagia and failed to ensure safe bed positioning for residents at risk of falls.
Failed to keep urinary catheter bag and tubing off the floor to prevent infections.
Failed to maintain resident's head of bed in upright position during tube feeding infusion.
Failed to provide a mechanically altered diet as ordered for a resident.
Failed to follow CDC guidelines for PPE use and isolation for residents under investigation for COVID-19, resulting in Immediate Jeopardy.
Failed to provide pneumococcal 23 vaccine to residents as required.
Failed to immediately perform COVID-19 testing on residents with symptoms, resulting in Immediate Jeopardy.
Report Facts
Residents reviewed: 28
Resident census: 141
Staff not vaccinated: 28
Residents not vaccinated: 6
N95 masks supply: 9000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Provided information on PPE use, vaccination, COVID testing, and infection control policies |
| V3 | Infection Control Nurse | Provided information on catheter care and COVID testing procedures |
| V4 | Registered Nurse | Provided information on resident isolation and infection control |
| V5 | Certified Nursing Assistant | Observed entering isolation rooms without PPE |
| V6 | Certified Nursing Assistant | Involved in resident care and observed not following infection control PPE |
| V8 | Purchasing | Provided information on PPE supply |
| V9 | Certified Nursing Assistant | Provided information on PPE requirements |
| V10 | Certified Nursing Assistant | Observed not wearing PPE in isolation room |
| V11 | Speech Therapist | Provided information on resident swallowing precautions |
| V22 | Wound Care Nurse | Provided wound care assessments and education |
| V25 | Registered Nurse | Involved in resident care and wound treatment |
| V26 | Certified Nursing Assistant | Provided resident care and information on bed positioning |
| V28 | Nurse Practitioner | Provided medical assessment of wound infection |
| V3 | Infection Control Preventionist | Provided information on COVID testing and quarantine procedures |
| V17 | Medical Director | Provided guidance on COVID testing and isolation |
| V2 | Administrator | Informed of Immediate Jeopardy and provided information on PPE supply |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jan 29, 2020
Visit Reason
Annual Licensure and Certification Survey including complaint investigation 2010177/IL119000 with no deficiencies found.
Complaint Details
Complaint 2010177/IL119000 was investigated during the annual survey and no deficiencies were found related to the complaint.
Findings
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.
Deficiencies (4)
Failure to assess and treat pressure ulcers for a resident at risk, including lack of timely treatment orders and inconsistent documentation.
Failure to provide peri-care in a manner to prevent infection for a resident treated for a urinary tract infection.
Failure to follow dietary recommendations for residents with weight loss, including not providing fortified desserts and proper meal assistance.
Failure to ensure staff removed gloves and washed hands to prevent cross contamination during care.
Report Facts
Residents reviewed: 34
Residents with pressure injuries reviewed: 4
Residents affected by pressure ulcer deficiency: 1
Residents affected by incontinence care deficiency: 1
Residents affected by dietary deficiency: 2
Residents affected by infection control deficiency: 2
Weight loss percentage: 9.8
Weight loss percentage: 10.2
Weight loss percentage: 8.6
Calories in Magic Cup: 290
Protein in Magic Cup: 9
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 18, 2019
Visit Reason
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.
Complaint Details
Complaint 1919716/IL118368 was substantiated as the facility failed to follow safe transfer protocols, increasing the resident's risk of fracture.
Findings
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.
Deficiencies (1)
Failure to use two staff members to safely transfer a resident with a mechanical lift, leading to a fracture.
Report Facts
Resident transfers to be audited: 25
Audit period: 12
Date of fracture: Nov 26, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V5 | Certified Nursing Assistant | Transferred resident alone leading to fracture; received disciplinary action and re-training. |
| V2 | Director of Nursing | Verified the CNA transferred resident alone and confirmed resident's high fracture risk. |
| V9 | Physician | Confirmed resident's high risk for fractures and emphasized need for cautious care. |
| V7 | Certified Nursing Assistant | Stated importance of two staff members during transfers. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 11, 2019
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to safely transfer a resident by not using a gait belt, resulting in a fall and right knee fracture.
Report Facts
Residents reviewed for safety: 5
Resident transfers audited weekly: 25
Audit duration weeks: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V6 | Certified Nursing Assistant | Named in deficiency for failure to use gait belt during transfer leading to resident fall |
| V2 | Director of Nursing | Provided statements about gait belt policy and disciplinary actions |
| V3 | Nurse Unit Manager | Reviewed fall incident and counseling of staff member |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 11, 2019
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to safely transfer a resident by not using a gait belt, resulting in a fall and right knee fracture.
