Inspection Reports for
Encore Village of Schaumburg

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.

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.

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 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 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.

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.

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

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.

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.

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 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.

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.

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.

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 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 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.

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.

Complaint Investigation 2418769/IL179924. The complaint involved 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 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.

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 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.

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.

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

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

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.

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.

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

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.

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

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.

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.

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

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.

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.

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.

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.

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 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.

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

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.

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.

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.

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.

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

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.