Inspection·December 27, 2023

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident's peritoneal dialysis treatments were initiated and monitored which applies to 1 of 1 resident (R1) reviewed for dialysis services in a sample of 1. Residents Affected - Few The findings include: On 12/27/23 at 8:20 AM, V3 Assistant Director of Nursing stated R1 is the only peritoneal dialysis (PD) resident in the facility. R1's Facesheet printed on 12/27/23 showed R1 to be an eighty four year old female resident readmitted to the facility on [DATE] with diagnoses which include: chronic kidney disease (CKD) stage 5, encounter for fitting and adjustment peritoneal dialysis catheter, and dependence on renal dialysis. R1's hospital records dated 12/23/23 showed R1's PD orders which were in R1's hospital record packet. On 12/27/23 at 2:40 PM, V6 3rd party Dialysis Nurse showed this writer the treatment history on R1's PD cycler. The cycler screen showed R1's last 2 treatments were on 12/9/23 (evening before hospital admission) and 12/26/23 (3 days after readmission). V6 stated the information on the screen showed R1 did not have a treatment on 12/23, 12/24, or 12/25. On 12/27/23 at 12:15 PM, V7 Registered Nurse entered R1's room with this writer. V7 stated the nurses are supposed to enter the PD information in the residents PD binder. The PD binder holds the treatment flowsheets. R1's Daily PD Flowsheet (undated) in the binder showed 1 entry of the date 12/26. None of the other PD information was documented which includes: resident's weight, vitals, PD solution used, medications (if added), drain volumes, and ultrafiltration (fluid output) for the treatment. On 12/27/23 at 11:50 AM, V5 Nephrology Nurse Practitioner stated Did she miss 3 PD treatments? Yes. Did this cause her to become unstable and need to be transferred out? No. V5 stated when R1 was discharged from the hospital with orders we presumed she would be getting the PD treatments as they were ordered. V5 stated she received a call from V4 Nursing Manager on 12/26/23 for PD orders. V5 stated she assumed R1 did not receive her previous PD treatments after V4's phone call. V5 stated she rounded on R1 on 12/26/23 to assess R1 and make changes to the PD orders if needed to pull more fluid if needed. No changes to R1's orders were needed. R1's Physician Order Sheet dated 12/27/23 showed R1's admission date of 12/23/23. R1's initial (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145341 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encore Village 350 West Schaumburg Road Schaumburg, IL 60194 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)