Report Facts
Deficiencies cited: 1
Resident transfers audited weekly: 25
Audit period: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V6 | Certified Nursing Assistant (CNA) | Named in deficiency for failure to use gait belt during resident transfer, received disciplinary action and termination |
| V2 | Director of Nursing (DON) | Provided statements regarding gait belt policy and disciplinary actions |
| V3 | Nurse Unit Manager | Reviewed fall incident and counseling of staff member V6 |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 6, 2019
Visit Reason
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.
Findings
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.
Deficiencies (1)
Resident self-administer medications - clinically appropriate; mupirocin ointment was improperly stored at resident R112's bedside.
Report Facts
Resident rooms audited per week: 25
Duration of audit period (weeks): 6
Completion date of corrective action: Feb 22, 2019
In-service training dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Responsible for random audits of resident rooms to ensure compliance |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 1, 2017
Visit Reason
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.
Complaint Details
Complaint number 1793157/IL94295 is referenced, indicating the Plan of Correction is in response to a complaint.
Findings
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.
Deficiencies (1)
Deficiency related to hazards, supervision, and devices (F323 SS=G)
Report Facts
Corrective action completion date: Jun 16, 2017
Audit period: 3
Audit frequency: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 30, 2017
Visit Reason
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.
Complaint Details
This Plan of Correction responds to complaints 1790067/IL90865 and 1791626/IL92621. The document does not state substantiation status.
Findings
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.
Deficiencies (1)
Failure to ensure residents are free of accident hazards and properly supervised during transfers using assistive devices.
Report Facts
Date for corrective action completion: May 14, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for observing resident transfers using assistive devices monthly and reporting to Quality Assurance |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 24, 2017
Visit Reason
This Plan of Correction is submitted as a written allegation of compliance for deficiencies cited during the inspection conducted on 3/24/17.
Findings
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.
Deficiencies (1)
Dignity and respect of individuality deficiency related to resident care and staff behavior.
Report Facts
Corrective action completion date: May 14, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Responsible for observing resident interactions and reporting to Quality Assurance |
| E3 | Employee removed from care and subsequently terminated related to deficiency |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jan 29, 2017
Visit Reason
This document is a Plan of Correction (POC) submitted by Friendship Village of Schaumburg to address deficiencies identified during a regulatory inspection.
Findings
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.
Deficiencies (4)
Call lights were not within reach of residents R7, R31, R35, R36, and R37.
Housekeeping and maintenance issues including improper labeling and storage of personal care items for residents R9, R10, R23, R46, R47, and R52-R56.
Accident hazards due to unsecured sharps and accessible hazardous items in the Spa Room.
Food procurement and storage deficiencies including discarded food items and improper hair restraint policy among dining staff.
Report Facts
Date for corrective action completion: Jan 29, 2017
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Nov 11, 2016
Visit Reason
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.
Complaint Details
This Plan of Correction is in response to a complaint survey identified as Complaint Survey 1695829/IL89113.
Findings
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.
Deficiencies (4)
Deficiency in treatment/services to improve/maintain ADLs (F311)
Deficiency in ADL care provided for dependent residents (F312)
Deficiency in treatment care for special needs (F328)
Deficiency in sufficient 24-hour nursing staff per care plans (F353)
Report Facts
Completion date for corrective actions: Dec 3, 2016
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 14, 2016
Visit Reason
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.
Findings
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.
Report Facts
Completion date: Mar 14, 2016
Compliance period: 3
Error rate threshold: 5
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Feb 26, 2015
Visit Reason
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.
Findings
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.
Deficiencies (2)
Free of accident hazards/supervision/devices related to unsecured oxygen cylinders, wheelchair leg rests, and unlocked electrical panels.
Treatment/care for special needs including proper handling and storage of oxygen nasal cannulas, spirometers, and nebulizer masks.
Report Facts
Corrective action completion date: Feb 26, 2015
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Feb 28, 2013
Visit Reason
This document is a Plan of Correction submitted by Friendship Village of Schaumburg in response to deficiencies identified during a prior inspection.
Findings
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.
Deficiencies (5)
Dignity and respect of individuality not maintained in dining arrangements.
Poor activity participation and lack of appropriate activity interventions.
Expired medical supplies found and emergency cart policies outdated.
Resident charts not secured properly on the Forest unit.
Staff not adequately trained on emergency procedures and location of emergency carts.
Report Facts
Corrective action completion date: Mar 20, 2013
Corrective action completion date: Apr 14, 2013
Random observations per month: 10
Random charts selected monthly: 12
Random clinical staff sample per month: 10
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Jan 18, 2012
Visit Reason
This document is a Plan of Correction submitted by Friendship Village in response to deficiencies identified during a survey conducted on January 18, 2012.
Findings
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.
Deficiencies (5)
Deficient practice related to development and revision of comprehensive care plans and treatment/services to maintain or improve ADLs.
Deficient practice in food procurement, storage, preparation, and serving, including improper food labeling and temperature control.
Deficient practice in maintaining a resident environment free of accident hazards and ensuring adequate supervision and use of assistive devices.
Deficient practice in drug records, labeling, and storage of drugs and biologics, including improperly labeled medications.
Deficient practice in infection control, including improper use of gloves and procedures for residents on isolation precautions.
Report Facts
Date of survey: Jan 18, 2012
Date for correction completion: Mar 9, 2012
Number of new admissions audited monthly: 10
Number of C.N.A.s audited randomly: 15
Compliance target: 90
Compliance target: 95
Duration of compliance monitoring: 3
Duration of compliance monitoring: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E7 | Counseled and disciplined for improper use of mechanical sit/stand lift | |
| R3 | Resident involved in care plan and infection control corrective actions | |
| R23 | Resident involved in mechanical lift use corrective actions | |
| DON | Director of Nursing | Completed review and involved in audits and corrective action plans |
| MDS | Resident Care Coordinator | Completed review and involved in audits and corrective action plans |
| Restorative Nurse | Involved in care plan review and audits | |
| ADON | Assistant Director of Nursing | Responsible for auditing C.N.A.s and nurses for compliance |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 10, 2011
Visit Reason
This document is a Plan of Correction submitted by Friendship Village of Schaumburg following an annual survey conducted on March 10, 2011.
Findings
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.
Deficiencies (2)
Deficient practice in conducting initial and periodic comprehensive assessments of each resident's functional capacity.
Deficient practice in infection control related to nasal cannula tubing, masks, nebulizers, and humidifier bottles not being changed and dated properly.
Report Facts
Charts audited per week: 10
Charts audited per week: 10
Compliance target: 90
Completion date: Apr 24, 2011
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Mar 24, 2010
Visit Reason
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.
Findings
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.
Deficiencies (6)
Failure to maintain resident dignity and respect, including assistance with food and privacy.
Inadequate comprehensive care plans and medication management, including unclear physician orders and medication errors.
Failure to ensure a safe environment free from accident hazards and adequate supervision.
Medication errors exceeding 5%, requiring monitoring and education.
Menus and nutritional services not fully meeting residents' needs and preferences.
Sanitary conditions issues including improper food handling and storage practices.
Report Facts
Date corrective actions to be completed: Mar 4, 2010
Medication error threshold: 5
Observation start date: Mar 1, 2010
Bread policy effective date: Jan 27, 2010
Dining services re-education date: Feb 19, 2010
Dining services cardboard box removal date: Jan 28, 2010
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 1, 2009
Visit Reason
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.
Complaint Details
Complaint investigation based on complaints #0993825 and #0994273. The report includes corrective actions taken and monitoring plans. Substantiation status is not explicitly stated.
Findings
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.
Deficiencies (2)
Error by surveyor: R3 did not have seizure; R2 had the seizure. Medication errors including missed eye drops for 2 days.
Glucerna feeding order was incorrect (1.2 cc/hr instead of 90 cc/hr), requiring physician order change.
Report Facts
Dates of corrective action: 2009
Audit compliance percentage: 75
Audit compliance percentage: 100
Audit compliance percentage: 50
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 6022853 View POC 023 6003404FIK01112018
Visit Reason
This document is a plan of correction addressing deficiencies related to infection prevention and control at Friendship Village of Schaumburg.
Findings
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.
Deficiencies (1)
Deficient practice related to hand washing and hand hygiene during medication administration
Report Facts
Date for completion of corrective action: Feb 25, 2018
Inspection Report
Plan of Correction
Deficiencies: 3
Date: 6022853 View POC 025 6003404FA12032010
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to notify physicians, legal representatives, or family members of significant changes in residents' physical, mental, or psychosocial condition.
Failure to provide care/services for highest practicable physical, mental, and psychosocial well-being.
Failure to promptly resolve grievances/issues of residents or families.
Report Facts
Completion Date: Jan 17, 2011
Complaint Number: 1093569
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Reminded staff of procedures and responsible for in-service training and monitoring |
| ADON | Assistant Director of Nursing | Reminded staff of procedures for Change in Condition |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 6022853 View POC 016 6003404FA09032010
Visit Reason
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.
Complaint Details
The document references complaints #1091464/IL46933, #1091888/IL47435, and IRI of 4/8/10/IL47283 but does not state substantiation status.
Findings
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.
Deficiencies (1)
Resident R9 was not put to bed at the requested time due to medication pass, staff breaks, and other residents being attended to.
Report Facts
In-service timeframe: 10
Breaks allowed: 1
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 6022853 View POC 010 6003404FIAK01152014
Visit Reason
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.
Findings
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.
Report Facts
Residents with unsecured charts: 30
Completion date: 2014
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